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

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Home Health Care 
The insurer denied increase in personal care aide level 2 services to 40 hours per week.
The denial is upheld.

The patient is a female with past medical history significant for atrial fibrillation, congestive heart failure, renal insufficiency and generalized medical debility. The patient had been receiving 25 hours a week Personal Care Aide services. This had been increased from 20 hours a week of services. The subject under review is the medical necessity for the Personal Care Aide Level 2: 8 hours per day, 5 days per week, for a total of 40 hours per week.

The health plan's determination is upheld.

The patient has been approved for 25 hours a week of services. Additional services are not medically necessary.

The patient has multiple medical problems and generalized debility, as noted above. The patient had 2 recent hospitalizations. The most recent hospitalization was secondary to congestive heart failure, anemia and chronic renal insufficiency.

Services were partially approved by the plan based upon the following statement. You do not meet increase in services due to criteria. You request an appeal because you were recently hospitalized and need temporary assistance with walking, getting dressed, meal preparation, housework and shopping due to your medical conditions. Recent Uniform Assessment System (UAS) State of New York showed that some of your personal care needs stayed the same and some declined. Your abilities to perform daily activities stayed the same for dressing lower body, bathing, toilet use, eating, meal preparation and medication management. Your abilities to perform activities of daily living declined for dressing upper body, personal hygiene, bed mobility, walking, locomotion, toilet transfer and housework.

Services were increased from 20 hours a week to 25 hours a week to accommodate the decline in function.

Uniform Assessments were reviewed.

Tasking tool recommended 4 days a week of services. The next tasking tool dated recommended 5 days a week of services.

The patient had a decrease in her functional ability subsequent to the hospitalizations. Nursing evaluation assessment was done post discharge from the hospital. It was done 7 days after discharge. It is reasonable say that the patient's level of care was assessed appropriately at that time in regard to her current medical needs. The patient does have an increase in medical need for certain activities of daily living (ADLs), which were accounted for in the increase in service hours, 5 additional hours per week.

The patient's daughter was concerned because she was noted to be a fall risk.

Additional services for "prevention of falls" or "monitoring" without services being provided are typically not covered. In order for services to be considered medically necessary, the aide must be performing a service such as medically necessary ADLs or instrumental activities of daily living (IADLs).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Hand cellulitis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient has a past medical history significant for immune compromise, hepatitis C, intravenous drug abuse (IVDA), basal and squamous cell carcinoma, benign prostatic hypertrophy, and asthma who presented to the emergency department with complaints of left hand pain and swelling. He was bitten by a cat one month prior. Vitals on presentation included: Temperature 97.8 Fahrenheit, blood pressure-152/104, pulse-83, respiratory rate-20, oxygen saturation-94% (percent). Laboratory values were notable for the following: white blood count (WBC)-7.8, hemoglobin (Hgb)-12.8, hematocrit (Hct)-38.8, creatinine-0.7, glucose-79.

The patient was admitted for a possible left hand infection. He was started empirically on antibiotics (Unasyn). X-ray of the hand showed diffuse osteopenia. Magnetic resonance imaging (MRI) of the left upper extremity revealed nonspecific tensynovitis with synovial enhancement in the flexor compartment of the wrist, no drainable abscess, no acute osteomyelitis. All cultures remained negative. The patient remained afebrile, hemodynamically and clinically stable. He was discharged to continue oral antibiotics (Amoxicillin/Clavulanate) as an outpatient.

According to documentation, the patient was admitted for a left hand cellulitis following a cat bite. Otherwise, patient was afebrile and hemodynamically stable with unremarkable laboratory results including a normal WBC. Moreover, there was no evidence of a systemic infection and no surgical intervention was required. Based on above findings, patient met criteria for observation level of care. Criteria for acute inpatient admission was not met.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis.
Treatment: Dupixent (dupilumab).

The insurer denied coverage for Dupixent (dupilumab).  The denial is overturned. 

This is a female patient who has a history of atopic dermatitis, anemia, gastroesophageal reflux disease (GERD), and sickle cell disease.  She presented to the dermatologist's office on for the evaluation of atopic dermatitis.  The patient had eczema on 90% of her body surface area (BSA).  She had failed fluticasone, Protopic, Elidel, mometasone, and triamcinolone.  The physician recommended administering 300 milligrams (mg) per 2 milliliters (ml) of subcutaneous (SC) Dupixent once a month and continuing tacrolimus.

Dupixent is medically necessary for the treatment of the patient's diagnosis, atopic dermatitis.  The patient has decreased systemic treatment options available which could safely be administered given her age and chronic medical conditions.  The patient has failed topical therapy with steroids, as well as non-steroidal anti-inflammatories-tacrolimus, pimecrolimus, and Eucrisa.  The extent of disease involvement, affecting 90% total body surface area (TBSA), requires systemic therapy.  Dupixent is approved for use in the treatment of the patient's atopic dermatitis under close medical supervision and at an appropriate dosing schedule, at the discretion of the treating physician.  

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

The carrier's denial of coverage for Dupixent (dupilumab) to treat atopic dermatitis is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and retainers for medical necessity. 
The denial was upheld. 

The patient is a female with a Class I occlusion with a 3-millimeter (mm) overbite and 5 mm overjet. She has minor maxillary and severe mandibular crowing. She has treatment planned for orthodontics with braces and retainer to correct her malocclusion.
At issue is the medical necessity of Braces and retainers.

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

The requested health service/treatment of Braces and retainers is not medically necessary for this patient.
The patient has crowding but no teeth are impacted. Her overbite is deep but there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows 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) on this patient. There are no anterior or posterior crossbites present.
There is no medical reason to correct her malocclusion with braces. While the patient has 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. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. If her teeth were aligned, it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health.
Therefore, the requested health treatment of Braces and retainers is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient admission for medical necessity. The denial was upheld. 

This patient is a female with hypertension and type 1 diabetes on insulin pump therapy. She presented with 4 to 5 days of abdominal pain without vomiting. She had loose stools at home. She was alert and oriented. She had previously been hospitalized for coronavirus disease 2019 (COVID-19). 

Her blood pressure (BP) was 130/80, heart rate was 121, temperature was 98.6, and pulse oxygen (O2) saturation was 100%. Her glucose was 195 milligrams (mg)/deciliter (dL), carbon dioxide (CO2) was 13, beta-hydroxybutyrate was greater than (>) 4, and potential hydrogen (pH) was 7.27. 

She was treated with Lantus and Lispro in the emergency department. The anion gap closed. She was transitioned back to her insulin pump therapy. 
At issue is the medical necessity of Inpatient stay. 

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

The requested health service/treatment of Inpatient stay is not medically necessary for this patient. 

This patient presented with known type 1 diabetes with mild diabetic ketoacidosis. Patients with diabetic ketoacidosis can be safely managed in an observation unit unless they present with severe alteration of mental status or with critical illness such as sepsis, [1] neither of which is documented in this case. This patient did not have a documented alteration in her mental status. She was hemodynamically stable. She responded quickly to treatment with normalization of her anion gap. 

Therefore, the requested treatment of Inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite with severe soft tissue damage

Treatment: D8080-comprehensive orthodontic treatment of the adolescent dentition and D8670-periodic orthodontic treatment visit

The insurer is denied coverage for D8080-comprehensive orthodontic treatment of the adolescent dentition and D8670-periodic orthodontic treatment visit.

The denial is upheld. 

This male patient has a history of Deep impinging overbite with severe soft tissue damage.

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, an HLD 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 insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 12 points (4 points overjet, 6 points overbite, and 2 points 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. This is confirmed by several studies.

Each of the 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.

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 D8080-comprehensive orthodontic treatment of the adolescent dentition and D8670-periodic orthodontic treatment visit is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces, monthly visits for medical necessity. The denial was upheld.

The patient is a male with Skeletal Class I and Dental Class II cuspids. He has mild mandibular crowding and mild maxillary crowding. There is an anterior crossbite at tooth number (#) 10 and posterior crossbite on the right side. The patient has treatment planned for braces and monthly visits.
At issue is the medical necessity of braces, monthly visits.

The health plan's determination is upheld in whole.
No, the requested health service/treatment of Braces, monthly visits, is not medically necessary for this patient.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 12 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9-millimeter (mm) or greater and an underbite 3.5 mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet criteria to be classified as handicapping and treatment would not be considered medically necessary. According to the standard of care, braces and monthly visits are not medically necessary for this patient.
Thus, the requested treatment of braces, monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heavy Vaginal Bleeding and Syncope
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who underwent cystocele repair with an anterior colporrhaphy.  She went home and had continued bleeding.  She became dizzy and nauseous.  She went to the emergency department (ED).  

The patient was pale, lethargic, and diaphoretic.  Her evaluation revealed heavy bleeding from the vagina.  She had Surgiflo and packing placed.  She had labs revealing elevated white blood cell count of 16.9, low hemoglobin of 11.4, and elevated lactate of 4.2.  She had a Foley catheter placed and was given intravenous (IV) fluids.  She was hypotensive 87/54.  She reported passing out at home.  Given there was not obstetrics/gynecology (OB/GYN) services at this facility she was transferred.  

At emergency department (ED) she was reevaluated with gynecology (GYN).  Speculum exam revealed scant bleeding, stitches in tact.  Repeat blood work revealed hemoglobin of 8.6.  She remained hypotensive with blood pressure (BP) of 94/58.  She received two units of packed red blood cells and was admitted for serial vital signs and complete blood count (CBC) monitoring.  By the next day she had stabilized.  Bleeding was less.  Her hemoglobin was ten.  Her white blood cell count and lactate were normal.  She was discharged home with follow up with her urologist.

No, the proposed inpatient admission was not medically necessary.
Per various Centers for Medicare and Medicaid Services (CMS) manuals, observation services are defined as: "a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital." In most cases, the Manuals provide that a beneficiary may not remain in observation status for more than 24 or 48 hours.

Observation services are also defined as: "an outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management.  It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient."  

In review of the medical record the inpatient level of care was not necessary.  The care provided for the patient could have been provided at a lower level of care such as observation.  Although the patient was hypotensive, she was not tachycardic and was not hemodynamically unstable.  Her bleeding was stopped without surgical intervention.  She received fluids and blood, both of which can be given in the observation setting.  She required less than a 48 hour admission.  There is no evidence that that patient's condition or interventions required inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure (CHF). 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with a history of congestive heart failure (CHF), hypertension, diabetes, and atrial fibrillation.  He presented to an outside hospital with complaints of lower extremity and scrotal swelling.  Laboratory test results included brain natriuretic peptide (BNP) 5,269 and troponin 0.042, with subsequent troponin level 0.062.  Chest x-ray revealed left pleural effusion and echocardiography revealed left ventricular ejection fraction (LVEF) 30-35% with decreased right ventricular function.  He was treated with intravenous (IV) diuretics with improvement in symptoms and was transferred for evaluation for interventional treatment.  

Vital signs on arrival included blood pressure (BP) 138/95, atrial fibrillation rates in the 80's, respiratory rate 18, oxygen saturation on room air 97% (percent), and temperature 97.8.  Electrocardiogram (EKG) revealed no acute findings with Q waves in the anterior leads and T wave inversions in the lateral and inferior leads.  Portable chest X-ray was unremarkable.  He was evaluated by interventional cardiology who determined that guideline directed medical therapy should be continued.  IV furosemide was continued, carvedilol and hydralazine dosages were decreased, enalapril was discontinued, spironolactone, Eliquis, and Entresto were added, and atorvastatin was changed to rosuvastatin.  Farxiga was added to his home regimen of insulin and glipizide for diabetic control.  He was discharged to home on the adjusted medical regimen with oral diuretics, for follow-up with his local cardiologist.

There is no evidence that the inpatient hospital admission was medically necessary for review of his previous coronary angiography by interventional cardiology or to improve his guideline directed medical therapy for treatment of acute on chronic heart failure.  This could have been completed at the referring facility, followed by outpatient management.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic Arthritis
Treatment: Xeljanz XR 11mg, Pre-service
The insurer denied the Xeljanz XR 11mg, Pre-service.
The denial is overturned.

The patient is a female with psoriasis and severe psoriatic arthritis.  She was treated with Cosentyx for approximately nine months, and lost responsiveness to Cosentyx.  She started Humira and saw no response to Humira treatment after six weeks.  Per the attending physician (AP) appeal letter, the patient then tried Enbrel for two months and saw no response.  The attending physician indicates that Plan-preferred Otezla is for milder disease, and not appropriate for this patient who already failed three biologic therapies.  Appeal is for Xeljanz XR for the treatment of severe psoriatic arthritis.

Yes, the proposed treatment with Xeljanz XR 11 milligrams is medically necessary.
Xeljanz is Food and Drug Administration (FDA)-approved for the treatment of psoriatic arthritis, as seen in this patient. This patient already failed treatment with three Plan-preferred biologic therapies (i.e, Cosentyx, Humira and Enbrel). Thus, it is clinically appropriate and in accordance with standard of care in the rheumatology community to now treat with Xeljanz, which has an alternate mechanism of action. 

Xeljanz has demonstrated efficacy in the treatment of psoriatic arthritis in several randomized trials, including patients with an inadequate response to tumor necrosis factor (TNF) inhibitor therapy (i.e, Humira and Enbrel).  Per a recent UpToDate review, the alternate Plan preferred agent Otezla would be appropriate for a patient with psoriatic arthritis who has failed non-steroidal anti-inflammatory drugs (NSAIDs) or other disease modifying antirheumatic drugs (DMARDs). Otezla would not be appropriate for this patient with severe psoriatic arthritis who already failed three biologic therapies.  

Therefore, the proposed Xeljanz XR for the treatment of psoriatic arthritis in this patient is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: overactive bladder

Treatment: Myrbetriq 50mg OR TB24

The insurer is denied coverage for Myrbetriq 50mg (milligram) OR (oral) TB24 (time based 24 hours).

The denial is overturned. 

This female patient has a history of overactive bladder.

This patient had suffered anticholiragic side effects from trospium, oxybutynin and it is more likely than not that she will experience similar side effects from tolterodine, darifenacin and soliferacin. Also, anticholinergic medications especially highly lipophilic drugs like oxybutynin, cause concern regarding high risk for dementia or cognitive decline. Older patients may be more susceptible to cognitive impairment because acetycholine in the central nervous system (CNS) decreases with older age. 

As noted by Up to Date, "Beta-3 adrenergic agonist drugs and antimuscarinic agents are the main options for treatment of OAB 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]."

Myrbetriq should be a formulary exception for this patient. She has failed 2 anticholinagic OAB (overactive bladder) drugs with similar side effects experienced. The formulary drugs listed by the insurer are more likely than not to cause this patient an adverse reaction. The requested drug (myrbetriq) is likely to be more effective than the formulary drugs remaining on the list. The patient reported good clinical results, minimal side effects with myrbetriq samples. This patient had similar side effects with oxybutriq/trospium and likely will do so with the other formulary drugs listed.

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 Myrbetriq 50mg OR TB24 is overturned.  The medical necessity is substantiated.