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

Diagnosis: schizophrenia/tachycardia
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This case involves a man with schizophrenia admitted to the hospital due to noncompliance with medications. He was brought into a psychiatric emergency department with hypertension and tachycardia. The patient was noted to be alert and oriented x3. Vital signs showed a heart rate of 120, temperature was normal, and respirations were 18. On exam, the patient did not appear distressed, with a tachycardic heart rate but no murmurs. 

The inpatient hospital admission was not medically necessary. Based on the provided documentation, no acute medical issue prevented the patient from transitioning to the next level of care, the inpatient psychiatric unit. The patient was noncompliant with his medication and had underlying tachycardia and hypertension, which improved. There was no evidence of end-organ damage, stroke, acute coronary syndrome, or renal failure warranting an inpatient hospital stay. The tachycardia was not hemodynamically significant, not related to an infection or sepsis, and was attributed to baseline obesity, obstructive sleep apnea, and deconditioning. No severe acute medical conditions prevented the patient from being treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal Polyp
Treatment: Dupixent Syn 300
The insurer denied: Dupixent Syn 300
The denial is overturned.

The patient is an adult male with a history of chronic rhinosinusitis with nasal polyps. The documentation indicates the patient trialed budesonide, triamcinolone, and fluticasone for six weeks each. The patient had trialed montelukast, orally, as well as cetirizine. Dupilumab was recommended biweekly for the chronic rhinosinusitis with nasal polyps 3 months ago. The 
patient noted improvement in nasal congestion and began "having a normal life." The request was denied as the patient did not meet medical criteria for its use for nasal polyps, specifically the patient did not trial at least three topical intranasal agents (For example (e.g.), steroids) for "an adequate period of time."

The requested health service is medically necessary.

Dupixent (dupilumab) is a biologic medication that is approved for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) in adults. Studies have shown that Dupixent can be efficacious in the treatment of chronic rhinosinusitis with nasal polyps, especially in patients who have severe disease or who have failed to respond to other treatments. The patient is documented to have tried and failed three different nasal sprays for six weeks each. Therefore, dupilumab is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

This is the case of a young male who presented to the emergency department (ED) with the acute onset of abdominal pain with vomiting x 2. The patient had a recent history of hospitalization for similar symptoms and intravenous fluids (IVF) with negative computed tomography (CT) scan evaluation. Past medical history includes asthma and allergic rhinitis. The review of symptoms (ROS) was otherwise negative.

The inpatient hospital admission was medically necessary for this patient. This patient presented with acute onset, repeat abdominal pain. There was concern for acute cholecystitis and need for surgical intervention. The patient was admitted for intravenous fluids (IVF), intravenous (IV) famotidine and ondansetron, labs, and gastrointestinal (GI) consult. Professional guidelines support cholecystectomy as soon as possible after diagnosis for symptomatic individuals. Therefore, an inpatient admission was medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman who presented with recurrent upper abdominal pain. Her past medical history includes hypertension, hyperlipidemia, and diabetes. At the time of presentation, the patient was without fever and vital signs were normal. She was tender in the supraumbilical area. The white blood cell (WBC) count was elevated at 14. The complete metabolic panel identified normal liver enzymes and normal bilirubin. Abdominal ultrasound did not identify gallstones or gallbladder wall thickening. She was admitted to the hospital with the diagnosis of cholecystitis.

The inpatient hospital admission was not medically necessary. This patient presented to the hospital with abdominal pain. She was determined to have symptomatic cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. The patient responded favorably to treatment and was stable for discharge from the hospital on the first post-surgical day with planned follow up. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for emergency department (ED) assessment, surgical assessment and monitoring, laparoscopic cholecystectomy, provision of intravenous ((IV ) antibiotics and fluid, and overnight care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing tooth #11
Treatment: Implant on tooth #11
The insurer denied the implant on tooth #11
The denial is overturned.

This patient is an elderly male requesting coverage for an implant in the area of tooth #11. The patient lost the tooth after it was cut off an existing bridge and extracted. The prior denial was due to the alternate benefits clause.

The requested health service is medically necessary.

The patient wants tooth #11 replaced with an implant. The tooth had been a terminal abutment for a five-unit bridge, but it had to be extracted, so a single implant was placed, which is a very stable, conservative treatment option. It is a better option than the partial denture being offered by the patient's policy. The patient had tried a partial denture but was unable to wear it without discomfort. The implant for tooth #11 is a good, medically necessary alternative to the partial denture. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented to the hospital for atrial fibrillation ablation. The patient was scheduled to undergo elective atrial fibrillation ablation. The patient had a past medical history of cerebrovascular accident (CVA), hepatitis C, rheumatoid arthritis, hypertension (HTN), HLD (hyperlipidemia), gastroesophageal reflux disease (GERD) and systolic heart failure. CVA was managed with tissue plasminogen activator (TPA) and mechanical thrombectomy.

The Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented to the hospital for elective procedure: atrial fibrillation ablation. Her condition upon presentation was stable, including her vital signs, physical examination and labs. The patient underwent the procedure as planned, without significant complications. She had a pericardial effusion, unchanged from previously documented. The patient developed bleeding from her groin when she got up after the procedure, but it was mild, did not require blood transfusion and was not complicated by hematoma.
Based on the above, considering that the procedure was elective, the patient's condition stable, and there were no significant complications which would elevate the level of care to inpatient level, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo
Treatment: Opzelura
The insurer denied Opzelura.
The health plan's determination is overturned.

The patient is a male with vitiligo, treated with triamcinolone and tacrolimus. The provider is requesting Opzelura. 

Opzelura is medically necessary for this patient. The aims of vitiligo treatments are repigmentation and stabilization of the depigmentation process. Treatment goals are to restore the function of melanocytes, which aid in protection of the skin from carcinomatous degeneration as is seen in Albino patients who also lack functional melanocytes. The importance of treating vitiligo was reviewed in the 2009 study cited below.

Opzelura is newly approved for vitiligo. In the randomized controlled trial (Rosmarin, et al), the primary endpoint at week 24 was reached by significantly more patients given ruxolitinib cream at 1.5% (percent) twice daily and 1.5% once daily than were treated with vehicle. Therefore, it is indicated for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis

Treatment: Home Care/Personal Care Level 2, increase to 84 hours per week

The insurer denied coverage for Home Care/Personal Care Level 2, increase to 84 hours per week

The denial is overturned

This is an adult with chronic medical problems including  multiple sclerosis, anxiety and hypothyroidism.
 
The New York State Uniform Assessment System (UAS-NY) Comprehensive Assessment forms were reviewed. The patient's cognitive skills are described as basically intact except for new situations. Memory is intact. The patient is assessed as requiring assistance for most Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL) tasks. The patient is totally dependent with stair climbing, bathing, dressing of the lower body, toilet use and transportation. The patient needs maximal assistance with meals, housekeeping, shopping, weight bearing and walking. The patient is able to walk only with maximal assistance because of their balance and weight bearing dependence. There has been one emergency department visit within the last 90 days.  The patient lives alone, has no informal help and is bowel incontinent. 

Personal Assistance Services (PAS) hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance. 
 
Based on the enclosed documents reviewed, the patient's health and safety cannot be appropriately provided and maintained with 56 PAS hours/week.  The patient's condition is deteriorating, and they need maximal assistance with walking and weight bearing. The patient is totally bowel incontinent, lives alone and has no informal helpers.  The patient's physician notes deterioration and expected further deterioration. The patient is certainly at high risk for falls. 
 
From a family medicine and home care perspective, as well as within a reasonable degree of medical judgment, the carrier's denial of 84 hours of PAS per week is not medically appropriate.  84 hours per week are needed. 
 
Based on the above, the insurer's denial must be reversed. 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 Home Care/Personal Care Level 2, increase to 84 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke with hemiplegia, heart disease, chronic back pain, and anxiety
Treatment: Personal Care Aide (PCA) services, 7 hours/day, 1 day/week; 9 hours/day, 2 days/week; 10 hours/day, 4 days/week
The insurer denied PCA services, 7 hours/day, 1 day/week; 9 hours/day, 2 days/week; 10 hours/day, 4 days/week.
The denial is overturned.

This elderly female patient has medical conditions that include stroke with hemiplegia, heart disease, chronic back pain, and anxiety. She lives alone. The denial of an increase in personal care aide (PCA) services, 7 hours/day, 1 day/week; 9 hours/day, 2 days/week; 10 hours/day, 4 days/week is being appealed. The health plan approved PCA services, 8 hours/day, 7 days/week. The Uniform Assessment System (UAS) evaluation completed the month prior shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances and medications, bathing, lower body dressing, and toilet use; extensive assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and bed mobility; and limited assistance with eating. The patient has bowel and bladder incontinence. She had a fall 2 months ago. Compared 
to UAS evaluation completed last year, there has been no significant change. The appeal statements report the patient has no informal support. Her functioning has 
deteriorated. She has poor vision. She needs frequent assistance with activities of daily living (ADLs) during nighttime due to incontinence. She is wheelchair bound due to unsteady gait. She has no informal support. Night logs shows average assistance every 1 to 2 hours, to include assistance with toileting and repositioning.

The requested health service is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with ADLs, health maintenance activities, and routine support services. This 
patient has multiple chronic conditions. The denial of an increase in PCA services, 7 hours/day, 1 day/week; 9 hours/day, 2 days/week; 10 hours/day, 4 days/week is being appealed. The health plan approved PCA services, 8 hours/day, 7 days/week. The UAS evaluation completed the month prior shows the patient requires assistance with all ADLs. She is incontinent of bowel and bladder. Compared to UAS evaluation completed last year, there is no significant change. However, appeal statements report a deterioration in the patient's condition. She is wheelchair bound and needs nighttime assistance. Night logs show average assistance every 1 to 2 hours, to include assistance with toileting and repositioning. The patient lives alone and has no informal support. The information provided shows that this patient has significant limitations in functioning. The information supports the need for additional assistance during nighttime. The approved PCA is insufficient to meet this patient's needs for assistance with ADLs. The proposed increase in PCA to 7 hours/day, 1 day/week; 9 hours/day, 2 days/week; 10 hours/day, 4 days/week is indicated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: psoriasis

Treatment: Sotyktu 6 milligram (mg) Tablet

The insurer denied coverage for Sotyktu 6 milligram (mg) Tablet

The denial is overturned 

 
The patient is an adult male with a history of psoriasis affecting the groin and elbows involving 11% (percent) total body surface area (TBSA).  The patient has failed therapy with acitretin, which resulted in worsening psychiatric symptoms and was unable to initiate Humira due to documented needle phobia. The requested medication is Sotyktu tablets.  

Based on the submitted documentation and the standard of care Sotyktu is medically necessary.  The patient has psoriasis affecting the penis and groin as well elbows.  The location of his psoriasis affecting the groin limits the patient's ability to use certain topical steroids and ultraviolet (UV) light therapy.  The patient has had psychiatric symptoms on acitretin and thus Otezla, would not be a good treatment option given potential risk of depression.  The patient was unable to start Humira due to documented needle phobia.  Although, numerous formulary alternatives exist, very few Food and Drug Administration (FDA) approved options remain due to the psychiatric symptoms with acitretin and needle phobia.  

Based on the clinical documentation provided and the side effects experienced with prior medications the use of Sotyktu is medically necessary.  The appeal is overturned.  

The formulary drugs are expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non- formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Sotyktu 6 mg Tablet to treat psoriasis is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia
Treatment: Formulary exception for Mounjaro 5mg (milligrams)/0.5 ML (milliliter) Pen
The insurer denied: Formulary exception for Mounjaro 5mg (milligrams)/0.5 ML (milliliter) Pen
The denial is upheld.

The patient is an adult female diagnosed with T2DM (type 2 diabetes mellitus) with hyperglycemia. This request is for Mounjaro. As per the provided letter, she has T2DM (type 2 
diabetes mellitus) as well as Obesity. She tried and failed Ozempic due to constipation and intermittent nausea. As per the visit note, the patient's weight remains about the same, with a body mass index of 31, despite taking Ozempic sample. The patient is also on Jardiance 25 milligrams daily, metformin 2000 milligrams daily, and Basaglar daily and Fiasp before meals. She reported she tried and failed Victoza due to vomiting and 
constipation. The patient's A1C (glycated hemoglobin) two months ago was 7.5 percent (%). Five months ago, it was 7% while on Ozempic. Six months ago, it was 7.9 % and eight months ago it was 7.2 %.

The health plan should not cover the Formulary exception for Mounjaro.

The health plan's formulary requires the trial and failure of the formulary alternatives Trulicity and Victoza. The patient is reported to have only failed Victoza due to side effects. The requested medication Mounjaro (Trizepatide) is FDA (United States Food and Drug Administration) approved for the treatment of adults with type 2 diabetes. It is a GLP-1 (glucagon-like peptide 1) and GIP (glucose-dependent insulinotropic polypeptide) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c (glycated hemoglobin) as well as weight loss (1-3). There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 (glucagon-like peptide 1) receptor agonists as a 1st line agent. There is no preference for the requested medication over GLP-1 (glucagon-like peptide 1) receptor agonists (4). The patient can try the formulary alternative Trulicity, which would be reasonably expected to be as effective with similar adverse effects to the requested non-formulary. The health plan should not cover the formulary exception for Mounjaro, as the request does not meet the formulary requirements or the standard of care and is therefore not medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment:  Inpatient admission
The insurer denied Inpatient admission.
The determination is overturned.

The patient is an adult male who was evaluated and subsequently admitted to inpatient level services for rehabilitation services and management of stimulant (cocaine) and nicotine (tobacco) class use disorders. The patient was using up to two grams of cocaine per day with intranasal administration, as well as tobacco at five or more packs per day in the context of heart disease and history of a stroke.
The patient was admitted to inpatient level care with rehabilitation services together with the availability of comfort medications, and medical monitoring. Following his first day of treatment, the patient began to participate in counseling and educational and group sessions, as well as recovery groups with peer support. His mental status examination included persistent symptoms of anxiety and irritability with associated symptoms of insomnia addressed with Benadryl. He was diagnosed with an unspecified mood disorder of the depressed type and obsessive-compulsive disorder (OCD). He did continue with the rehabilitation treatment including motivational techniques and involvement in 12-step recovery groups, as well as work on coping skills and a relapse prevention plan with identification of triggers. The patient made steady progress. 
At issue is the medical necessity of inpatient admission.
The requested health service/treatment of inpatient admission was medically necessary for this patient.
The adult inpatient treatment of this patient's substance-related disorders and general medical comorbidities did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders, and the associated psychosocial stressors and impairment of functioning, as well as the concerns for biomedical complications and need to monitor. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition to lower-level rehabilitation substance use disorder treatment. Thus, the patient did require a safe and effective inpatient level of care during the time frame under review with associated substance use disorder treatments in keeping with New York State OASAS LOCADTR Criteria-referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion
Treatment: braces/monthly visits
The insurer denied braces/monthly visits
The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion with 4 millimeter (mm) overbite and 4 mm overjet. She has moderate maxillary and mandibular crowing. Tooth 20 is blocked out to the lingual. She is treatment planned for Braces and Monthly Visits (x12) to correct her malocclusion. 

The braces and monthly visits (x12) are not medically necessary. The patient has crowding. 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 not contacting palate in occlusion. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. Tooth 20 is not impacted - it has erupted and is present in the mouth. Tooth 20 is in blocked out to the lingual but tooth 13 is contacting tooth 19 in occlusion so it is not at risk of super-eruption as a result of the position of tooth 20.
At this time, there is no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no anterior 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. The patient's overjet is slightly more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 mm. If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Therefore, the requested Orthodontic treatment is not medically necessary.