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

Diagnosis: Kinked arteriovenous (AV) fistula. 

Treatment: Acute hospital stay. 

The insurer is denied coverage for acute hospital stay. 

The denial is upheld. 

This female patient has a history of end stage renal disease (ESRD) on dialysis, hypertension, hyperlipidemia (HLD) and a cerebrovascular accident (CVA). 

The sequence of events should have been the following: 

Ultrasonography (USG) of left arm. 

Consult Vascular Surgery/IR to perform a fistulogram. 

Fistulogram results seen intraoperatively and progression to attempted treatment. If crossing of central venous stenosis (left brachio-cephalic vein occlusion) could not be accomplished, and the left arm arteriovenous fistula (AVF) is threatened by this, then the patient immediately at the same setting in the Operating Room (OR) or procedure area should have had a lower extremity semi-permanent dialysis catheter place (tunneled dual lumen or Permacath), with possible consideration of ligation of the left arm AVF to correct the edema. 

Once the above was done, then dialysis via the femoral Permacath and then discharge to home with plans for elective further attempts at crossing central vein occlusion with left arm and femoral approaches, or elective placement (after all appropriate pre-operative imaging, clearance, and consent obtained) lower extremity arteriovenous graft (AVG) placement such as a femoral artery-femoral vein looped thigh AVG. 

This can all be accomplished either totally as an outpatient (aggressive cost savings) or at an observational level of care, followed by more elective endovascular and/or surgical management. This was not done and a long inpatient stay was performed which was not necessary. 

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 acute hospital stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines. 
Treatment: Nurtec. 

The insurer is denied coverage for Nurtec. 

The denial is upheld. 

This male patient has a history of history of migraines, alcohol abuse, and tobacco abuse. 

He was seen for further evaluation of neck and head pain.  The documentation indicated no significant examination abnormalities.  The patient likely had cervical migrainous headaches which led to more than 15 headache days a month and more than 8 of which were migraines.  It was recommended he undergo an magnetic resonance imaging (MRI) of the brain to rule out a structural abnormality. 

The patient has tried Botox and the headaches were not fully controlled, but documentation does not state that he has tried any other medication for headaches.

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 Nurtec is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: Braces (Pre-service).
The insurer denied the Braces (Pre-service).
The denial is overturned.

The patient is a female.  The request is for benefits for orthodontic treatment.

Yes, the proposed braces are medically necessary.
The patient has a crossbite of an anterior tooth (#22 lower left canine) with clinical attachment (gum) loss. This is an automatic qualifier according to the handicapping index scale.  This treatment is expected to be health beneficial to the patient and withholding the treatment could result in irreversible damage to the dentition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment that has advanced to dementia. 
Treatment: Personal Care Assistance (PCA) services of 8 hours per day, 7 days per week for a total of 56 hours per week. 

The insurer is denied coverage for PCA services of 8 hours per day, 7 days per week for a total of 56 hours per week. 

The denial is overturned. 

This female patient has a history of choledocholithiasis with obstruction. 

On the office visit notes indicated that the patient's home health aide was giving 4 hours of help per day during the day. The patient's proxy was requesting more hours of home health assistance. The patient's memory was getting worse since the home health aide had met her over the past few months and there was a concern for the patient safety. The patient forgot many things and her memory had been declining. The patient had left the stove on. The patient tried to leave the residence and going to the hallway. There was a concern that the patient was by herself in the afternoon. 

The patient had a fall in the bathroom and the home health aide had to pick her up. The patient had multiple falls over the past few weeks. The patient was alone in the evening. The patient had vertigo daily. The patient was noted to have no stability. The patient did not eat much and had to be encouraged to eat. The patient was depressed. The patient was wearing Pampers and could not hold in stool and urine. This was a new occurrence over the past few months, and it was worse. The urine had been very yellow-dark. 

The request was made for 6 hours 7 days/week (42 hours) which was denied. The situation had changed drastically over the past few months. The Mini-Mental Status Examination score was 13/30 compared to a prior assessment of 25/30. The provider documented that the patient seemed to have cognitive impairment that has been advanced to dementia, but rapid progression and it was unclear if this was due to Covid isolation, depression, and recent prolonged travel. The patient had a change in her medical status/condition and was now dependent for all activities of daily living (ADLs) and most instrumental activities of daily living (IADLs). The patient was a high fall risk. Due to the above and change in condition the patient needed an increase in hours. 

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 PCA services of 8 hours per day, 7 days per week for a total of 56 hours per week is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic inflammatory sinusitis.

Treatment: Dupixent.

The insurer is denied coverage for Dupixent.

The denial is upheld. 

This male patient has a history of chronic inflammatory sinusitis, nasal polyps, recurrent sinus infections and congestion.

The use of Dupixent in this setting was summarized by Up to Date, "It was approved by the US Food and Drug Administration (FDA) for treatment of CRS (chronic rhinosinusitis) with NP on June 2019. In two multicenter randomized trials including 724 patients with CRS with NP (nasal polyps), dupilumab therapy for 24 or 52 weeks resulted in significant improvements in the primary endpoints of nasal polyp scores, nasal congestion/obstruction, and sinus Lund-MacKay CT scores compared with placebo, and was well tolerated [113]. Dupilumab-treated patients also experienced improvements in olfaction and overall CRS symptoms.."

Thus, the patient would be a good candidate to start & continue subcutaneous Dupixent biologic therapy if he has had recurrence of nasal polyps since November 2020 surgery. This would be best seen on nasal endoscopic exam. While the use of the medication may be appropriate, an updated endoscopy would need to be reviewed to determine the above.

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 Dupixent is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overactive Bladder (OAB). 
Treatment: Myrbetriq. 

The insurer denied coverage for Myrbetriq. 

The denial is overturned. 

This is a were urgency/frequency. No history of diabetes or previous surgery. There is no prior history of chronic pelvic pain syndrome (CPPS), interstitial cystitis (IC), urinary tract infection (UTI) and bladder cancer. Myrbetrig 25 mg (milligrams) once daily was prescribed at the office visit. 

The insurer has denied coverage for the Myrbetrig as treatment for this patient's urinary symptoms as not medically necessary. They stated that the requested health service did not meet medical criteria. The insurer asked for records stating that the patient failed or could not take the remaining covered drugs to treat this condition, namely the drug Toviaz. The insurer also asked for records pertaining to the dates/length of the patient's trial with this drug, and they have not received such records. 

As there are many available medications for the treatment of overactive bladder, many carriers have a policy for therapeutic equivalents, stating that they must have shown therapeutic failure or intolerance to certain older or generic drugs prior to a newer medication being covered. 

Apparently for coverage of Mybetrig under this particular policy the patient must try/fail a medication such as Toviaz; this medication has a higher selectivity for the bladder than for salivary glands, which may reduce dry mouth. 

Per the records, patient had minimal response to Oxybutynin ER (extended-release) 10 mg per day. Myrbetrig was prescribed at, as minimal response to Oxybutynin ER 10mg was noted. There was no mention of Toviaz usage or prior history of response to this medication. 

The healthcare plan did not act reasonably and with sound medical judgement and in the best interest of patient. 

The medication Mybetriq is considered medically necessary for this patient. 

It appears that patient has tried and failed Oxybutynin ER 10mg. Oxybutynin and Toviaz are both antimuscarinics. There are few, if any, head-to-head trials for overactive blabber (OAB) medication. Myrbetriq is a newer class of beta agonist which has fewer side effects. 

As per Up to Date "Beta-3 adrenergic agonist drugs and antimuscarinic agents are the main options for treatment of OAB (overreactive bladder) symptoms (table 3) [4]. As efficacy is similar for the two groups, we and others suggest initial drug treatment with beta-3 adrenergic agonists because of the increased risk of side effects, including long-term risk of dementia, with anticholinergic drugs as reported in case-control and cohort studies [4,16-20]". 
 
The insurer's denial of coverage for the medication Myrbetriq is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class II, retruded mandible, excessive overjet, maxillary, and mandibular spacing, and deep impinging overbite.

Treatment: braces and monthly visits.

The insurer denied coverage for braces and monthly visits.

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 skeletal Class II, retruded mandible, excessive overjet, maxillary, and mandibular spacing, and deep impinging overbite. The Orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 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 on the HLD index attaining 19 points on review by internal reviewers. The Orthodontist is appealing on behalf of the patient.

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, a Handicapping Labiolingual Deviation Index is utilized. 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 deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 19 points (9 points overjet, 6 points overbite, and 4 points labiolingual spread).

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

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

Diagnosis: Infertility
Treatment: In-vitro fertilization (IVF) with biopsy of the embryos and transfer
The insurer denied In-vitro fertilization (IVF) with biopsy of the embryos and transfer.
The determination is overturned.

The patient is trying to conceive a baby. She and her partner are both carriers of Tay-Sachs disease. At issue is the medical necessity of in vitro fertilization (IVF) with PGT-M (preimplantation genetic testing for monogenic disorders) for Tay-Sachs. 

IVF and biopsy is medically necessary for this patient, has been having unprotected intercourse for at least 6 months and she and her partner are carriers for Tay Sachs. It is standard of care to offer couples who are both carriers of Tay Sachs the ability to use PGT-M with IVF to avoid having a child with this devastating disease. Although not all couples will use PGT-M, it is standard of care to offer this technology to improve the odds of having an unaffected child. Therefore, the requested services are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Forearm Ulcers
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of intravenous drug use and developed bilateral forearm ulcers secondary to subcutaneous injections of heroin. He was initially treated with oral antibiotics and local wound care. The ulcers did not resolve. The patient presented to the hospital with large, draining forearm ulcerations, erythema and tenderness. He was afebrile with stable vital signs and had a normal white blood cell count and was not in any distress. There was no documented active infection, no streaking erythema and he was hemodynamically stable. He was admitted to the hospital as an inpatient for wound care, orthopedic consultation and further evaluation for abscess. He ultimately signed out of the hospital against medical advice. At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary. The patient remained hemodynamically stable throughout the admission. There was no documented active infection. Laboratory values revealed a normal white blood cell count. Imaging could have been arranged as an outpatient. There was no active infection over a prosthesis. The patient was not febrile. Workup for abscess could have occurred at a lower level of care. Skin and soft tissue infections are one of the most common causes for hospital evaluations of injection drug users. Cutaneous and subcutaneous cellulitis and abscesses are common and often occur when drug users are no longer able to inject intravenously and resort to injection directly into skin or muscle. Many can be treated in the emergency department setting with local wound care, occasional bedside irrigation and debridement and further workup such as advanced imaging performed on an outpatient basis. The patient remained hemodynamically stable and there is no documentation that the condition was rapidly progressing. A lower level of care would have been appropriate to assess for disease progression and to facilitate additional work up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: physical and cognitive decline

Treatment: the personal care services (PCS) of 24 hours per day (live-in) at 7 days per week.

The insurer is denied coverage for the personal care services of 24 hours per day (live-in) at 7 days per week.

The denial is overturned. 

This female patient has a history of Parkinson's disease, hypertension, osteoporosis, depression and generalized weakness and fatigue.

Based on the patient's medical history and functional status, it is medically necessary for the patient to have assistance with all daily activities; and with very limited informal help as per UAS (Uniform Assessment System), she is dependent on personal care services for all ADLs (activities of daily living)  and IADLs (Instrumental activities of daily living). This includes preparation and service of all 3 meals per day and assistance with eating. She needs ADL assistance for bathing daily; and personal hygiene and dressing morning and evening. She needs assistance for toileting and incontinence care which occurs at various unscheduled times of the day and night. The patient's mobility is severely impaired, and she needs help for transfers in and out of bed, transport in wheelchair, and for bed mobility for repositioning. Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all of the patient's care needs must be considered in the determination of the patient's personal care service hours.
Although it cannot be definitively determined from the available records how often the patient needs help at night, it is medically necessary for the patient to have caregiver assistance for ADLs at various times of the day and night to prevent adverse health and safety events as previously noted in this review. The available records do not identify informal caregivers who can provide sufficient and consistent care when the PCS aide is not present. As per NYS regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care when needed on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed throughout the day and night. 
With live-in services, the patient will benefit from additional ADL assistance during the evening/night hours that is not available to her with her current services (PCS 10 hours per day). The live-in aide will be able to identify the patient's evening and nighttime ADL needs. 


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 personal care services of 24 hours per day (live-in) at 7 days per week is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar I disorder, suicidal ideation, symptoms of depression.
Treatment: Continued Residential Mental Health Treatment with 24-Hour/Day Support.
The insurer denied the Continued Residential Mental Health Treatment with 24-Hour/Day Support.
The denial is upheld.

The patient is a female diagnosed with bipolar I disorder, borderline personality
disorder, and cannabis use disorder. The patient was admitted to residential
treatment due to suicidal ideation and symptoms of depression. The patient was
noted to be experiencing difficulty taking care of her daily needs, fatigue and a
depressed mood. The patient was noted as previously being discharged from
residential treatment.

The patient made little to no progress in over 91 days at the facility. She was noted
as being able to contract for safety. There had been no active discharge planning.
No family sessions were noted. There was no report of homicidal ideation or
hallucinations.

No, the proposed continued residential mental health treatment with 24-hour per
day support was not medically necessary.

The patient is diagnosed with bipolar I disorder, borderline personality disorder, and
cannabis use disorder. The patient was not reported to be suicidal, homicidal, or
gravely impaired for self-care. There was no report of self-harm. The patient was
not reported to be aggressive. There was no report of any auditory or visual
hallucinations. The patient did not have any severe depressive symptoms that
required 24-hour nursing supervision. Based on the clinical evidence, the patient
could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis with a micro-perforation

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission. 

The denial is upheld. 

This is a female patient with a history of asthma, diverticulitis, and hypertension. She presented to the hospital with left lower quadrant (LLQ) abdominal pain. She had a previous history of diverticulitis with an abscess. She was afebrile and her vital signs were stable. An initial tachycardia resolved. There was no abdominal rebound or guarding. A computerized axial tomography (CAT) scan was read as diverticulitis with a micro-perforation. She was kept on nothing by mouth (NPO) status and given intravenous (IV) antibiotics. She developed a low grade fever. She defervesced and her leukocytosis improved. She was given a clear liquid diet.

Clinical indications for admission for Acute Diverticulitis based on Milliman Care Guidelines (MCG) include hemodynamic instability, peritoneal signs, persistent gross bleeding, or a significant abnormality on imaging studies. This abnormality can be a fistula, obstruction, abscess, or a free perforation such as free air under the diaphragm. The patient did not have these conditions. There was a micro-perforation, but not a free perforation. The patient also did not have severe pain, severe vomiting, severe dehydration, or an inability to maintain oral hydration after observation care.

This patient had diverticulitis with a micro-perforation. She required a period of being NPO and IV antibiotics. This could have been done with Observation status. After the second day of treatment, she had improved and was able to tolerate a diet. She could then have been discharged on oral antibiotics. She did not meet MCG criteria for admission for acute diverticulitis. The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.