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

Diagnosis: Dental Disorder.
Treatment: braces; monthly visit; orthodontic retention.
The insurer denied braces; monthly visit; orthodontic retention.
The determination is upheld.

This is a male patient with a Class I occlusion with appropriate overbite and overjet. He has minor maxillary and mandibular crowding. He has a fully erupted supernumerary maxillary left lateral incisor. He is treatment planned for orthodontics to correct his malocclusion at issue is the medical necessity of braces; monthly visit; orthodontic retention.

There is no medical reason to correct the malocclusion with braces. While the patient has minor crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. (2) If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
This adult patient presented to the hospital complaining of chest pain while playing with his grandchild. Past medical history was significant for heart failure with a reduced ejection fraction 40-45%, atrial flutter, cocaine abuse, GI (gastrointestinal) bleeding, and diabetes mellitus.  Upon arrival to the hospital vital signs were stable.  Physical examination was remarkable for an irregular rhythm. 12 lead electrocardiogram (EKG) revealed atrial flutter with rapid ventricular rates. No ST or T wave abnormalities were noted. Serum blood testing revealed high sensitivity troponin levels that were not significantly elevated and anemia with a hemoglobin ranging from 7.5 to 9.6.  Urine toxicology was positive for cocaine. The patient was admitted to the hospital for further testing and treatment. Echocardiogram revealed an ejection fraction of 50%.  The patient was treated with a rate control strategy using diltiazem and beta blocker therapies. He was referred for gastroenterologic evaluation but ultimately refused endoscopy. He was discharged with follow up. 

This patient presented with chest pain in the setting of active cocaine use.  He was noted to have atrial flutter with rapid ventricular conduction as well as severe iron deficiency anemia that required further evaluation. The patient's pretest probability of coronary artery disease is moderate. (Reference 1)  Utilizing the HEART (history, ECG, age, risk factors, troponin) score he was considered moderate risk. (Reference 2)  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score he also had a moderate risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a moderate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  

In addition to his moderate risk for major adverse cardiac events, this patient was actively using cocaine. Investigators studying more than 300,000 hospital admissions for chest pain in the setting of cocaine abuse, found that patients over age 50, with concomitant heart failure and valvular disease had the highest risk of major adverse cardiac events and mortality. They concluded that such patients did require hospital admission. (4).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Diabetes Mellitus Type 2.
Treatment:  Mounjaro 10mg/0.5ml pen injector.

The insurer denied Mounjaro 10mg/0.5ml pen injector.  The determination is overturned.

This is a female patient with type 2 diabetes and obesity. She has tried and developed allergic dermatitis with Victoza and Ozempic. The medical necessity for Mounjaro is under review.

This request is for Mounjaro for the treatment of type 2 diabetes in this patient with obesity. The prior authorization criteria requires a trial of two of the following: Victoza, Ozempic, and/or Trulicity. This patient has tried and developed allergic dermatitis with Victoza and Ozempic. The patient has paid claims of Ozempic. The plan did not accept the trial of Victoza, as the patient does not have documentation of this trial of Victoza, such as paid claims of Victoza, but this trial was before the patient enrolled in this insurance plan. In addition, the American Diabetes Association clinical guidelines recommend the use of Ozempic or Mounjaro for the treatment of type 2 diabetes in patients with a goal of weight loss. The patient has already had a trial of Ozempic. Mounjaro is indicated over all of the remaining formulary alternatives in this patient with type 2 diabetes and obesity, as supported by the American Diabetes Association clinical guidelines. Without Mounjaro, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, the requested Mounjaro is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis
Treatment: Evenity 210 milligrams (mg)
The insurer denied: Evenity 210 mg
The denial is: Upheld

The patient is a female diagnosed with osteoporosis. This request is for Evenity. As per letter; she has had a history of breast cancer and premature surgical menopause. Her weight was 130 pounds; height is 63 inches; body mass index (BMI) was 23. Her vitamin D was 36; calcium was 9.7; parathyroid hormone (PTH) was 49. Her standard score (T)-score at spine was -3.5; femoral neck (FN) was -2.2; total hip was -1.4. The subject under review is whether Evenity is medically necessary for this patient.

Evenity is not medically necessary. The requested medication is Food and Drug Administration (FDA) approved for osteoporosis as described below[1]. It has been shown to be effective in the treatment of osteoporosis [2, 3]. The American Association of Clinical Endocrinologists recommend the use of the requested medication over other treatments in patients with very high risk of fracture defined below [4]:
These include recent fracture (e.g., within preceding 12months), fracture while on anti-osteoporosis medication, multiple fractures, fractures while taking drugs that affect bone adversely (e.g., long-term glucocorticoid therapy), a bone mass density (BMD) T-score less than or equal to (<=)3, high risk of falls or previous history of injurious falls, and a very high fracture probability (the example given is a Fracture Risk Assessment [FRAX] score greater than [>]30% for major osteoporotic fracture and >4.6% for hip fracture).
The patient has osteoporosis and is not at very high risk for a fracture. The patient can try the formulary alternative Zoledronic Acid as it is the first line of treatment for patients with osteoporosis. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia.
Treatment: home health care.
The insurer denied Consumer Directed Personal Assistant Services (CDPAS), Level 2: Total 168 Hours per Week (24 Hours per Day, Split-Shift - 7 Days per Week). 
The health plan's determination is overturned. 

The patient is a female with past medical history of atrial fibrillation on chronic anticoagulation, history of stomach cancer, severe scoliosis, peptic ulcer disease, compression fractures of the thoracic spine, chronic kidney disease stage III, osteoarthritis, coronary artery disease, chronic obstructive pulmonary disease (COPD), hypertension, congestive heart failure, and bowel and bladder incontinence who had been assigned a CDPAP (Consumer Directed Personal Assistant) services. 

Consumer Directed Personal Assistant Services (CDPAS), Level 2: Total 168 Hours per Week (24 Hours per Day, Split-Shift - 7 Days per Week) are medically necessary for this patient.
There is documentation from the patient's medical provider of worsening cognitive and physical functioning following hospitalization. In addition, there is documentation of medical necessity of increased personal care services. There are overnight care logs documenting assistance needs in the overnight hours that would not allow a CDPAP/PCA (personal care aide) 5 hours of uninterrupted sleep. The requested increase in personal care services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services to total 168 Hours per Week (24 Hours per Day, Split-Shift - 7 Days per Week) are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back pain.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a male with a past medical history (PMH) significant for diabetes, hypertension, and hyperlipidemia, who presented for elective bilateral L (lumbar) 4/5 hemilaminotomies for back and right leg pain. Pre-operative magnetic resonance imaging (MRI) showed severe central and bilateral lateral recess stenosis. Pre-operative physical exam was within normal limits. No intraoperative complications occurred. Post-operatively, the patient received pain control, prophylactic antibiotics for 24 hours, acetylsalicylic acid (ASA) for deep vein thrombosis (DVT) prophylaxis, insulin per sliding scale and home medications. The Hospitalist service was consulted for medical management.

The inpatient hospital admission was not medically necessary. The patient underwent a bilateral L4/5 decompression. No intraoperative complications occurred.

The patient does not meet inpatient criteria. Admission and surgery are appropriate for outpatient status. The standard of care is to perform this procedure as an outpatient procedure. Inpatient stay may be needed for major medical complications, dural tear, hemorrhage or nerve root injury. None of these circumstances occurred. This patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis (MS), osteoarthritis, hypertension, right side paralysis, coronary heart disease, atrial fibrillation, and peripheral edema

Treatment: Personal care aide (PCA) level 2: 12 hours per day- 7 days per week for a total of 84 hours per week

The insurer denied coverage for PCA level 2: 12 hours per day- 7 days per week for a total of 84 hours per week

The denial is reversed

This is the case of a male with history of multiple sclerosis (MS), osteoarthritis, hypertension, right side paralysis, coronary heart disease, atrial fibrillation, and peripheral edema. The patient lives with his wife in a two-bedroom apartment. Patient reports friends are supportive, and children call often; however, do not live close. Patient has grab bar, motorized scooter, shower chair, walker, 40 units pull-ups, 1-unit gloves to assist with needs.

The calculation of the number of hours recommended was reviewed along with the adjustments that were made. The client task form appears to take into consideration the patient's need for maximal assistance in most activities as documented.

The undated Nurse Practitioner (NP) letter documents a discussion of the patient's activities of daily living (ADLs) and the need for 84 hours per week. A visit with the NP documented a request for additional hours. This report documents a normal exam with right hand contracture, no movement of the right leg and decreased strength of the left leg. The patient was seated in a power wheelchair. The plan was to consult with the social worker to see if the patient qualifies for additional hours. There was no functional assessment performed supporting the need for increased hours. There is no provider documentation of the patient's diagnoses, severity, functional assessment or opinion related to the patient's medically necessary needs.  

Based on the professional findings and recommendations, the medical necessity for the requested 84 hours is supported

Review of the documentation presented at the time of the appeal indicates the records noted the patient lives with his wife. The Unform Assessment System (UAS) mentioned the patient said his wife does not help. 

The rebuttal letter from the appealer working on behalf of the patient and a rebuttal letter from the treating neurologist further clarified the degree to which the wife is not involved indicating that they are estranged living in separate rooms. The wife refuses to assist in the patient's care. Since the wife does not help with the patient's care, the requested hours are medically necessary. 

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

PCA level 2: 12 hours per day- 7 days per week for a total of 84 hours per week is medically necessary. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Prediabetes.
Treatment:  Freestyle Libre 2 Sensor.

The insurer denied Freestyle Libre 2 Sensor. The health plan's determination is upheld. 

The patient is a female diagnosed with Pre-diabetes. As per a visit note, she is on Freestyle Libre sensor. She has symptoms concerning for hypoglycemia. Her hemoglobin A1C was 6.6 % (percent).

The Freestyle Libre 2 sensor is not medically necessary.

The requested device is a flash glucose monitoring system that is Food and Drug Administration (FDA) approved for persons aged 18 and older with diabetes. It has been shown to be effective in patients with type II diabetes who are on an intensive insulin regimen. It was associated with sustained reduction in hypoglycemia and safely and effectively replaced blood glucose monitoring. This patient has prediabetes. The patient is not on an intensive insulin regimen. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: congestive heart failure
Treatment: Home health care
The insurer denied Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day, 7 Days per Week and 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, congestive heart failure, diabetes mellitus type 2, dementia, history of colon cancer, urinary incontinence, bowel incontinence, gastrointestinal (GI) blood loss, uterovaginal bleeding, bronchiectasis, obesity, syncope, and hyperlipidemia who had been assigned PCA (personal care assistant) services.

Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day, 7 Days per Week and 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week medically necessary for this patient.
There is documentation from the patient's medical provider at rehabilitation of medical necessity of turning and repositioning every 2 hours. Although the patient did not have a significant change comparing her previous assessments, the patient required at least maximum assistance with transfer toilet and toilet use which are unpredictable and unscheduled care needs. The insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The plan assumed the patient had informal support outside of the currently assigned hours. The patient has care needs in the overnight hours that would not allow a PCA 5 hours of uninterrupted sleep. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 Hours per Day, 7 Days per Week and 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hernia.
Treatment: Inpatient emergency admission.
The health plan denied: Inpatient emergency admission.
The determination is: Upheld.

This patient is a female with a ventral hernia. She presented to the hospital brought in by Emergency Medical Services (EMS) due to erratic behavior. She has a history of schizoaffective disorder, bipolar type, obesity, prior stroke, chronic obstructive pulmonary disease (COPD), sleep apnea, hyperlipidemia, and hypothyroidism. She was evaluated by trauma surgery for the hernia.
The patient was noted to have normal vital signs. She had a large ventral hernia with chronic incarceration. There were no signs of obstruction or strangulation. She had no abdominal tenderness. A computed tomography (CT) scan showed a fat containing umbilical hernia with no associated inflammation. Consultations from cardiology and psychiatry were requested prior to surgery, and the patient was scheduled for laparoscopic ventral hernia repair with mesh. She was granted psychiatric and cardiology clearance for surgery.
The patient remained clinically stable until the time of surgery. The operative dictation describes performance of laparoscopic ventral hernia repair with mesh. The fascial defect measured 3.5 centimeters (cm), and the mesh used for repair was 15 cm Symbotex mesh positioned in the intra-peritoneal space. There was incarcerated but viable omental fat.
The patient was provided a diet, and her pain was controlled with oral medications. Daily progress notes document clinical stability and pain management. The patient continued to tolerate a diet and had adequate pain control. She was discharged from the hospital.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient emergency admission was not medically necessary for this patient.
This patient had a long-standing abdominal wall hernia. The patient was admitted to the hospital and was clinically stable at this time. Her vital signs were normal, and lab data was within normal limits. She was evaluated prior to surgery with cardiology and psychiatric consultations. She underwent the scheduled repair of this ventral hernia with mesh. The operation was performed without complication. The corresponding progress notes prior to surgery document clinical stability and tolerance of diet. Likewise, the progress notes after surgery document a normal post-surgical recovery with normal vital signs, tolerance of diet, ability to ambulate and pain control with oral medications.
An inpatient level of care was not medically necessary in this case, as the care provided could have been rendered with an alternate level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type II Diabetes Mellitus
Treatment: Mounjaro
The insurer denied the request for Mounjaro.
The health plan's determination is overturned.

The patient is a male with type 2 diabetes and chronic kidney disease. He was intolerant to Ozempic (diarrhea), Trulicity (diarrhea), Metformin (diarrhea), and Rybelsus (diarrhea). His hemoglobin A1C (hgbA1C) was 7.7 percent (%). The request for continuation of Mounjaro is under review.

No, the health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient. The patient has experienced intolerance to two of the formulary alternatives as supported by submitted clinical documentation. The requested Mounjaro was denied, but it is medically necessary.

The requested Mounjaro is medically necessary for this patient. This request is for Mounjaro for the treatment of type two diabetes. The formulary alternatives are Ozempic, Trulicity, and Victoza. The appeal documentation includes progress notes indicating the patient was not able to tolerate Ozempic or Trulicity due to gastrointestinal side effects. The submitted progress notes also indicate that the patient is doing well on Mounjaro without side effects. The patient is at a high risk of also being intolerant to Victoza, the remaining formulary alternative, given Victoza is in the same drug class as Ozempic and Trulicity. Without Mounjaro, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. 

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