Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Heparin Induced Thrombocytopenia (HIT)
Treatment: Formulary exception for Pradaxa (dabigatran)
The insurer denied the Formulary exception for Pradaxa (dabigatran). 
The denial is overturned. 

The patient is a male. The patient was diagnosed with acute DVT (deep venous thrombosis).  He had been taking warfarin for cardiac disease at the time, and INR (international normalized ratio) was above 3 when he was diagnosed with the DVT.  He was treated with Eliquis and discharged.  

Repeat doppler ultrasound was done and revealed evidence of worsening DVT, with clot extension into the left femoral vein.  The patient was switched to Pradaxa based on that finding.

Yes, the health plan should cover the Formulary exception for Pradaxa (dabigatran).

This patient had a DVT diagnosed while on warfarin, with an INR over 3.  This indicates that warfarin treatment failed to prevent this initial clot, and therefore this medication would not be indicated to treat the clot it failed to prevent.  He had worsening of the same clot while taking Eliquis.  Both Eliquis and Xarelto are Factor Xa inhibitors. Pradaxa is a direct thrombin inhibitor.  Given that this patient failed both warfarin and a Factor Xa inhibitor, treatment with another Factor Xa inhibitor would not be indicated.  Switching to a different class of agent would be recommended and indicated for this patient's treatment, as it is unlikely that another Factor Xa inhibitor (Xarelto) would be effective.  Given these considerations, Pradaxa should be considered medically necessary and should be covered.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Skeletal Class I malocclusion and significant crowding
Treatment: Braces
The insurer denied Braces and monthly visits. The health plan's determination is overturned. 

The patient in question is a male with an anterior crossbite on teeth 7 and 10. He presents with a skeletal Class I malocclusion and significant crowding. Teeth 6, 22 and 27 are completely blocked out to the labial. He is treatment planned for 24-30 months of orthodontics with extraction of teeth 5, 12, 21 and 28 to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

Braces and Monthly Visit are medically necessary for this patient.

This patient presents with an anterior crossbite on teeth 7 and 10, as well as severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular teeth that can lead to periodontal defects.

If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

This patient, with a history of coronary artery disease and surgical and percutaneous coronary revascularization, presented to the hospital for elective cardiac catheterization. The procedure was recommended for symptoms of exertional chest pain and an abnormal myocardial perfusion imaging study. Coronary angiography showed a patent left internal mammary artery graft to the left anterior descending artery and occluded grafts to the right coronary artery and an obtuse marginal artery. There was in-stent restenosis in the left circumflex artery. The lesion was heavily calcified and was treated with rotational atherectomy. While in the cardiac catheterization laboratory the patient developed chest pain and intravenous nitroglycerin infusion was started. He was admitted to the hospital. His chest pain persisted requiring titration of the nitroglycerin to a higher dose. His serum troponin level which had been normal at 0.01 ng/ml initially, increased to a peak of 4.36 ng/ml. There were no acute electrocardiographic changes.
The nitroglycerin was titrated off and oral nitrates were started. The patient was discharged. An inpatient admission is at issue for medical necessity.

The health plan's determination of medical necessity is overturned in whole. 

The inpatient stay was medically necessary for this patient.
This patient, with multivessel coronary artery disease, underwent complex percutaneous coronary intervention for a heavy calcified lesion in his left circumflex coronary artery. The procedure was complicated by prolonged chest pain necessitating intravenous nitroglycerin infusion. His serum troponin level increased markedly from .01 ng/ml to 4.36 ng/ml. The universal definition of a percutaneous coronary intervention (PCI) related myocardial infarction is an increase in serum troponin to more than five times the 99th percentile upper reference limit within 48 hours of the procedure in patients whose level was initially normal along with evidence of prolonged ischemia (such as prolonged chest pain).
Thus, this patient met criteria for a diagnosis of a PCI related myocardial infarction. Per the 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions, inpatient admission is recommended for patients whose procedure is complicated by acute myocardial infarction. In addition, this patient required continuous infusion and titration of intravenous nitroglycerin. This is associated with a risk of hypotension and requires careful monitoring. This warranted an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Cardiac. 
Diagnostic Testing (other than Radiology). 

Diagnosis: Congenital Heart Disease. 
Treatment: Psychological Testing. 

The insurer denied Psychological Testing. The health plan's determination is upheld. 

The patient is a female with a history of congenital heart disease who underwent psychological testing. She was born with a structural heart defect, transposition of the great arteries, for which she underwent an arterial switch operation in early infancy. She met developmental milestones appropriately. Her parents had some concern regarding her speech abilities. She had a spoken vocabulary of about 100 words and was starting to put two words together into short sentences. In response to the parental concerns, the cardiologist ordered psychological testing to assess her cognitive and developmental skills. She underwent two hours of psychological testing. This was denied by the health plan as not medically necessary. 

Psychological Testing was not medically necessary. 

The patient was very young at the time of the psychological testing. A person needs to be older and have greater cognitive and language abilities to have valid psychological testing results. This patient's developmental status could have been determined through a clinic exam and discussion with the parents. A two-hour formal psychological examination was not medically necessary. 

The patient's parents had questions regarding her developmental progress in the area of speech. It is common and appropriate for parents to have these types of concerns, especially for children who were born with cardiac defects and who have undergone substantial cardiac interventions. However, this patient's developmental status in speech was completely normal for a child her age. She had an appropriate vocabulary and was putting two words together into sentences. Psychological testing was not medically necessary to make this determination. Developmental status for young children is customarily and effectively determined by simply assessing children in clinic or by asking the parents what milestones a child has achieved. Formal psychological testing as a means of determining developmental status is not necessary for young children.

Psychological testing can be medically necessary for some reasons, including:

1) to confirm or rule out a thought disorder, 2) to make a diagnosis of a psychiatric disorder when the diagnosis cannot be made in other ways, and 3) to diagnose an intellectual disability following evaluation and recommendation by a developmental pediatrician. There was no concern that the patient had a thought disorder or a psychiatric disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III malocclusion, Hypoplastic maxilla, Maxillary and mandibular crowding, Anterior crossbite. 

Treatment: D8070 braces and D8670 monthly visit x 12. 

The insurer denied coverage for D8070 braces and D8670 monthly visit x 12. 

The denial is overturned. 

This is a female patient who presented for an evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding, Class III malocclusion, hypoplastic maxilla, and anterior crossbite with gingival attachment loss (mandibular left canine). The orthodontist has completed the Handicapping Labio-Lingual Deviation index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining a score of 17 points on the Handicapping Labio-Lingual Deviation index where 26 points is required. 

Based on clinical documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation index.  This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating Orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is clearly met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 
 
D8070 braces and D8670 monthly visit x 12 are considered medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for D8070 braces and D8670 monthly visit x 12 should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II canines, maxillary and mandibular crowding, and anterior crossbite

Treatment: Orthodontic Treatment (braces) and periodic treatment visits

The insurer denied the orthodontic treatment (braces) and periodic treatment visits.

The denial was upheld.  

This is a patient who presented to an orthodontist for evaluation for orthodontic care.  The evaluation included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images. Recommendations were made for comprehensive orthodontics due to Class II canines, maxillary and mandibular crowding, and anterior crossbite. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore, does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 8 points (3 points overjet, 3 point overbite, and 2 points labiolingual spread).

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for orthodontic treatment (braces) and periodic treatment visits is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Malocclusion
Treatment: Braces and Monthly Visit (x4) 
The insurer denied Braces and Monthly Visit (x4). The health plan's determination is overturned. 

The patient in question is a female with impacted teeth #6 and #11. Tooth #11 is completely blocked out. She presents with a skeletal Class I malocclusion and significant crowding. She is treatment planned for braces with premolar extractions to address the crowding and impacted teeth, but treatment was denied due to lack of medical necessity.

Braces and Monthly Visit (x4) are medically necessary for this patient.
It is in the best interest of patients to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered. This patient has impacted teeth #6 and #11. Tooth #11 is completely blocked out and there is a skeletal Class I malocclusion and significant crowding.
If left untreated the damage that will likely occur to the patient's teeth will be more time consuming and difficult to correct than the patient's existing orthodontic problem. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  History of fibromyalgia, osteoarthritis, cervical and lumbar degenerative disc disease (DDD). 
Treatment:  Increase of Personal Care Aide (PCA) Level 2: 6 hours per day - 5 days per week - for a total of 30 hours per week.

The insurer denied the Increase of Personal Care Aide (PCA) Level 2: 6 hours per day - 5 days per week - for a total of 30 hours per week.  The denial is overturned. 

Yes, the Increase of Personal Care Aide (PCA) Level 2: 6 hours per day - 5 days per week - for a total of 30 hours per week is medically necessary. 

The patient is a female with a history of fibromyalgia, osteoarthritis, cervical, and lumbar degenerative disc disease.  Due to impairments related to these conditions, she requires assistance for the completion of the majority of her activities of daily living (ADLs).  Recent documentation received from the patient's physician indicates that due to worsening musculoskeletal pain in her affected joints, worsening lower extremity weakness, worsening fatigue, and worsening gait ataxia, the currently approved plan of 27 hours/week is insufficient to meet the patient's current needs.  For these reasons, the proposed treatment 30 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Dysphagia, Esophageal Reflux.
Treatment:  Protonix Packets (pantoprazole).

The insurer denied the Protonix Packets (pantoprazole).  The denial was upheld. 

This is a male patient, who has history of supraventricular tachycardia (SVT), irritable bowel syndrome, esophageal reflux and chronic dysphagia.  The patient reported that he has heart palpitations and premature ventricular contractions (PVCs) with the previously used omeprazole and lansoprazole.  The patient has been able to tolerate a diet but reports difficulty swallowing pantoprazole.  The medical record indicates that he was previously treated with an increased dose of pantoprazole and Carafate.

The American Gastroenterological Association (AGA) has published guidelines on gastroesophageal reflux disease (GERD).  Proton pump inhibitor (PPI) therapy is part of GERD management.  However, there is no recommendation that one PPI is superior to another.  In addition there is no recommendation that Protonix Packets are superior to generic pantoprazole.

Based on the review of the medical record, this patient has a diagnosis of gastroesophageal reflux disease (GERD).  The patient's endoscopy was negative for esophageal obstruction.  The Ear Nose &Throat (ENT) evaluation also did not find any obstruction.  The patient has been able to swallow other oral medications.  Protonix Packets and pantoprazole have the same active ingredient.  The medical record does not document sufficiently a medical condition precluding giving oral pantoprazole for this patient.  Protonix Packets are not more effective than pantoprazole unless there is an esophageal obstruction.  This patient does not have esophageal obstruction.  Thus, Protonix Packets are not medically necessary for this patient. 

The carrier's denial of Formulary Exception for Protonix Packets (pantoprazole) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Concussion

Treatment: Inpatient admission

The insurer denied the inpatient admission. 

The denial was upheld.

This is a male patient who presented to the Emergency Department (ED) by Emergency Medical Services (EMS) after being found lying on the ground, unconscious and confused. It was reported that the patient was unresponsive for an unknown period of time and on arrival, the patient was awake and alert and repeatedly asked where his keys were and what happened. An examination of the patient was performed that revealed swelling and tenderness to palpation to the right forehead.  The patient's pupils were 3 mm bilaterally and they were round and reactive to light.  The patient's laboratory studies did not reveal any significant abnormalities.  The patient's CT scan of the head revealed no signs of intracranial hemorrhage, mass, midline shift or extra-axial collection.  The documentation indicated that there were no laboratory abnormalities of acute significance.  The patient underwent an electrocardiogram (EKG) revealing sinus bradycardia 53 bpm.  Upon recheck, the patient's condition was unchanged.  The patient be admitted for a 24-hour of observation. The patient was able to ambulate without ataxia as well as speak clearly. The patient did not wish to be admitted and left the hospital Against Medical Advice (AMA). 

According to the guidelines provided by the InterQual 2019, this acuity of this case is considered to have required observation as the patient with a transient neurologic of unknown cause although intoxication is suspected. Upon arrival to the hospital, the patient was not considered to be in status epilepticus. No events concerning for seizures were noted during the stay. Precautionary testing with computed tomography (CT) scan and electrocardiogram (EKG) were performed without revealing any abnormality. No other interventions were necessary. The patient was described as interactive and was able to be discharged. The patient did not require an escalated level of care.

The current literature indicates that a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. As per the submitted documentation, the patient's condition has not trialed and failed at the lower level care, such as observation. The patient was back at his baseline and elected to self-discharge.  Inpatient level of care was not medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient level of care is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease. 
Treatment: Pharmacy/Prescription Drugs.  
The insurer denied: Vemlidy. 
The denial is upheld in whole. 

The patient is a  male infected with hepatitis B. The patient underwent liver transplant or hep B/C. Hep C was eradicated with Harvoni. He has IgA nephropathy. The patient has been on treatment with Vemlidy for a couple of years as he has a documented contraindication to tenofovir disoproxil fumarate (TDF).
The patient's provider has recommended treatment with Vemlidy 25 milligrams (mg). This request was denied by the plan because there is no Hep B viral load result within the past 12 months.
The subject under review is the medical necessity for Vemlidy.

The health plan's determination is upheld in whole.

There is a lack of information in order to support the medical necessity of Vemlidy for this patient. It is critically important to follow the hepatitis B virus (HBV) deoxyribonucleic acid (DNA) level while on tenofovir and it is very reasonable to request regular measurements of this value.
If the patient has been compliant with Vemlidy and the HBV viral load remains suppressed, then it is critically important in his care so that he does not lose the liver allograft. However, if the value of HBV DNA is high either through non-compliance or the emergence of viral resistance, then a different approach would be warranted based on the circumstances.
However, based on the information provided medical necessity cannot be established.