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

Diagnosis: Psoriasis and Psoriatic Arthritis. 
Treatment: Taltz. 

The insurer denied the Taltz. 
The denial is overturned. 

The patient is a man with psoriasis and psoriatic arthritis for whom Taltz injections are requested. He has tried and failed Humira, Prednisone, Cimzia, Simponi and other TNF (tumor necrosis factor) alpha inhibitors. He has been on Taltz for the past three years with excellent results. 

Yes, the treatment with Taltz is medically necessary. 

The patient has been on Taltz for three years and is completely clear, with no joint pain and no adverse effects. He is stable after three years of treatment with Taltz, and it is medically appropriate and necessary to continue this treatment. Requesting for the patient to try a different treatment at this time is not medically appropriate because he is being successfully treated with Taltz for a long period of time and is doing well and is stable. It would risk the patient's psoriasis flaring and the disease becoming less manageable. Taltz is medically necessary as continuation of therapy. 

Even though Cosentyx is an IL17 (interleukin 17) inhibitor, there are no studies suggesting it is interchangeable with Taltz. Also, Cosentyx has a greater number of possible adverse events. Side effects of Cosentyx that are different from Taltz include diarrhea, oral herpes, hives, tonsillitis, oral thrush, impetigo, inflammatory bowel disease, ear infection, eye infection or inflammation (conjunctivitis), increased liver transaminases, and low white blood cell count (neutropenia). These drugs have not been directly compared in clinical studies. However, one review of studies of plaque psoriasis found that Taltz was more effective than Cosentyx at reducing symptoms of psoriasis. 

In the meta-analysis of studies with active comparators, PASI (Psoriasis Area and Severity Index) 90 response rates were 12.7% [95% confidence interval (CI) 5.5-19.8], 10.0% (95% CI [confidence interval] 2.1-18.0) and 11.2% (95% CI [confidence interval] 3.2-19.1) higher and PASI (Psoriasis Area and Severity Index) 100 response rates were 11.7% (95% CI [confidence interval] 5.9-17.5), 12.7% (95% CI [confidence interval] 6.0-19.4) and 13.1% (95% CI [confidence interval] 6.3-19.9) higher for ixekizumab compared with secukinumab using BU (Bucher), SG (Signorovitch) total and SG (Signorovitch) separate methods. Ixekizumab had higher PASI (Psoriasis Area and Severity Index) 90 and PASI (Psoriasis Area and Severity Index) 100 responses at week 12 compared with secukinumab using adjusted indirect comparisons. 

Therefore, given the above, the treatment with Taltz is medically necessary for this patient. 

Published data on safety and efficacy supports continued use of Taltz in this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Angiodysplasia, atrial fibrillation.
Treatment: Procedure code 33340 - heart surgery (transcatheter closure of the left atrial appendage) and one day inpatient hospital admission, Pre-service.
The insurer denied the Procedure code 33340 - heart surgery (transcatheter closure of the left atrial appendage) and one day inpatient hospital admission, Pre-service.
The denial is overturned. 

The patient is a female for which a left atrial appendage closure is under review. There was a hisotry of Celiac disease and multiple hospitalizations for gastrointestinal (GI) bleeding requiring blood transfusions. There were also arteriovenous malformations (AVMs). The patient requires anticoagulation for stroke prevention but it was not started due to bleeding concerns.

Yes, the health plan should cover the proposed treatment.
Left atrial appendage closure devices, such as the Watchman, have been considered a mechanical method to prevent stroke in those with atrial fibrillation (afib) requiring anticoagulation, both as a substitute for  anticoagulation and for individuals with a contraindication to anticoagulation. It has not, however, been generally established as standard of care towards improved atrial fibrillation stroke prevention outcomes compared to oral anticoagulation in an individual tolerating oral anticoagulation. However, in this case the individual has had numerous gastrointestinal (GI) bleeds requiring transfusions in the setting of Celiac Disease and arteriovenous malformations (AVMs). There is thus an anticoagulation contraindication. In this setting, left atrial appendage closure has been demonstrated safe and effective towards attempted atrial fibrillation related stroke prevention. There are also no other treatment options in this case. Therefore, it is considered medically indicated in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Angiodysplasia, atrial fibrillation.
Treatment: Procedure code 33340 - heart surgery (transcatheter closure of the left atrial appendage) and one day inpatient hospital admission, Pre-service.
The insurer denied the Procedure code 33340 - heart surgery (transcatheter closure of the left atrial appendage) and one day inpatient hospital admission, Pre-service.
The denial is overturned. 

The patient is a female with a history of hypertension (HTN), celiac disease, angiodysplasia, arteriovenous malformation (AVMs), and gastrointestinal (GI) bleeds, requiring multiple transfusions.  She was diagnosed with atrial fibrillation. She is at high risk for bleeding with anticoagulation. Use of Watchman device for cerebral vascular accident (CVA) prevention was requested.

Yes, the health plan should cover the proposed treatment.

Yes, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition.
The patient has a documented history of paroxysmal atrial fibrillation, and an elevated congestive heart failure, hypertension, age greater than or equal to 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category (CHADS-VASC) score, and it would be consistent with the current guidelines that chronic anticoagulation be used for reduction of her risk of thromboembolic complications, such as cerebral vascular accident (CVA). The Watchman Left Appendage Closure Device is Food and Drug Administration (FDA) approved and is currently considered to be an appropriate therapy for patients in whom the use of long-term anticoagulation is not an option, which would be consistent with the medical history in this case, given history of arteriovenous malformations (AVMs) and gastrointestinal (GI) bleeding. Therefore the use of the requested device would be considered to be medically indicated in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite with gingival attachment loss

Treatment: D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss. The orthodontist has completed the Handicapping labio-lingual deviation (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 (study models were not provided for review), 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 the 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. This reviewer concurs with the HLD index of the insurer attaining 24 points (3 overjet, 4 overbite, 10 mandibular protrusion, 5 anterior crowding and 2 labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer-reviewed journals that this methodology for assessing orthodontic need is a valid approach.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The patient's clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. As presented, there was sufficient evidence to support that D8080 (braces) and D8670 (monthly visit) were not considered medically necessary for the patient's condition.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior Crossbite with gingival attachment loss.
Treatment braces (comprehensive orthodontic treatment).
The insurer denied coverage for braces (comprehensive orthodontic treatment).
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss in addition to other clinical findings. The orthodontist has completed the handicapping labio-lingual deviation (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 is present. 

Although study models were not provided for review, 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. 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 met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer-reviewed journals that this methodology for assessing orthodontic need is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

On review, there was sufficient evidence to support that braces were considered medically necessary treatment for the patient's condition.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for braces (comprehensive orthodontic treatment) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic iron overload.
Treatment: Jadenu.
The insurer is denied coverage for Jadenu.
The denial is upheld. 

This female patient has a history of transfusion dependent Beta Thalassemia Major, vitamin D deficiency, and migraines.

"Deferasirox is a once-daily oral iron chelator with established dose-dependent efficacy in both adult and pediatric patients with transfusional iron overload. The clinical development program has demonstrated the efficacy of deferasirox for up to 4.5 years of treatment in patients with various underlying anemias, including beta-thalassemia, myelodysplastic syndromes, sickle cell disease, aplastic anemia, and other rare anemias." (Cappellini, et al., 2009).

"These data confirm that deferasirox was well tolerated and effective in reducing iron burden in patients with hereditary hemochromatosis and could be a safe alternative to phlebotomy in selected patients." (Cancado, et al., 2015).

"Authors' conclusions: Deferasirox offers an important treatment option for people with thalassaemia and secondary iron overload. Based on the available data, deferasirox does not seem to be superior to deferoxamine at the usually recommended ratio of 1 mg of deferasirox to 2 mg of deferoxamine. However, similar efficacy seems to be achievable depending on the dose and ratio of deferasirox compared to deferoxamine." (Bollig, et al., 2017).        
                                                 
The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the Jadenu is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heterotaxy polysplenia syndrome and a complex cardiac history.

Treatment: inpatient hospital admission.

The insurer is denied coverage for inpatient hospital admission.

The denial is overturned. 

This female patient has a history of heterotaxy polysplenia syndrome and a complex cardiac history

An uncomplicated patient could have been treated as an outpatient as the insurance company proposes in their letter. However this patient was too complicated to not be admitted as an inpatient given the clinical evidence provided. The patient had congenital heart disease, particularly one associated with asplenia and therefore an immune deficiency. Furthermore, the patient was acidotic and demonstrating evidence of renal compromise.      

The patient had complex congenital heart disease subject to deterioration.  The laboratory tests indicated a low carbon dioxide of 19, therefore acidosis, and a Creatinine of 0.43 which is elevated in an infant and therefore demonstrating evidence of renal compromise. This patient has mild cyanosis, as all patients with Kawashima repair do and probably asplenia/immunocompromise and was presenting with a fungal infection.

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 the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Abdominal pain, diarrhea and also fever.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned, in part. 

The patient is a male who had a prior history of hypertension and diverticulitis. The patient presented to the emergency room of the facility filing the appeal with the complaints of lower abdominal pain for one day preceding the admission. The patient had a previous admission two months earlier for diverticulitis which was treated conservatively. 

On this admission, the patient had moderate to severe abdominal pain, diarrhea and also fever. A computed tomography (CT) scan showed acute sigmoid diverticulitis as well as microperforations with free air under the diaphragm and multiple foci of intraperitoneal pericolonic free air. The patient was rendered nothing by mouth (NPO) and was started on intravenous (IV) antibiotics. The patient was seen by Surgery and Infectious Disease consultants. The patient's pain worsened with guarding and rebound tenderness and a repeat computed tomography (CT) scan was performed which showed air reabsorption. The patient continued to received intravenous antibiotics and a diet was advanced. The patient was discharged home on oral antibiotics.

Yes, in part; the proposed inpatient admission was medically necessary for the first five days of admission.  However, the proposed inpatient admission was not medically necessary for the remaining two days of admission.
The patient evidenced acute diverticulitis with microperforations, abdominal pain and free air under the diaphragm. The patient required an extended 'nothing by mouth' (NPO) period and close monitoring. The patient's length of care exceeded an observation level and the severity of his condition mandated a full, acute admission. 

However, by day six, the patient was tolerating oral intake with significant resolution of his pain.  As such, day six could have been the date of discharge.  The stay for days six and seven was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: physical and cognitive impairment

Treatment: directed personal assistance services for a total of 40 hours per week.

The insurer is denied coverage for directed personal assistance services for a total of 40 hours per week.

The denial is overturned. 

This male patient has a history of type 2 diabetes mellitus, high cholesterol, paroxysmal atrial fibrillation, hypertension, Alzheimer's disease and chronic obstructive pulmonary disease.

Having caregiver assistance for transfers and ambulation can provide at least limited (non-weight-bearing) assistance for stability; and when necessary, weight-bearing assistance when the patient needs more physical support.  Providing cues/prompting can also be provided to facilitate safe mobility. Providing physical support and cognitive cueing can help decrease the occurrence of falls during mobility related activities.  
The information provided for review supports the patient's need for assistance with most daily activities. The patient depends on personal care services for assistance with daily activities, including IADLs (Instrumental Activities of Daily Living), routine ADLs (e.g. bathing, dressing, personal hygiene), and ADLs (Activities of Daily Living) that occur at various unscheduled times throughout the day (i.e. toileting/incontinence care, transfers, ambulation.
With consideration of all the issues impacting the patient's health and safety, it is medically necessary and, in the patient's, best interest to have caregiver assistance for a more extended period of the day. The current availability of other informal caregivers is not known; but considering the request is for CDPAS (Consumer Directed Personal Assistance Services) 40 hours per week, it is reasonable to conclude that informal caregiver services are not available for that period of time per week. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at various and unscheduled times throughout the day. The patient would benefit from more assistance with ADLs (including mobility and toileting related tasks). CDPAS hours can be flexible, and so the 40 hours should be allocated to provide assistance during times of the day when the patient needs the most assistance, and informal caregivers are unavailable.

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 the directed personal assistance services for a total of 40 hours per week is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic T3N2M1 stage IV left upper lung small cell carcinoma. 

Treatment: Radiation Therapy for metastases - Bone: 1 fraction (treatment session) of Stereotactic Body Radiation Therapy (SBRT) (using photons) Image Guided Radiation Therapy (IGRT). 

The insurer is denied coverage for Radiation Therapy for metastases - Bone: 1 fraction (treatment session) of Stereotactic Body Radiation Therapy (SBRT) (using photons) Image Guided Radiation Therapy (IGRT). 

The denial is upheld. 

This female patient has a history of chronic obstructive pulmonary disease (COPD) and locally advanced and metastatic T3N2M1 stage IV left upper lung small cell carcinoma. 

The American Society for Therapeutic Radiology and Oncology (ASTRO) Model Policy for Stereotactic Body Radiation Therapy (SBRT) indicates that SBRT can be reasonable for patients with limited metastatic disease and reasonable performance status where treating limited disease may reduce the tumor burden in a manner that may improve progression-free survival. However, for uncomplicated, previously untreated bone metastases in a patient with widespread progressive boney disease, where the prognosis is unfavorable, it is generally appropriate to use a technically less complex form of palliative radiation rather than SBRT. This patient has extensive metastatic disease, not limited disease. 

Additionally, the patient is in a phase II study where the treatment of SBRT is yet not proven to be a standard of care. Since SBRT is being studied to determine if it should be considered a standard, at this point, the literature does not support the treatment as an evidence based medical necessity for this clinical circumstance. 

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

The carrier's denial of coverage for the Radiation Therapy for metastases - Bone: 1 fraction (treatment session) of Stereotactic Body Radiation Therapy (SBRT) (using photons) Image Guided Radiation Therapy (IGRT) is upheld.  The medical necessity is not substantiated.