Persius/hicric huggingface dataset:
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia

Treatment: implant placement for teeth 2, 14, 15, 18, 19, 29, 31 and sinus augmentation with bone or bone.

The insurer denied coverage for implant placement for teeth 2, 14, 15, 18, 19, 29, 31 and sinus augmentation with bone or bone.

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants and grafting procedures. The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits a heavily restored maxilla and oligodontia in the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. In this case the removable partial dentures would be entirely tooth borne, the most stable and retentive of all removable appliances. Further the documentation provided does not support, justify, or substantiate the requested treatment. Therefore, as removable dentures (partial removable) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

An appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable full and partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment, this renders the endosteal implants and associated services not medically necessary.

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

The insurer's denial of coverage for the implant placement for teeth 2, 14, 15, 18, 19, 29, 31 and sinus augmentation with bone or bone substitutes is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes mellitus, hypertension, benign prostatic hyperplasia, chronic leg pains, depression, anxiety.

Treatment temporary consumer directed personal care assistance services of 6 hours per week.

The insurer denied coverage for temporary consumer directed personal care assistance services of 6 hours per week.

The denial is upheld.

The patient has a history of diabetes mellitus, hypertension, benign prostatic hyperplasia, chronic leg pains, depression, anxiety and a hoarding disorder. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient lives alone on the fourth floor of an apartment building with elevator access. The patient needs maximum assistance with ordinary housework. He needs extensive assistance with meal preparation, managing stairs, shopping, and transportation. The patient needs limited assistance with bathing, dressing his upper and lower body and locomotion. He uses an assistive device for locomotion indoors. The patient needs supervision, oversight or cueing with managing finances, managing medications and walking. He needs setup help only with phone use and equipment management. The patient is independent and needs setup help only with personal hygiene, bed mobility, eating, toilet transfer and toilet use. He is frequently bladder incontinent but has complete bowel control. The patient uses incontinence supplies. The patient reported that he follows up with his psychiatrist every three months, and he receives psychotherapy every two weeks. He also reported that he was admitted to the hospital because he was not feeling well. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse...

The patent needs help with instrumental activities of daily living (IADL) but he is basically independent in activities of daily living (ADL). He is in day-care 4 days a week and receives 12 hours/week of services; task tool allots 8. He has psychiatric problems with hoarding, but an additional few hours/week of supervision is not covered. There is no documentation that he has deteriorated. The time allotted by the plan is supported by the documentation.

Based on the above, the medical necessity for the Temporary Consumer Directed Personal Care Assistance Services of 6 hours per week is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with sickle cell anemia and diabetes. She presented to the hospital with abdominal pain with nausea and vomiting with diarrhea. The symptoms started after eating Chinese food and were persistent for 1 week. The patient was noted with creatinine to 1.7 mg/dl (milligrams per deciliter) and an elevated white count. CT (computed tomography) scan of the abdomen was without acute pathology. The patient was started on IV (intravenous) fluids and antibiotics.

No, the Inpatient admission was not medically necessary.

The inpatient admission was not medically necessary as supported by current medical literature. The request would not be a generally accepted national standard of medical practice, provided primarily for convenience of the patient or the practitioner nor the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

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

The patient had gastrointestinal symptoms, including nausea and diarrhea. CT (computed tomography) imaging was without acute pathology and did not note free air, or free fluid and did not require surgical intervention. The patient was hemodynamically stable, with stable electrolytes and respiratory status.  There was no liver dysfunction or obstruction of the intestines that required inpatient level of care. Based on available data, patient could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, gait ataxia, urinary/fecal incontinence, muscle weakness and chronic fatigue.
Treatment: Increase Personal Care Assistance Services From 49 To 84 Hours Per Week.
The insurer denied the Increase Personal Care Assistance Services From 49 To 84 Hours Per Week.
The denial is overturned.

The patient is a female with a history of hypertension, gait ataxia, urinary/fecal incontinence, muscle weakness and chronic fatigue. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 84 hours/week Personal Care Assistance Services is deemed medically necessary.

The patient is a female with a history of hypertension, gait ataxia, urinary/fecal incontinence, muscle weakness and chronic fatigue. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).

Recent correspondence from the patient's physician indicates that due to progressively worsening functional and cognitive decline; including worsening weakness, gait ataxia, poor appetite, unintended weight loss and insomnia; the patient is now fully dependent on others for assistance with completion of all of her ADLs (activities of daily living), including bathing, cooking, cleaning and shopping. This documentation reveals that the currently approved plan of 49 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory failure
Treatment: Increase Personal Assistance from 63 Hours per Week to 147 Hours per Week
The insurer denied the Increase Personal Assistance from 63 Hours per Week to 147 Hours per Week.
The denial is overturned. 

The patient is a female with a history of respiratory failure due to severe and advancing interstitial/idiopathic lung disease. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 147 hours per week Personal Assistance Services to offer increased activities of daily living support.

Yes, the proposed treatment of 147 hours per week Personal Assistance Services is deemed medically necessary.

Recent correspondence from the patient's medical provider indicates that due to progressively worsening dyspnea, fatigue, and generalized weakness due to her worsening respiratory failure, she is now fully dependent on others for assistance with completion of all activities of daily living. Hence, the currently approved plan of 63 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 147 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

This is a female who presented to the emergency department (ED) with a three-day history of right knee pain. She had fallen. Her past history was significant for multiple sclerosis (MS) and requiring wheelchair. She had used ice and Epson salts which did not provide benefit. X-rays were completed demonstrating demineralization and fractures to the tibia and fibula (right and left) metaphysis. A brace was ordered. The patient left against medical advice (AMA). 

No, the proposed treatment, inpatient admission, was not medically necessary. 

The records show the patient sustained injury to both legs days prior. She was found to have fractures to both legs which would be considered pathologic, ie - demineralized bone. She was non ambulatory with contractures. 

Admission would be reasonable if the patient had intractable pain and immediate subspecialty service necessary. The facts were: the diagnosis was established in the emergency department (ED) (plain radiographs), there was no indication of inability to tolerate oral pain medication, and there was no evidence of bleeding, infection nor unstable vital signs. 

The patient's treatment consisted of recommendation to apply a brace. The orthopedic and neurology consultation reported no need for acute intervention. Physical therapy services were not necessary as she was not ambulatory. She signed out against medical advice (AMA). 

The patient did not require treatment for an underlying medical problem. There was thus no reason why acute inpatient admission was necessary.  There were no extenuating circumstances to substantiate the level of service provided.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: COPD (chronic obstructive pulmonary disease)

Treatment: Formulary Exception for Yupelri 175 microgram (mcg)/3milliliter (mL) solution for inhalation

The insurer denied coverage for Formulary Exception for Yupelri 175 microgram (mcg)/3milliliter (mL) solution for inhalation

The denial is upheld.

The patient has a history of chronic obstructive pulmonary disease (COPD) and extensive emphysema on computed tomography (CT) chest. The patient was seen in follow up by their primary medical doctor (PMD). As per the clinic notes, the patient's main complaint was COPD (chronic obstructive pulmonary disease)/ dyspnea on exertion (DOE).  Vital signs were noted as the following: afebrile, hemodynamically (HD) stable, oxygen (O2) saturations 98% (percent). The patient was in no acute distress (NAD). The lung exam revealed some decreased breath sounds (BS) at the bases. The patient was alert and oriented.  The patient's medications included Trelegy long-acting muscarinic antagonist/long-acting beta2-agonist/inhaled corticosteroid (LAMA/LABA/ICS) Albuterol PRN (as needed). The patient did not tolerate Daliresp - got some diarrhea from it. The patient's medical doctor (MD) states that the patient feels that she does not get enough inspiratory flow from the inhalers. The patient's physician prescribed Yupelri long-acting muscarinic antagonist (LAMA) for nebulized therapy.

This drug is not on the formulary for the insurance company. Other alternatives include Spiriva (also a LAMA) via Handi Haler or Respimat. As noted by Hvisdas  "Revefenacin was also demonstrated to have efficacy similar to that of tiotropium. The clinical trial findings indicated no significant difference between revefenacin and tiotropium with regard to rates of adverse events." Spiriva is tiotropium bromide.   Ipratropium (A short acting anti muscarinic) is also available as an inhaler solution on the formulary.

Based on the information provided it appears that this patient could be tried on Spiriva Respimat which is a soft mist inhaler with a different delivery mode than the traditional inhalers.  In case patient unable to tolerate it then Yupelri could be considered.

The requested drug is not likely to produce a more clinically beneficial outcome over the formulary options.

The insurer's denial of coverage for Formulary Exception for Yupelri 175 microgram (mcg)/3milliliter (mL) solution for inhalation is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Dupixent. 
The denial is upheld in whole. 

The patient is a male with atopic dermatitis (AD). He has tried and failed clobetasol, tacrolimus, hydrocortisone, betamethasone, cephalexin, and azithromycin. His scalp is affected. His dermatologist has recommended Dupixent for his dermatitis.
At issue is Dupixent 200 milligrams (MG) 1.14 milliliters (ML) SC SOPN (subcutaneous solution pen-injector). 

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

The requested health treatment of Dupixent 200 MG 1.14 ML SC SOPN is not medically necessary for this patient. 
Based on the evidence-based literature, Dupixent is not medically necessary. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, medicines such as methotrexate are effective treatments for the management of atopic dermatitis, including in pediatric patients. (1, 2) Within the peer-reviewed literature, in 2018, Gerbens et al writes "Methotrexate (MTX) and azathioprine (AZA) seem to be effective and safe as maintenance treatments in moderate to severe AD up to 5 years." (3) Shah et al writes "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk." (4)  There are several published studies that show that methotrexate is effective and safe for moderate-severe atopic dermatitis. (5-8) The evidence-based literature is consistent. There are no unique clinical circumstances to this patient that would make Dupixent medically necessary. The formulary medications should be tried and failed prior to initiating Dupixent, as the patient has no true contraindications to the use of the formulary medications. 

Therefore, Dupixent 200 MG 1.14 ML SC SOPN is not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Tinea Unguium
Treatment: Formulary exception for Jublia 10% EX SOLN, Pre-service
The insurer denied the Formulary exception for Jublia 10% EX SOLN, Pre-service.
The denial is overturned.

The patient is a female with tinea unguium, treated with ciclopirox solution. Her provider is requesting Jublia solution. The health plan requires a trial and failure to all preferred alternatives: ciclopirox solution, itraconazole tablets, terbinafine tablets, and oral griseofulvin.

Yes, the health plan should cover the formulary exception for Jublia.

Jublia is an approved, safe and effective medication for onychomycosis. The patient has tried ciclopirox topical, and Jublia has shown superior efficacy to ciclopirox.

There are no firm guidelines indicating patients must undergo Terbinafine before topical therapy can be utilized. Terbinafine has potential liver toxicity and should not be required before much safer newer topicals. New therapies for onychomycosis continue to be developed, yet treatments are seldom directly compared in randomized controlled trials. Jublia has documented efficacy and some studies have suggested similar efficacy to Terbinafine. Efinaconazole is a potent antifungal with a broad spectrum of activity and should be available to patients without requiring systemic therapy first.

After review of the evidence based medical literature for onychomycosis, there are no strict requirements for Itraconazole or other systemic anti-fungals before topical anti-fungals.

The meta-analysis referenced attempted to compare data among the systemic anti-fungals and found superiority of oral Lamisil over other systemic anti-fungals, but did not compare the systemic agents to topical agents. The topical agents were compared to placebo and showed similar efficacy to systemics. The analysis concluded that because treatments are seldom directly compared in randomized controlled trials, more comparative studies are needed before firm guidelines can be established.

The comparative analysis in showed that "Efinaconazole potency against many common onychomycosis organisms was similar to or greater than those of antifungal drugs currently used in onychomycosis, including amorolfine, ciclopirox, itraconazole, and terbinafine."

In the recent therapeutic recommendations by Lipner, et al, Jublia is recommended as first line for mild and moderate disease, with oral therapy only as an addition for more severe disease or diabetic patients. Therefore the health plan should cover Jublia. Griseofulvin is generally not used to treat onychomycosis and is not recommended in most guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral infection. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for an inpatient hospital admission. 

The denial is upheld. 

This is the case of a male infant with no past medical history, who presented to the emergency department (ED) with 3 days of fever, runny nose, cough, multiple episodes of emesis, some post-tussive and some after feedings, decreased oral intake and decreased urine output. There was a recent history of bilateral ear otitis media for which he had received 10 days of amoxicillin. There were multiple sick contacts. 

There is documented mottled skin, 3-second capillary refill, moaning when febrile, ill appearing, clear nasal discharge, tympanic membranes (TM's) with good light reflex and no effusion. However, the ED primary nurse note entered at approximately an hour later shows a well-appearing patient with capillary refill less than two seconds. Lab values were within normal limits and a chest X-ray showed bilateral perihilar infiltrates consistent with a viral infection. The physician statement noted that delivery of care was not feasible as an outpatient due to infectious process causing sepsis requiring intravenous (IV) antibiotics and close monitoring for deterioration. 

The patient had evidence of a new viral illness. There was no objective evidence of dehydration, and the normal vital signs (other than fever) and lack of a toxic appearance were not consistent with sepsis. Even if the patient was assessed as having mild dehydration, per current literature on management of dehydration in children, and using the Children's Hospital of Philadelphia (CHOP) pathway accessed online, a trial of oral rehydration following a bolus of intravenous (IV) fluids should have been done, especially as there were no ongoing losses (there was no ongoing diarrhea). This could have been tried during a further period of observation and treatment in the ED for at least several more hours. 

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic Care after Surgical Amputation. 

Treatment: Continued Inpatient Admission at a skilled nursing facility (SNF) alternative level of care. 

The insurer denied coverage for continued inpatient admission at a skilled nursing facility (SNF) alternative level of care. 

The denial is upheld. 

The patient has chronic medical problems including diabetes mellitus, hypertension and hyperlipidemia.  She underwent a right below knee amputation (BKA) and transferred to a skilled nursing facility (SNF) for rehabilitation.  Under review is the medical necessity of continued inpatient admission at a skilled nursing facility (SNF) alternative level of care. 

The patient was initially an appropriate candidate for subacute rehabilitation.  She had functional (mobility and activities of daily living) deficits that were potentially amenable to comprehensive rehabilitation.  The patient was seen by her treating physician.  There were no acute medical problems that warranted continued inpatient physician treatment at that time.  The patient was "seen for epistaxis.  Advised against nose picking."  The doctor ordered a "nasal saline spray."  There was no documented therapy or nursing issues that warranted continued SNF care. 

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued inpatient admission at a skilled nursing facility (SNF) alternative level of care was not medically necessary. 

The insurer's denial of coverage for a continued inpatient admission at a skilled nursing facility (SNF) alternative level of care upheld. Medical Necessity is not substantiated.