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

Diagnosis: Alopecia Areata. 
Treatment: Xeljanz. 

The insurer denied Xeljanz. 
The determination is upheld. 

This is a male patient with alopecia areata. The alopecia areata is severe. The prescriber is a dermatologist. The medication under review for medical necessity is Xeljanz. 

The requested health service/treatment of Xeljanz is not medically necessary for this patient. There is no documentation that the patient has exhausted all topical options, and that it would therefore be medically necessary to start systemic treatment which would carry a higher side effect profile. 
For example, there is no documentation provided that the patient has tried and failed topical immunotherapy, such as Diphenylcyclopropenone (DPCP). Chiang et al writes their 2015 study findings: that for DPCP "treatment success, defined as 50 percent (%) terminal hair regrowth, was reached in 71% of alopecia totalis patients and in 56% of alopecia universalis patients" (1). There is no documentation that the patient has tried and failed topical minoxidil. A recent study reports that treatment of alopecia areata "with 5% minoxidil proved effective, and clinically and statistically safe" (2). Topical squaric acid dibutylester is a sensitizing agent which is also used for the treatment of alopecia areata and has been shown to be effective in several studies (3). Based on the documentation provided, the patient has not tried and failed all topical therapies available. These topical medications, which have been shown to be effective for the patient's condition, should be tried and failed prior to initiating Xeljanz. Therefore, Xeljanz is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite/Underbite
Treatment: Dental/Orthodontic Procedure- Braces and monthly visits.
The insurer denied Dental/Orthodontic Procedure- Braces and monthly visits.
The determination is upheld.

This patient has a class II occlusion and slightly high overjet and overbite. Both arches have moderate crowding. The treatment plan includes orthodontics to correct the malocclusion. At issue is the requested health service/treatment of braces and monthly visits.

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

The requested health service/treatment of braces and monthly visits is not medically necessary for this patient. The patient has crowding. The patient's bite is slightly deep but there is no indication of damage to the incisors or the palate in the photographs, and the cephalometric radiograph showed the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) to this patient.

There is no medical reason to correct the malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not show any damage to the teeth or soft tissue damage from their current position. There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another (1). Deep bites may be corrected in adulthood, so it is not as if they will lose the ability to correct their malocclusion should they choose to do so as an adult.

There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence (3). This patient presents with none of those conditions and if they chose to have orthodontic treatment in the future there will be no negative repercussions to waiting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: osteoarthritis/decreased.
Treatment: Home Health Care 84 Hours per week of Consumer Directed Personal Assistance.
The insurer denied 84 Hours per week of Consumer Directed Personal Assistance Services. 
The health plan's determination is overturned. 

The patient is a male with past medical history of chronic obstructive pulmonary disease (COPD), oxygen dependent, osteoarthritis, benign prostatic hyperplasia (BPH), low back pain with sciatica, anxiety, depression, bipolar disorder venous insufficiency, carpal tunnel syndrome, hyperlipidemia, diabetes mellitus type 2 with neuropathy, urinary incontinence, and peripheral vascular disease who had been assigned to CDPAS (Consumer Directed Personal Assistance Services).

The 84 Hours per week of Consumer Directed Personal Assistance Services are medically necessary for this patient.
There is documentation from the patient's medical provider of worsening physical functioning related to low back pain, osteoarthritis, and peripheral vascular disease. The provider also noted the patient had sedation related to medications he was taking which made the patient reliant on others for daily tasks. The patient's universal assessment underestimated the patient's care needs. The patient requires supervision with walking and locomotion, limited assistance with toilet use, and extensive assistance with transfer toilet and therefore has unpredictable and unscheduled care needs. The insurer failed to document a plan to meet the patient's unpredictable and unscheduled care needs. The requested increase in CDPAS 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 plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 84 hours/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 his own home.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Osteoarthritis, osteoporosis, Parkinson's disease with gait imbalance, macular degeneration, intermittent urinary incontinence, falls, hand tremor and recent pleural effusion.

Treatment: Consumer directed personal assistance program (CDPAP) to 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week.

The insurer denied coverage for consumer directed personal assistance program (CDPAP) to 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week.

The denial is overturned.

 
This is an elderly patient with Parkinson's disease, macular degeneration and a lung mass. She has been placed on furosemide and anticoagulation due to pleural effusion and deep venous thrombosis, respectively. She lives on the ground floor of a private residence, where her daughter and her family live upstairs. The insurer approved consumer directed personal assistance program (CDPAS) 12 hours/day, 7 days/week and the request is for an increase in consumer directed personal assistance program (CDPAP) hours to 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as modified independent. She is totally dependent to maximal assistance for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She is totally dependent for bathing, lower body dressing, locomotion, toilet transfer, and ambulation. Maximal assistance is needed for upper body dressing and toilet use. She requires extensive assistance for eating. She is frequently incontinent of bladder and occasionally incontinent of bowel. Her ADL and self-sufficiency have declined over the prior 90 days. The combination of the patient's clinical condition, (including increased use of diuretics and anticoagulation) and functional needs support the request for CDPAS 24 hours/day, 7 days/week, split shift. 

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 an increase in consumer directed personal assistance program (CDPAP) to: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure
Treatment: Entresto
The insurer denied Entresto.
The determination is overturned.

This is a male patient with a history of atrial fibrillation and nonischemic cardiomyopathy. An echocardiogram showed a dilated left ventricle with global hypokinesis and a left ventricular ejection fraction of 25-30 percent (%). There was severe mitral regurgitation. Per the physician's appeal letter the patient has New York Heart Association Functional Class II heart failure. The medical necessity for Entresto is at issue.

Based on the information provided, Entresto is medically necessary.

Entresto (sacubitril/valsartan) is a relatively new, first-in-class medication that combines an angiotensin receptor blocker with a neprilysin inhibitor. In the pivotal trial of Entresto, 4187 patients with New York Heart Association (NYHA) Class II-IV heart failure and reduced left ventricular ejection fractions (less than or equal to 40%) were randomly assigned to receive either Entresto or standard therapy with enalapril, an angiotensin converting enzyme (ACE) inhibitor. During a median follow-up time of 27 months, the combined endpoint of death from cardiovascular cause or heart failure hospitalization occurred in 21.8% of the Entresto group versus 26.5% of the enalapril group; this difference was highly significant and in favor of the Entresto group. The American College of Cardiology (ACC) / American Heart Association (AHA) / Heart Failure Society of America (HFSA) guidelines for heart failure have given its use a Class I recommendation in this patient population.

Per the policy provided Entresto is medically necessary when:
1.	The individual is at least 18 years of age; (MET)
2.	The individual is using the drug for NYHA class II, III or IV symptoms: (MET)
3.	AND
4.	The individual has a left ventricular ejection fraction of 57% or less. (MET)
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.

Treatment: Braces and monthly visits.

The insurer denied coverage for braces and monthly visits.

The denial is overturned.
 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index Report choosing the automatically qualifying condition of deep impinging overbite with severe soft tissue damage on the HLD index. 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 by internal reviewers attaining a score of 14 points. 

Upon review of the submitted documentation 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 requites the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after 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 completed the HLD index, choosing the deep impinging criterion and impacted permanent anteriors criterion to justify orthodontic care. The clinical circumstance meets this criterion for approval of 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 approach. Each of these peer reviewed articles concludes that this index 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.

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 braces and monthly visits is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abfraction/cervical abrasion

Treatment: Crowns for teeth #s 13 and 14

The insurer denied coverage for crowns for teeth #s (numbers) 13 and 14

The denial is upheld

 
Upon review of the documentation provided which includes copies of undated full mouth series radiographs, complete dental clinical treatment notes, multiple montages of extraoral and lntraoral pretreatment clinical photographs and insurer correspondence, it appears that this patient presented to the dentist for comprehensive dental care. The treating dentist recommended full coverage crowns for #13 and #14, presumably due to significant abfraction/cervical abrasion. The insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic Injury or decay, provided to support the necessity of this service, the documentation is insufficient to approve treatment, and therefore the service does not meet medical necessity criteria. 

The objective documentation provided for review are copies of full mouth series radiographs and multiple clinical photographs over a three-year period. The dental record documentation provided for review does not necessarily include rationale for placement of the restorations, but it is presumably to treat the noncarious cervical lesions (abfraction/cervical abrasion). The clinical photos do demonstrate abfraction with preexisting cervical composite restorations. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental service as enumerated above. Further, as per recent 2022 peer reviewed literature the standard of care for management of these lesions is not full coverage restorations but conservative direct placement restorations.

Uphold denial of coverage for crowns for teeth #s 13 and 14, as the current standard of care as per the specialty of prosthodontics is not full coverage restorations.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for crowns for teeth # 13 and # 14 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: right middle lobe pneumonias 
Treatment: Intrapulmonary Percussive Ventilator (Volara System) 
The insurer denied Intrapulmonary Percussive Ventilator (Volara System). The health plan's determination is upheld.

The patient is a girl with recurrent right middle lobe pneumonias resulting in computerized-tomography-proven RML (Rhabdomyolysis) bronchiectasis (RML syndrome); she also has congenital heart disease. Despite being compliant with therapies, she has failed inhalations, manual chest physical therapy, and chest physical therapy delivered with the VEST. Because she is at risk for worsening bronchiectasis, an Intrapulmonary Percussive Ventilator (IPV, Volara System) has been requested for her. 

Intrapulmonary Percussive Ventilator (Volara System) is not medically necessary for this patient.
While effective airway clearance is extremely important in children with bronchiectasis and/or chronic suppurative lung diseases, unfortunately, available studies do not demonstrate effectiveness of IPV in this patient population or in other populations. Therefore, its use in this patient is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: Personal Care Aide (PCA) Level 2 Services: 9 Hours per Day, 7 Days per Week - Total of 63 Hours per Week
The insurer denied Personal Care Aide (PCA) Level 2 Services: 9 Hours per Day, 7 Days per Week - Total of 63 Hours per Week. The health plan's determination is overturned. 

The patient is a male with past medical history of Alzheimer's dementia, seizure disorder, osteoarthritis, hyperlipidemia, and depression who had been assigned PCA (personal care assistant) services.

Personal Care Aide (PCA) Level 2 Services: 9 Hours per Day, 7 Days per Week - Total of 63 Hours per Week are medically necessary for this patient.
The patient's neurologist and PCP (primary care provider) have requested an increase in PCA services and the neurologist, specifically requested 24 hours/day. The patient has at least limited assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient will require PCA assistance outside of the hours he has informal help. 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). 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, PCA services 9 hours/day, 7 days/week, to total 63 hours/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 his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cholelithiasis.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
The patient was referred to the emergency room (ER) after being found to have elevated liver enzymes. He was having abdominal pain and nausea. He was treated in urgent care for gastroesophageal reflux disease (GERD), and his symptoms improved. The abdominal exam revealed mild tenderness with no rebound or guarding. The alanine transaminase (ALT) was 1132, aspartate transferase (AST) 667, and bilirubin 2.2. An abdominal ultrasound showed a contracted gallbladder with gallstones. The repeat bilirubin came down to 0.9 by the time of admission. The magnetic resonance cholangiopancreatography (MRCP) showed cholelithiasis with no evidence of acute cholecystitis or choledocholithiasis. The Hepatitis B surface antibody was positive. The gastroenterologist advised that he could be followed as an outpatient. 

Clinical indications for admission per Milliman Care Guidelines (MCG) for Gallbladder or Bile Duct Inflammation or Obstruction (MCG M-555) include having acute cholecystitis or acute cholangitis with systemic signs of inflammation. In this case, the MRCP was negative for both acute cholecystitis or acute cholangitis, and he did not have systemic signs of inflammation. He also did not have hemodynamic instability, common bile duct (CBD) obstruction, severe vomiting, severe pain, or bacteremia. Clinical indications for admission for Liver Disease (MCG M-570) include having acute liver failure, hepatic encephalopathy, hepatorenal syndrome, and infected ascites. The patient did not have these conditions. 

This patient had elevated liver enzymes that were trending down. He had gallbladder disease but did not have acute cholecystitis or acute cholangitis. The gallbladder did not require any acute interventions at this time. The liver enzymes could have been monitored as an outpatient. He did not meet MCG criteria for admission for either Gallbladder or Bile Duct Inflammation or Obstruction or Liver Disease. He could have received observation care. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Issues, with a Class III malocclusion, minor crowding of the upper and lower arches and anterior crossbite of #8-9.
Treatment: braces and monthly visits.
The health plan denied the requested braces and monthly visits as not medically necessary. 
The health plan's determination is overturned.

The patient in question is a male with a Class III malocclusion, minor crowding of the upper and lower arches and anterior crossbite of #8-9. Teeth 8 and 9 have significant wear due to the crossbite. He is missing teeth 5, 12, 21, and 28. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion.
At issue is the medical necessity for the requested health service/treatment of braces and monthly visits.

I overturn, in whole the health plan's determination of medical necessity.

This patient presented with an anterior crossbite and minor 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. [1,2,3] These problems are much more time consuming and costly to correct than the patient's current orthodontic problem.
The patient has #8-9 in crossbite, and they are significantly worn. It will be impossible to restore these teeth while they are in their current position due to the traumatic occlusion. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, [4] which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, orthodontic treatment is medically necessary.