Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned


Diagnosis: Hepatocellular carcinoma
Treatment: Y90 Radioembolization
The insurer denied Y90 Radioembolization
The health plan's determination is upheld.

This is a male patient with cirrhosis, ascites, and splenomegaly who has multiple liver masses on magnetic resonance imaging (MRI) and an elevated AFP (alpha-fetoprotein) 61.9. He is not a candidate for surgical resection. 

The Y90 Radioembolization is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There is a lack of peer-reviewed literature supporting a better outcome with Y-90 radioembolization for this clinical presentation compared to standard medical treatments of chemoembolization, radiation therapy, systemic chemotherapy, etc. The medical records do not show that the hepatic lesions are biopsy proven hepatocellular carcinoma (HCC) and could be other types of metastatic disease, for which the proposed Y-90 radioembolization would not be considered a standard medical treatment. The medical records do not indicate the proposed procedure is a bridge to liver transplantation.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Generalized Anxiety Disorder. 
Treatment: Vilazodone. 
The insurer denied:  Vilazodone. 
The denial is upheld. 

The patient is a teenage female. She is diagnosed with generalized anxiety disorder (GAD), comorbid ADHD (attention deficit hyperactivity disorder)-inattentive type, and unspecified trauma and stressor related disorder. The patient is prescribed Viibryd at the starting or initial dose of 10 mg (milligrams) together with Wellbutrin XL (extended release) 150 mg (milligrams) daily. There is a history of treatment resistance or tolerability issues with fluoxetine. Moreover, several antidepressant medications were shown to pose a risk for gene-drug interactions, as indicated with pharmacogenomic testing. 
The health plan denied coverage for Viibryd based on plan coverage criteria indicating that three formulary alternatives must be tried and failed or formulary alternative must be contraindicated before an exception is allowed. Suggested formulary alternatives include citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and Trintellix. The prescribing clinician is requesting health plan coverage for Viibryd in view of the lack of a clinical response or tolerability issues with fluoxetine and genetic testing, which indicates a gene-drug interaction with several other antidepressant/anxiolytic medications, including the suggested formulary alternative, except for Trintellix, which is in the "use as directed" list along with multiple other formulary options, which include mirtazapine, trazodone, TCAs (tricyclic antidepressants), and SNRIs (serotonin-norepinephrine reuptake inhibitors). 

The health plan should not cover the Formulary exception for Vilazodone in this case. 

Alternative and remaining formulary antidepressant medications potentially available for treatment of GAD (generalized anxiety disorder) include the suggested formulary alternative of Trintellix, which is in the "use as directed" category with the genetic testing, as well as several of the suggested formulary alternatives that are in the "use with caution" category. There is no evidence that the formulary drugs had been ineffective for this patient or would not be as effective as the requested non-formulary drug or would have adverse effects for this patient. This includes information provided with pharmacogenomic testing. This answer is consistent with the scientific literature and published guideline, referenced below, as well as prevailing standards of medical practice and the instruction for this New York State review pertaining to formulary alternatives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease (dialysis), hypertension and diabetes

Treatment: Consumer Directed Personal Assistance Program (CDPAP), 8 hours per day, 7 days per week, total of 56 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP), 8 hours per day, 7 days per week, total of 56 hours per week

The denial is overturned

 
This is an elderly male with medical problems that include end stage renal disease (dialysis), hypertension and diabetes.  He lives with his daughter in a private residence.  The patient is approved for personal care assistance (PCA) 6 hours/day, 5 days/week for a total of 30 hours/week and is requesting Consumer Directed Personal Assistance Program (CDPAP), 8 hours per day 7 days per week for a total of 56 hours per week, leading to external review.  

The patient's cognition is "minimally impaired."  His ability to perform Instrumental Activities of Daily Living (IADL) tasks varies from maximal assistance to total dependence.   The patient is also totally dependent for locomotion (Hoyer lift), toilet transfer and ambulation.  Maximal assistance is reportedly needed for bathing, lower body dressing and toilet use.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility and eating.   The patient is incontinent of bladder and bowel.  

The letter from the patient's treating physician describing his clinical condition and need for additional CDPAP services was reviewed.  However, the doctor  does not include the associated treatment notes for review.  In addition, the physical and occupational therapy Discharge Summaries clearly document the patient's significant functional impairments and need for daily care assistance.  

After reviewing the clinical documents, it is this physician's opinion, the patient's clinical condition and functional deficits are at a level to require the requested (CDPAP), 8 hours per day 7 days per week for a total of 56 hours per week.  

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 Consumer Directed Personal Assistance Program (CDPAP), 8 hours per day, 7 days per week, total of 56 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Right-sided neck pain and right arm pain.
Treatment:  Inpatient Hospital Admission.
The insurer denied Inpatient Hospital Admission.  The denial is partially overturned.

The patient is an adult female, who presented to the emergency department with right-sided neck pain and right arm pain. Magnetic resonance imaging (MRI) showed herniated disc, and the patient was recommended for surgery. The patient represented nearly 3 weeks later with the same complaints. The patient was admitted and underwent an anterior cervical discectomy and fusion (ACDF). The patient required intravenous Dilaudid on post-operative day # (number)  four times. X-ray was performed on post-operative day #2 and the patient was discharged on the same day.

The hospital treatment in the acute setting is approved as medically necessary for post-operative day #1 and day #2. However, the hospital treatment in the acute setting is not approved as medically necessary for the date of admission.

The records do not show any significant medical issues that required acute inpatient hospitalization on the date of admission. Based on the records, it is unclear as to why the patient was admitted, as she did not require acute inpatient level of care. 
However, the post-operative day #1 and day #2 are considered medically necessary, as the patient underwent surgery, and it is within the standard of care for close monitoring after the surgery. This is to evaluate for any neurological deficits or any issues, such as pain or weakness. Close monitoring is warranted in an acute level of care, as there are no other options at a lower level that are appropriate. In this setting, the 2 post-operative days are approved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The patient has a history of mild intermittent asthma and presented to the emergency department (ED) with a three-day history of shortness of breath, wheezing, chest tightness, and some productive cough with yellow sputum. The patient took nebulizer treatments at home but did not improve.  In the ED, the patient's vital signs were Temperature 99 Fahrenheit (F), blood pressure (BP) 150/88, pulse 121, respiratory rate (RR), and oxygen saturation 93% on room air (RA). The patient's peak expiratory flow (PEF) was 120. A lung exam revealed bilateral wheezing.  A cardiovascular exam revealed tachycardia. The patient was alert and oriented x 3.

The patient was treated with steroids, bronchodilators, and magnesium.  The patient improved with treatment in the ED.  The patient's PEF improved to 375. The patient was admitted to the hospital for an asthma exacerbation.  Vital signs per the history and physical were Temperature 98.4F, pulse 101, RR 18, BP 140/80, and oxygen saturation 98% on room air. The patient was in no acute distress.  The patient had scattered wheezing but was speaking in full sentences.  The patient was still alert and oriented x 3. A venous blood gas (VBG) showed a pH of 7.44, bicarbonate of 35, and carbon dioxide level of 45.  Electrolytes were within normal limits. A chest x-ray (CXR) revealed no infiltrates, effusions, or pneumothorax. The next day, the patient was switched to oral steroids.  The patient was continued on bronchodilators, inhaled corticosteroid (ICS)/long-acting beta-agonists (LABA), and Singulair and was discharged home.

This patient did not need acute inpatient hospitalization. The patient could have been placed in observation status which could be for up to 48 hours. During this time, diagnostic testing and treatment could have been initiated.  The patient improved rapidly.  The patient was stable to be discharged home on oral medications after a period of observation.  The patient remained afebrile and hemodynamically stable throughout, and was not hypoxic, with oxygen saturation 93-98% on room air.  The patient was speaking in full sentences and tolerating oral intake. The patient's PEF had improved to 375 after treatments in the ED.  The patient was discharged after one.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of coronary artery disease (CAD), myocardial diverticulum, hypertension, hyperlipidemia, and diabetes. She had fatigue, chest pain, and dyspnea on exertion. Computed tomography (CT) angiography was suggestive of flow limiting CAD in the left anterior descending (LAD) and right coronary artery (RCA). The left ventricular ejection fraction (LVEF) was normal. She was admitted electively for cardiac catheterization. She underwent an uncomplicated catheterization. She had a post procedure vagal episode which resolved. There was nonobstructive CAD. She remained stable and was discharged. At issue is the medical necessity of an inpatient admission.

This patient underwent successful elective and non-emergent heart catheterization. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, need for mechanical or pressor cardiac support, requirement for ongoing invasive hemodynamic monitoring, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to for example observation or outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: D8080 Braces and D8670 monthly visits x 12.

The insurer denied coverage for D8080 Braces and D8670 monthly visits x 12.  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 overjet, open bite, posterior crossbite and anterior crowding among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation Index (HLD) index attaining 28 total points. 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, attaining 13 points on the HLD index by internal reviewers.

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, 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 completes the second portion of the index arriving at 28 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist, which remains above the threshold of 26 points to support orthodontic 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 and this has been determined to represent an appropriate approach for assessing orthodontic need.

Overturn denial as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care, as it meets the accepted criteria for approval.

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 D8080 Braces and D8670 monthly visits x 12  is substantiated.
Appeal type: Formulary Exception
Decision: Overturned



Diagnosis: gastroesophageal reflux disease (GERD).
Treatment: Dexilant.
The insurer denied Dexilant.
The health plan's determination is overturned. 

The patient is a male with chronic severe gastroesophageal reflux disease (GERD). He has failed esomeprazole, lansoprazole, omeprazole, and pantoprazole. He has been stable on Dexilant; he has recurrent symptoms within 2 days of discontinuation. 

The request for the continuation of Dexilant over the formulary alternatives is supported in this case. Comparison of multiple proton pump inhibitors (PPIs) has found no difference in the control and healing of GERD between medications such as omeprazole, lansoprazole, pantoprazole, and rabeprazole (Katz, et al.; Remak, et al.; Dupas, et al). Dexilant, unlike all other proton pump inhibitors, is released in an extended fashion; this delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric potential hydrogen (pH) than other proton pump inhibitors (Vakily, et al). A significant majority of patients (88%) requiring other PPIs twice daily were able to control symptoms on Dexilant once daily (Fass, et al). Dexilant is also more effective in treating heartburn than alternatives such as esomeprazole (Sharma, et al; Davies, et al).
The American College of Gastroenterology guidelines for the treatment of GERD do recommend proton pump inhibitor therapy for the control of symptoms and prevention of complications (Katz, et al.; Shaheen, et al.; Freedberg, et al.).
In this case, based on current medical literature, it is unlikely that a patient who has failed multiple conventional proton pump inhibitors (such as esomeprazole, omeprazole, lansoprazole, and pantoprazole) in the past will find relief with another one of those proton pump inhibitors. Dexilant, unlike alternatives, has been effective in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cavities
Treatment: Outpatient Procedure (dental work 41899 x 32)
The insurer denied: Outpatient Procedure (dental work 41899 x 32)
The denial is overturned.

The patient is a school aged female with multiple very deep carious lesions (cavities), most of which are into the nerves of the teeth. This is a request for dental work (procedure code 41899 x 32). Prior denial for requested procedures was due to the procedures being deemed "not medically necessary." 

The proposed treatment of an Outpatient Procedure (dental work 41899 x 32) is considered medically necessary.

Due to the extent and complexities of all the procedures needed, the patient is not a candidate for just using oral conscious sedation in an office setting. She will need general anesthesia to accomplish all recommended treatment due to a medical history of acute reaction to stress, general anxiety, behavioral issues, and dental caries. The x-rays help show the extent of all the cavities present, and the anesthesia is medically necessary to facilitate treatment in as harmless a process as possible for this young patient. The x-rays presented also show that several of the decayed teeth have decay into their nerves. These teeth need to be treated to prevent multiple oral infections. Several teeth were noted to be severely damaged and needed to be extracted. Multiple other teeth need fillings to stop the decay process. Sealants placed on two posterior teeth will help prevent future cavities. The lingual and maxillary frenectomies are needed to free up the tongue and upper lip from muscle pulls. As such, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns of abdominal pain. Pertinent history included anemia, pelvic inflammatory disease, and hypothyroidism. Initial vital signs revealed a temperature of 98.6oF (Fahrenheit), heart rate (HR) 98, blood pressure (BP) 132/77, respiratory rate 18, and pulse oximetry 99% (percent) on room air. Initial examination revealed diffuse abdominal tenderness without cervical motion tenderness, cervical discharge, or adnexal tenderness. Initial laboratory testing revealed a white blood cell count (WBC) 8.5.0, HGB (Hemoglobin) 10.7, platelets (Plt) 170, blood urea nitrogen (BUN) 20, Creatinine (Cr) 0.97, Na (sodium)139, K (potassium)3.8, Glucose 81, thyroid stimulating hormone (TSH) 13.6, Lipase 30, Tbil (total bilirubin) 0.7, aspartate aminotransferase (AST) 34, and alanine aminotransferase (ALT) 23. A computed tomography (CT) abdomen/pelvis revealed nonspecific inflammatory nodule in the soft tissues of the right lower quadrant abdominal wall, otherwise no evidence of acute intra-abdominal pathology. The patient was placed in the hospital thereafter with an impression of abdominal pain.

The inpatient hospital admission was not medically necessary. The patient had a history of pelvic inflammatory disease and hernia repair who presented with abdominal pain. Initial examination documented the patient as afebrile, hemodynamically stable, without cervical or adnexal findings, and without peritoneal signs. Initial evaluation included relatively unremarkable laboratory testing, unremarkable CT imaging, and an unremarkable transvaginal ultrasound. Treatment included supportive care and empiric fluconazole for vaginal discharge. Following observation care, the patient was discharged. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and Monthly Visits
The insurer denied Braces and Monthly Visits.
The determination is upheld.

This is a male patient with a crossbite of anterior teeth 9 and 10. He presented with a skeletal Class I malocclusion with moderate spacing in the maxilla and mandible. He is treatment planned for 24-30 months of orthodontics to address the spacing and crossbite, but the treatment was denied due to lack of medical necessity. At issue is the medical necessity of braces and monthly visits.

This patient presented with an anterior crossbite on teeth 9 and 10, as well as moderate spacing. 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) It appears the lower anterior teeth are migrating labially in the arch.
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, treatment is medically necessary.