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

Diagnosis: anterior crossbite.
Treatment: Braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth. She presents with a Class II malocclusion with mild crowding in the maxilla and mandible. She has a posterior crossbite on the right with a functional shift to the right. She is treatment planned for 24-30 months of orthodontics to address the crowding and crossbites, but the treatment was denied due to lack of medical necessity.

Braces and monthly visits are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 7, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated, the damage that will occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the Braces and monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home health care. 
The insurer denied Increase in personal care hours to 69 per week. 
The denial is upheld.

The patient is a female with past medical history significant for Charcot-Marie-Tooth disease, spinal stenosis, hypertension, hyperlipidemia, depression, and epilepsy. The patient is requesting Personal Care Aide Level II 69 hours per week, 9-10 hours per day, 7 days per week. The patient is currently receiving 56 hours per week. This was denied by the health plan as not medically necessary.

The health plan's determination is upheld in whole.

The additional Consumer Directed Personal Assistance Services (CDPAS) are not medically necessary for this patient.
The patient is a female with past medical history as listed above with progressive neurological disorder resulting in generalized medical decline and debility. Additional services were denied by her insurance stating due to lack of medical necessity.
Uniform Assessment System (UAS) State of New York were reviewed. When comparing assessments done there does not appear to be a significant decline in the patient's medical status.
The personal care tasking tool notes a total of 8 hours per day 7 days a week for total of 56 hours a week of services. The personal care tasking tool dated months earlier notes a total of 8 hours per day 7 days a week for a total of 56 hours a week of services.
Physical exam noted that the patient's skin was warm and dry. Assessment noted stage I pressure ulcer on the left buttock with recommendations for an egg crate pad for the chair.
There is a physician's statement stating that the patient's condition was stable, with need for assistance with all activities of daily living (ADLs).
The patient currently receives 56 hours a week of services and is requesting an additional 13 hours a week of services.
According to the appeal and the documentation provided there are no services that are being requested that could not be provided during the allotted time. Specifically, the patient has been allotted 56 hours a week divided over 7 days for services including ADLs and instrumental activities of daily living (IADLs). The patient's health status according to the assessment provided did not change significantly. The patient did have increasing weakness and a stage I pressure ulcer. The stage I pressure ulcer was recommended to be treated with an egg crate pad on her chair, however this did not specifically affect or increase the necessity for utilization of requested services. In order for services to be considered medically necessary, the aide must be performing a service such as a medically necessary ADL or IADL.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Respiratory System-asthma.
Treatment: Dulera.

The insurer denied Dulera. The denial is upheld. 

The patient is a male with history of severe persistent asthma and with environmental allergies. He is receiving biologics for his asthma. He has had no recent asthma exacerbations or hospitalization. Recent pulmonary function tests (PFTs) were not provided. He was apparently not responding to Advair and the treating pediatric pulmonologist wants to start Dulera. There is no information provided regarding any nocturnal cough or presence of exercise induced asthma. Recent chest x-ray (CXR)/imaging/bronchoscopy were not provided.

In this case the formulary drug Symbicort could be tried.

There is no data that Dulera is superior to Symbicort in treating pediatric asthma. Both are in the same class, however mometasone furoate (Dulera) may have less absorption from lung to gastrointestinal (GI) tract. There is no documentation that the patient has any growth failure. The patient had no documented adverse effects from the Advair or formulary alternatives. There is no randomized controlled trial (RCT) nor any class one evidence that formulary alternatives are inferior to Dulera or would have more adverse effects than Dulera. Moreover, the patient is on step five of the Global Initiative for Asthma (GINA) guideline for severe asthma and on biologics, hence the short acting beta agonist/inhaled corticosteroid (SABA /ICS) combination is only complimentary and not a sole therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: malignant melanoma.
Treatment: Gamma Knife Radiosurgery.
The insurer denied the Gamma Knife Radiosurgery. The health plan's determination is overturned.

The patient is a male who was diagnosed with stage IV malignant melanoma. Two intracranial metastatic lesions were diagnosed and treated with SRS (stereotactic radiosurgery) with Gamma Knife technology. He did well but 2 more lesions were diagnosed and treated. When having a staging procedure for a possible clinical trial, 15 more lesions were diagnosed and he underwent SRS once again. Additional SRS was undertaken. He complained of blurred vision, and a repeat magnetic resonance imaging (MRI) revealed a hemorrhagic occipital lobe metastasis that was treated with Decadron. Another recent MRI done after a seizure, reported 4 new additional brain metastases and another Gamma Knife SRS treatment has been recommended. 

Radiation Therapy for Brain Metastases (Gamma Knife Radiosurgery) is medically necessary and appropriate for this patient at this time.
Metastases to the brain in patients with malignant melanoma are one of the most common and lethal complications of the disease. For many years, WBRT (whole brain radiation therapy) and corticosteroids were the mainstay of treatment with very short life expectancies. However, in recent years stereotactic radiosurgery (SRS) (utilizing either Gamma Knife or LINAC(linear accelerator) systems) has become one of the preferred treatment approaches for this disease (Nowak-Sadzikowska et al), reserving WBRT for palliation who have multiple MBMs (melanoma brain metastases) and contraindications to surgery or SRS. Surgical intervention is also considered for large or symptomatic MBMs, while SRS is recommended for 1 to 4 smaller lesions, and is being explored for up to 15 intracranial metastases for improved local control (Rishi et al). In addition, Bauer-Nilsen et al reported that hemorrhagic MBMs, a common occurrence for this type of metastatic lesion to the brain, are associated with inferior local tumor control when treated with SRS and highlighted the importance of early SRS in patients with MBMs before hemorrhage has occurred.
Current areas of investigation for this deadly disease now includes pairing SRS with immunotherapy and other targeted chemotherapeutic agents, combinations which have shown significant promise in recent years and are undergoing multiple prospective ongoing trials at this time (Glitza Oliva et al, Gutzmer et al, and Eastman et al). Nowhere in any of these recent reviews and updated management recommendations was any specific mention of 3D (three dimensional) conformal radiation therapy for the treatment of MBMs. And while 3D conformal radiation therapy is a form of delivering tumoricidal doses to intracranial lesions while sparing normal brain tissue, it has not been studied head-to-head with the Gamma Knife SRS, which is the most often cited form of SRS in the literature for MBMs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Arrhythmia-Anoxic brain injury due to cardiac arrest.
Treatment: Acute Inpatient hospital for Brain Injury Rehabilitation.

The health plan denied the admission to the acute inpatient hospital for brain injury rehabilitation.  The reviewer has overturned in whole the health plan's determination.

This case involves a patient with a history of idiopathic ventricular arrhythmias who presented with an out of hospital cardiac arrest while driving a motor vehicle. In the field, the patient was treated with defibrillation and cardiopulmonary resuscitation with return of spontaneous circulation; however, due to recurrent cardiac arrest and hemodynamic instability, she was placed on Venoarterial extracorporeal membrane oxygenation (VA ECMO) support. The patient had a complicated course significant for recurrent cardiac arrest, bacteremia, ventilator dependent respiratory failure, and severe anoxic brain injury. The patient was treated with targeted temperature management and required tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement and has remained in a persistent vegetative state but has shown some signs of neurologic improvement. The patient has been evaluated by Physical Medicine and Rehabilitation (PM&R) brain injury experts, and they have recommended acute inpatient hospitalization for acute inpatient brain injury rehabilitation. 

Acute inpatient brain injury rehabilitation is medically necessary, appropriate, and in the best interest of this patient to achieve neurologic recovery. Alternative, lower levels of rehabilitation in the context of this patient's severe anoxic brain injury would not meet standard of care nor provide this patient the best opportunity to improve.

This patient suffered an out of hospital cardiac arrest resulting in severe anoxic brain injury. The patient has demonstrated significant medical improvement being able to be weaned off VA ECMO and tolerating tracheostomy collar. In the opinion of her medical team, including PM&R physician experts in the field of disorders of consciousness, the patient is appropriate for acute inpatient brain injury rehabilitation with the goals of regaining neurologic function and consciousness. The recommendation for acute inpatient brain injury rehabilitation is standard of care, supported by peer reviewed medical literature and expert consensus guidelines on brain injury rehabilitation. 
According to the patient's medical team including PM&R brain injury experts and supported by expert consensus guidelines on disorders of consciousness, the acute inpatient rehab program would offer the patient the best chance for neurologic recovery and improvement in overall prognosis.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Rosacea.
Treatment: Formulary Exception for Soolantra 1% cream. 

The insurer denied the Formulary Exception for Soolantra 1% cream.  The denial is upheld. 

This is a female patient with a diagnosis of rosacea.  The patient is noted to have failed topical metronidazole.  The patient is not noted to have failed any other topical therapies and is not documented to have a contraindication to other topical therapies.  The patient has not failed oral antibiotics, commonly used for the treatment of rosacea.  The prescribing provider does not believe that the patient's rosacea, described as "mild-moderate" is sufficient to warrant oral therapy.  The requested medication is Soolantra cream.  

There are numerous topical therapies, including topical azelaic acid gel and foam as well as sodium sulfacetamide cream, lotion, and wash, which have been shown to successfully treat the signs and symptoms of rosacea, which have not been tried and failed.  Similarly, no documentation is provided to indicate that there is any contraindication to the use of these commonly used topical therapies.  There is no evidence that Soolantra would have a clinically significantly improved efficacy or side effect profile compared to other topical therapies.  

As such, the request for Formulary exception for Soolantra is not supported. The non-formulary drug will not be more effective than the formulary drug.

The insurer's denial of Request for Formulary Exception for Soolantra 1% cream is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Testicular pain.

Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission. 

The denial is upheld. 

This patient is a male child with a past medical history of asthma. The patient presented to the hospital as a transfer from an outside hospital (OSH) with complaints of testicular pain. Doppler vital signs at the OSH revealed no arterial blood flow to the left testicle. The patient was manually detorsed at the OSH. The patient was taken to the Operating Room (Or) for bilateral scrotal exploration and bilateral orchidopexy. The patient tolerated the procedure well and was admitted for postoperative care. The patient is noted to have recovered well. On post-operative day #1 he was voiding freely, tolerating a regular diet, afebrile with stable vitals. The patient was discharged home on Tylenol with outpatient Urology follow-up.  

Per Milliman Care Guidelines (MCG) Health (24th Edition) Urologic Surgery or Procedure, the patient is noted to have met the discharge parameter within 24 hours post procedure. As per the guideline, this surgery is performed in the Ambulatory Surgery setting for goal length of stay (LOS).

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 the full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rosacea

Treatment: Pre-service request for Azelaic Acid (Finacea) 15% ex gel

The insurer denied coverage for pre-service request for Azelaic Acid (Finacea) 15% ex gel

The denial is overturned

The patient is a pregnant female with a diagnosis of rosacea who has failed treatment with metronidazole, doxycycline, SulfaCleanse, and erythromycin. The patient's Dermatologist has asked her to discontinue SulfaCleanse as well as Soolantra 1% cream as they are of unknown safety during pregnancy. The patient was prescribed erythromycin and switched from Finacea gel to Finacea foam due to adverse effect of dryness from the Finacea gel.The Dermatologist is requesting Finacea foam due to the side effect associated with Finacea gel and given that it is in pregnancy. 

The standard of care for treatment of rosacea in pregnancy includes the use of Finacea, given its more delineated pregnancy category and risk stratification. Since this patient is limited in options, the use of Finacea is within the standard of care given her diagnosis and associated medical condition, rosacea in pregnancy. Given the limited options during pregnancy and breastfeeding, Finacea is clinically warranted. Furthermore, the patient is documented to have experienced dryness from the gel formulation of Finacea. It is thus reasonable to attempt Finacea foam to determine if the foam base will be tolerable. The decision is reversed and Finacea Foam is approved for use in this patient.

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

The insurer's denial of coverage for the pre-service request for Azelaic Acid (Finacea) 15% ex gel to treat rosacea is reversed.  Medical necessity is substantiated
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicidal ideation. 
Treatment: Continued Inpatient Mental Health Services. 

The insurer denied the Continued Inpatient Mental Health Services. 
The denial is upheld. 

The patient is a female with major depression and generalized anxiety disorder. She was admitted to inpatient psychiatric hospitalization. She presented after reporting a suicide attempt by hanging herself soon after discharge from her previous hospital stay. The patient made a prior suicide attempt by overdosing approximately two years prior. 

The patient's medications included Wellbutrin, Seroquel, Lexapro and Vistaril. Custody issues were present, with a reported court hearing involving the patient's father and CPS (child protective services) involvement. Continued inpatient treatment is the subject of the review. 

No, the Continued Inpatient Mental Health Services was not medically necessary. 

The documentation provided did not indicate ongoing acute safety concerns that would have necessitated 24 hours a day 7 days a week mental health treatment. This is because there was no documented persistent pervasive suicidal or homicidal ideation. 

The patient reported "fleeting thoughts" of suicide, but no documentation of any suicidal intent or plan, so the patient was not an imminent risk of harm to herself. There were no psychotic symptoms. The patient did not engage in any significant self-injurious behaviors, as skin scratching episodically would not require 24 hour nursing supervision. She did not need to be placed in restraints or seclusion for any physical aggression. She was capable of doing ADLs (activities of daily living). She was medically stable and tolerated the medications prescribed. There were no documented drug-related issues such as withdrawal symptoms needing 24 hour supervision. The progress notes documented "She made no reports of SI [suicidal ideation]/HI [homicidal ideation] or thoughts of self harm" and she was "social with both peers and staff." She rated her depression as 4/10 and anxiety 1/10, and: SI [suicidal ideation] 0/10; she "appears bright with congruent affect. She is an active participant in her treatment plan and is future-oriented." 

As a result, the patient's treatment did not require the intensity of inpatient level of care, but instead would have been more appropriate for continuation of treatment in a less restrictive setting. Continued residential treatment was not medically necessary. 

The clinical documentation did not indicate any persisting pervasive severe mental health symptoms that necessitated 24-hour inpatient treatment. As such, denial of this intensity of level of care was appropriate. There were also issues of patient placement documented regarding custody court procedure and CPS (child protective services) involvement. This indicated that custodial issues were more salient during the dates of service under review. This provides additional clinical support for the denial decision by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Covid 19.
Treatment: Ambulance transport.
The insurer denied the ambulance transport. 
The health plan's determination is upheld. 

The patient is a male who was admitted to the hospital due to shortness of breath. This was determined to be secondary to a mitral valve problem which was treated with emergent surgery. Subsequent to the surgery, the patient underwent rehab at a skilled facility. He contracted Covid 19 during the stay. The patient was stable enough to be transferred home. The patient was transferred home using ambulance services. The question is whether these services were medically necessary or not. The patient's wife did not want to physically drive him home due to the patient having symptoms of Covid, in order to decrease her exposure.

Ambulance Transportation from Hospital to Residence is not medically necessary for this patient. The patient was able to ambulate at the time but did require assistance with transfers.
The following is a definition of ambulance versus ambulette services.
Ambulance is a vehicle that is mainly used for life saving whereas an ambulette is used to carry disabled persons. An ambulette is just like an ambulance but these vehicles are not for any emergency needs. An ambulance is equipped with life support system, which is generally not seen in an ambulette.
It is reasonable to say that the patient's transportation from the facility to home was not an acute life-threatening emergency. The transportation was used as a way to bring the patient home with limiting exposure to the patient's wife to potential Covid infection. This does not fit the definition of medical necessity of acute ambulance services. Transportation could have been provided in an alternative means, i.e. ambulette services in a non-emergent manner.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diffused Patella 
Treatment: Autologous cultured chondrocytes implant

The insurer denied coverage for autologous cultured chondrocytes implant. The denial is upheld.

This is the case of a female patient with a history of chronic right knee pain, primarily isolated to the patellofemoral joint. The patient had failed multiple courses of conservative measures. Pain had increased and attempts at physical therapy failed to improve the patient's symptoms. Magnetic Resonance Imaging (MRI) confirmed high-grade full-thickness chondral damage diffusely throughout the patella. The patient also demonstrated examination findings consistent with patellar malalignment secondary to combination of rotational and genu valgus malalignment. The patient underwent a right knee arthroscopy with abrasion chondroplasty of the patella, partial lateral meniscectomy, and a cartilage biopsy for future matrix-induced autologous chondrocyte implantation (MACI) from the notch. Orthopedic Surgeon is requesting coverage for: autologous cultured chondrocytes implant. 

The scientific literature has recommended the MACI procedure, but with specific indications. Reconstruction of isolated articular cartilage injuries can be successful in the right clinical setting. 

The facts are the physician has reported a malalignment problem. He has proposed a tibial tubercle osteotomy to balance the abnormal pressures. Performing a MACI prior to realignment will unlikely provide benefit, as continued joint pressures will not improve. 

The second issue is a "kissing lesion". The MRI has shown chondral damage to the trochlea. The opposing surface of the patella has pathology. Articular cartilage reconstructive procedures have worse results in this scenario. A MACI procedure will only address the patella. There likely will be ongoing symptoms from the trochlea. 

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

The insurer's denial of coverage for autologous cultured chondrocytes implant is upheld. Medical Necessity is not substantiated.