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

Diagnosis: Diabetes.
Treatment: Increase in personal care assistant (PCA) services from 35 hrs./week to 56 hrs./week.
The health plan denied: Increase in PCA services from 35 hrs./week to 56 hrs./week.
The determination is: Upheld.

The patient is a male with medical history notable for diabetes and hypertension. The patient is approved for 35 hours (hrs) per week of personal care assistant (PCA) services. The patient and his care team requested an increase to 56 hours per week, and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has diabetes, hypertension, hyperlipidemia, gait imbalance, and vertigo. The letter states that the physician believes it is necessary for the patient to have help in the home 7 days per week. The letter does not discuss any unmet personal care needs.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone in an apartment. He receives 7 hours per day, 5 days per week at the time of the evaluation. The patient is alert and oriented to person and place only. He was able to recall 2/3 words at five minutes. He can call for help in an emergency. He is hard of hearing. For his instrumental activities of daily living (IADL), he requires total dependence for meal preparation, housework, and shopping. He requires maximal assistance for stairs and transportation. He requires extensive assistance for finances, medications, and phone use. For his activities of daily living (ADL), he requires maximal assistance for bathing. He requires extensive assistance for hygiene, dressing, walking, locomotion, toilet transfer, and toilet use. He uses a walker but needs assistance with getting up due to balance issues. He is continent of urine and stool. A task tool recommended 32.25 hours per week to address his personal care needs.
At issue is the medical necessity of an increase in PCA services from 35 hrs/week to 56 hrs/week.
The health plan's determination of medical necessity is upheld in whole.
The requested health service of increase in PCA services from 35 hrs/week to 56 hrs/week has not been demonstrated to be medically necessary for this patient.
The patient has several functional limitations as outlined by the UAS. He requires hands-on assistance for all IADL's and requires some assistance for ADL's. It is unclear which personal care needs, if any, are not being met by his current allotment of hours. His physician recommends care 7 days per week but did not identify any specific needs not being met. There is no documentation stating that his hours cannot be spread out over 7 days. There is insufficient evidence for the medical necessity of the requested increase in personal care hours.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

Patient was a child with a past medical history notable for asthma and constipation that presented to the Emergency Department complaining of non-bloody non bilious vomiting for 4 days, right upper quadrant abdominal pain, decreased oral intake and 2 days of non-bloody diarrhea. There were no associated fevers, dizziness, cough, congestion, weight loss, decreased urine output or dysuria. There were no sick contacts. The patient's vitals were normal. Physical exam showed an awake and alert female in no apparent distress. She had moist mucus membranes with normal capillary refill. Lungs were clear with normal effort. Cardiac exam was unremarkable. Abdomen exam was soft with epigastric/right lower quadrant (suprapubic) discomfort to palpation. There was no associated organomegaly, distension, rebound, guarding or masses. There was no rectal exam reported. Admitting laboratories were notable for sodium 137, potassium 4, bicarbonate 22, Blood urea nitrogen (BUN) 12, creatinine 0.69, glucose 90, lipase 13, and a normal liver profile. Respiratory viral panel was negative. Urine pregnancy test was negative. She was given Zofran 4 milligrams (mg) intravenous (IV), Pepcid 20mg IV, Tylenol orally and antacid 20 cubic centimeters (cc) orally. She received one 1-liter bolus of normal saline followed by additional IV fluids at 100cc/hour. A limited right upper quadrant abdominal sonogram was normal. The patient was offered oral fluids and became nauseous after a few sips leading to the decision to admit the patient to the inpatient unit for hydration and observation. Her admitting weight was 63.9 kilograms, and her height was 152 centimeters. Her heart rate at this time was 75. Once admitted she received intravenous fluid with potassium added. She was offered a regular diet and tolerated it without further vomiting. She never developed fever. No repeat labs were performed. No additional medications were given. She was discharged home with a heart rate of 60.

This child appears to have gastroenteritis with self-limited vomiting, followed by diarrhea, and mild dehydration without ketosis that resolved prior to admission to the inpatient setting. She did not manifest any criteria to merit the inpatient setting. 

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 hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Respiratory Failure.
Treatment: Home Ventilator.
The insurer denied the request for the home ventilator.
The health plan's determination is overturned.

The patient is a male who is seeking approval for a home ventilator. According to documentation the patient received a home ventilator on intelligent Volume Assured Pressure Support( iVAPS).

The health plan in its determination of medical necessity did not act reasonably or with sound medical judgement or in the best interest of the patient.

The requested health service of a home ventilator is medically necessary for the patient. The patient saw his provider and was noted to have a history of obstructive sleep apnea (OSA) on sleep study in addition to prediabetes, obesity, and pulmonary nodules. His body mass index (BMI) was 40. The patient was noted to be using his home ventilator and is compliant. He is on 2 liters with the astral ventilator. He was also diagnosed with chronic respiratory failure. Bilevel was considered unsuitable because breath stacking was thought to be dangerous for the patient and a backup battery was necessary. His chronic obstructive pulmonary disease (COPD) is also worsening.
According to GOLD (2023), NICE (2018), and Wedzicha (2017), the patient has COPD, chronic respiratory failure, and morbid obesity. Appropriate reasoning and medical necessity statements were documented as well as a statement that the patient was compliant and tolerating it well. It would be unreasonable to take this therapy away from the patient.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal failure. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male with a history of nephrolithiasis who presented with diarrhea and vomiting for one day. He states that he had 5-6 episodes of emesis associated with multiple bouts of loose stools. His vitals showed that he was afebrile with a blood pressure of 100/71, a pulse of 92, a respiratory rate of 16 and a room air pulse oximetry of 96%. On exam, he was not in any acute distress. His labs showed a creatinine of 2.37, a potassium of 4.7, a carbon dioxide (CO2) of 16.9, a blood urea nitrogen (BUN) of 39, a hemoglobin of 20.6, and a white blood cell count (WBC) of 5.7. A computed tomography (CT) scan of his abdomen and pelvis showed possible inflammatory changes of rectum but no other acute findings. He was started on intravenous (IV) fluids and was admitted for further management of acute kidney injury. 

The inpatient hospital admission was not medically necessary. The patient presented with a one day history of emesis, nausea and diarrhea from likely viral gastroenteritis. He was clinically dehydrated with an elevated creatinine and hemoglobin. However, he was hemodynamically stable. He did not have severe or persistent nausea or vomiting. He did not have acute kidney injury that did not respond to intravenous (IV) hydration. He did not have severe electrolyte or metabolic abnormalities. He did not have orthostatic vital signs. He responded appropriately to IV fluids and was able to tolerate oral foods by the following morning. He had no documented clinical worsening of his condition. The patient could have been safely and appropriately managed at a lower level with subsequent transition to outpatient follow up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nonrheumatic pulmonary valve insufficiency. 
Treatment: Cardiology service(s) - replacement of the pulmonary heart valve using the Harmony heart valve. 

The insurer denied Cardiology service(s) - replacement of the pulmonary heart valve using the Harmony heart valve. 
The determination is overturned. 

This patient has a past medical history of Epstein's anomaly, congenital pulmonary valve stenosis status/post (s/p) valvulotomy as a neonate who has developed progressive severe pulmonary valve regurgitation with secondary right ventricle (RV) dysfunction and dilation. Pulmonary valve replacement is medically necessary currently for the treatment of pulmonary regurgitation to reduce the risk of progressive right ventricle (RV) failure and death. 

According to the patient's medical provider, the Harmony transcatheter pulmonary valve is medically appropriate for this valve condition. Other valve replacement options (Melody, Sapien), covered by the patient's health plan, are not medically appropriate for this patient due to prohibitive cardiac anatomy of the patient's surgically repaired right ventricular outflow tract (RVOT)/main pulmonary artery (PA). Whereas the Harmony valve device will be able to be appropriately positioned based on cardiac imaging results. At issue is the medical necessity of the requested health service/treatment of Harmony valve. 

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient. The Harmony Transcatheter Pulmonary Valve (TPV) replacement is Food and Drug Administration (FDA) approved for treatment of severe pulmonic valve regurgitation in patients with native or surgically repaired right ventricular outflow tract (RVOT). This patient meets Food and Drug Administration (FDA) criteria for Harmony valve implant and based on records provided for review of this case, has no other medically appropriate transcatheter options due to prohibitive cardiac anatomy. 

Both the health plan's approved Transcatheter Pulmonary Valve (TPV) replacement options (Melody/Sapien) are not medically appropriate for this patient due to the size and landing size of the patient's surgically repaired right ventricular outflow tract (RVOT)/main pulmonary artery (PA). 

Furthermore, peer reviewed published medical literature to date has demonstrated that the Harmony device is both safe and effective to treat severe pulmonic valve regurgitation demonstrating stable prosthetic valve function and freedom from moderate to severe pulmonic valve regurgitation at 5 years follow-up (1, 2). 

The requested health service/treatment of Harmony valve is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left temporal glioblastoma
Treatment: Optune Device
The insurer denied the Optune Device.
The determination is overturned.

This is a patient with a left temporal glioblastoma (isocitrate dehydrogenase 1 (IDH1) wild type). The patient has undergone resection. Adjuvant temozolamide and radiation were administered. Adjuvant temozolomaide and tumor treatment fields (TTF) were recommended following radiotherapy. TTF (Optune) is under review for medical necessity.

The Optune Device is medically necessary for this patient.
Data supporting the role of tumor treating (TT) Fields in the up-front setting consists of an unblinded, multicenter international trial in which 695 patients with newly diagnosed glioblastoma were randomly assigned in a 2:1 fashion to monthly temozolomide plus TTFields or monthly temozolomide alone upon completion of standard radiation and concurrent daily temozolomide. Eligible patients must have completed concurrent radiation and daily temozolomide without progression and were enrolled within seven weeks of completing radiation. The primary endpoint was progression-free survival. The trial was stopped early for benefit, at the time of a planned interim analysis of the first 315 patients with greater than or equal to 18 months of follow-up; at this time, trial enrollment had already reached the intended 695 patients. After a median follow-up of 40 months in surviving patients, those assigned to the TTFields device had improved progression-free survival compared with those assigned to temozolomide alone (6.7 versus 4.0 months). Overall survival from the time of randomization was also improved (20.9 versus 16.0 months).

Based on this study, the National Comprehensive Cancer Network (NCCN) considers TTF a category 1 recommendation for the treatment of glioblastoma multiforme in this clinical scenario. This is supported in the peer-reviewed literature and by the authors of UpToDate. It is not the subject of ongoing investigation for safety or efficacy. Criteria for medical necessity have been satisfied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immunologic Disorders/Other/Psoriatic arthritis. 
Treatment: Tremfya. 

The health plan denied the requested prescription medication, Tremfya, as not medically necessary. The health plan's determination is upheld. 

The patient is a male with moderate to severe psoriasis that includes the arms, legs, and hands, The patient has tried and failed oral Methotrexate, Infliximab (Remicade), Secukinumab (Cosentyx), Leflunomide, Updadacitinib (Rinvoq), phototherapy (burning was noted), and topical agents such as augmented Betamethasone Dipropionate, Calcipotriene, Taclonex, Halobetasol, and Protopic. The latest biologic treatment has been Golimumab (Simponi) prescribed by Rheumatology, and without notable improvement. 

The requested health service of Tremfya is under review for medical necessity. 

The health plan denial of Tremfya coverage is recommended to be upheld, in whole. 

The requested service of Tremfya is not medically necessary for this patient. Having reviewed the case thoroughly, based on the information provided, it is not certain as to whether or not the patient's Simponi will be discontinued if Tremfya is started. Having failed Remicade and Simponi, it is appropriate medically to choose a non-Tumor Necrosis Factor inhibiting biologic alternative (such as Tremfya). However, it is not supported by medical literature [1-4] or standards of care to be on both Simponi and Tremfya concurrently. It is not inappropriate to use Methotrexate with either Simponi or with Tremfya, but not the latter two medications (both biologic medications) used concurrently. It should be confirmed that Simponi will be discontinued first.
The patient has failed both Tumor Necrosis Factor inhibitors (Remicade and Simponi), an Interleukin-17 inhibitor (Cosentyx), and a Janus Kinase inhibitor (Rinvoq) in the treatment of this patient's psoriasis of the skin and joints. Traditional therapies with topical and first-line oral medications (such as Methotrexate and Leflunomide) are indeed appropriate for concurrent use with biologic therapies, but concurrent use of two biologic agents (such as Simponi and Tremfya) is not medically supported by current medical literature reviews [1-4] in the treatment of psoriasis of either the skin and/or joints. Simponi and Tremfya are not appropriate when they are used together.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mobility issues
Treatment: Personal care services
The insurer denied personal care services.
The health plan's determination is overturned.

The patient is a female with history of chronic fatigue, neuropathy, and neck pain who requested PCA (personal care assistant) services and the time task summary stated the patient needed help with managing bed, linen change, tidying up, vacuuming, mopping, trash removal, dusting, kitchen cleanup, dishes, and bathroom cleanup as well as shopping. 

Personal Care Services are medically necessary for this patient.

The patient's medical provider noted the patient required additional help with activities of daily living (ADL). The patient, herself, reported assistance needs with housekeeping, laundry, cooking, and shopping. The patient's assessment was via video and underestimated the patient's care needs. 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 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 her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth decay
Treatment: White Glass with Metal Crown Tooth #28
The insurer denied: White Glass with Metal Crown Tooth #28
The denial is upheld

The patient is an adult female requesting a crown on tooth #28. The prior denial was due to no decay being seen under the existing crown.

The proposed treatment is not medically necessary.

According to the x-rays provided, no recurrent decay is seen under the existing crown. A photo would possibly show any new decay, but one was not provided. Since no decay was evident, no new crown is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding, deep bite, excessive overjet and impacted maxillary canines. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. 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 reaching a score of 7 points.

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 the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the 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 claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify 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 needs 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 D8080 braces and D8670 monthly visit is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety Disorder
Treatment: Clomipramine 50 milligrams (mg)
The insurer denied:  Clomipramine 50 milligrams (mg)
The denial is: Upheld

The patient is a female diagnosed with unspecified anxiety disorder and treatment with clomipramine at a dose of 50 milligrams (mg) daily. The patient has failed to respond to other unspecified medications. There is no mention of combination or augmentation therapy in this case. There is no mention of comorbid conditions or co-occurring substance use disorder.
The health plan has denied coverage for clomipramine as based on the pharmacy records there is no evidence that the patient has tried and failed the plan's preferred alternatives.
The medical necessity for clomipramine is the subject under review.

The requested treatment with Clomipramine is not medically necessary for this patient.
The plan alternatives: Fluvoxamine, Sertraline, Paroxetine tablets, and Fluoxetine capsules are reasonable and covered under the plan. There is no evidence that clomipramine offers any advantage over the plan's alternatives known to be effective and indicated for the treatment of anxiety disorders.
The preferred drug list covered under the plan is reasonable and in keeping with prevailing standards of medical practice for treatment of the condition diagnosed in this case; and the plan formulary alternatives available in this case are clinically appropriate and backed by credible scientific evidence known to benefit patients with the condition diagnosed in this case.
This answer is in keeping with the scientific literature.