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

Diagnosis: Obesity.
Treatment: Wegovy 0.25MG (milligrams) /0.5ML (milliliter) SC (subcutaneous) SOAJ (solution auto injector).
The insurer denied coverage for Wegovy 0.25MG/0.5ML SC SOAJ.
The denial is overturned.

The patient has obesity, and the Body Mass Index (BMI) is reported to be over 30. A questionnaire was submitted that states that the patient was not in a comprehensive weight management program which includes behavioral modification and increased physical activity. However, the patient has submitted a letter stating that he has been in a weight loss program and continues to be in a program. In addition, he has bad knees and is awaiting knee surgery. His joint disease is limiting his ability to exercise.

UpToDate has an article titled "Obesity in Adults: Drug Therapy." The article states that a number of medications are approved by the Food and Drug Administration (FDA) for the treatment of obesity in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those with a BMI over 30 or a BMI over 27 with related comorbidities. Semaglutide is a GLP-1 (glucagon-like peptide) agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction, as well as improvement in glycemia and lipids. It has also demonstrated cardiovascular benefits.

This patient has obesity with a BMI over 30. He has been in a weight loss program and his joint disease is preventing him from fully exercising. He needs to lose weight in order to have knee surgery. The FDA has approved Wegovy for weight loss in patients with a BMI of 30 or greater. The UpToDate article also supports giving Wegovy as a treatment to assist with weight loss.

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 Wegovy 0.25MG/0.5ML SC SOAJ services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8070 braces and D8670 monthly visit x 4
The insurer denied coverage for D8070 braces and D8670 monthly visit x 4
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 anterior impactions. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index Report choosing the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated on the HLD index. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. 

Upon review of the submitted documentation it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 
In this case, the treating orthodontist completed the HLD index, choosing the impacted permanent anteriors criterion to justify orthodontic care. The clinical circumstance meets this criterion for approval of care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Overturn the denial as the clinical circumstance as presented meets and substantiates 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 D8070 braces and D8670 monthly visit x 4 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Acute cholecystitis is a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes.

Per clinical documentation, this patient presented to the emergency department (ED) with a three-day history of acute right upper quadrant abdominal pain. There was associated nausea and vomiting. Vital signs in the ED (emergency department) were significant for an elevated blood pressure of 166/99. The patient had an ultrasound that demonstrated findings consistent with acute cholecystitis. The white blood cell count was 12.3. The total bilirubin was elevated to 2.1. The remaining liver function tests were within normal limits. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. The patient was discharged. Per Milliman Care Guidelines (MCG) criteria, admission is indicated for calculus or obstruction of gallbladder or bile duct and either hemodynamic instability, common bile duct obstruction, severe or persistent vomiting or dehydration, severe pain, or bacteremia. According to clinical documentation, the patient did not meet criteria for inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Therefore, the requested hospital stay should be observation status. An inpatient admission is not medically necessary, and the health plan acted reasonably. 

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 at Montefiore Medical Center is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Myelogenous Leukemia (AML)
Treatment: Xospata
The insurer denied: Xospata
The denial is: Upheld

The patient is a female fms-like tyrosine kinase 3 (FLT-3) acute myelogenous leukemia. The patient has received indication therapy with 7+ (plus) 93 and crenolanib. The patient has undergone consolidation with High dose intermittent ARA-C (HIDAC) and a matched unrelated stem cell transplant. The patient is without evidence of acute leukemia on bone marrow biopsy. Xospata (Gilteritinib) has been recommended and is under review.

The treatment with Xospata 40 milligrams (mg) tablets is not medically necessary for this patient. While FLT3 inhibitor maintenance is recommended by the National Comprehensive Cancer Network (NCCN), data supporting the use of Xospata for this purpose is scant and it is not recommended by the NCCN, the peer-reviewed literature, nor by the authors of UpToDate. A review of clinicaltrials.gov did not demonstrate any previous nor active trials evaluating the approach as requested by this provider. Lacking evidence of efficacy, medical necessity for this service cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, Atrial Fibrillation and Vertigo
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 7 days per week 2-12 hours split shift
The insurer denied coverage for CDPAS 7 days per week 2-12 hours split shift.
The denial is upheld.

This is an elderly patient with chronic medical problems including diabetes, atrial fibrillation and vertigo. The patient is currently approved by the insurer for CDPAS 24 hours/day, 7 days/week (live-in). A change to 7 days per week 2-12 hours split shift is being requested.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as modified independent. The patient is fully alert and oriented, but sometimes forgetful. Maximal assistance is required for bathing and lower body dressing. Extensive assistance is needed for upper body dressing, bed mobility and toilet transfer/use. The patient is frequently bladder incontinent and occasionally bowel incontinent. Supervision is needed for eating. The patient was observed ambulating with a rollator and the assistance of his daughter during the assessment.

The currently approved CDPAS 24 hours a day, 7 days a week (live-in) is sufficient to meet the patient's daily/nightly functional needs. The patient's condition and frequency of functional needs are not at a level or unpredictable as to require the requested CDPAS 24 hours a day, 7 days a week (split shift). Based on the records reviewed, the PCA (personal care assistance) is able to provide for the patient's functional needs with the ability to obtain uninterrupted 5 hours of sleep. The patient's health and safety can be appropriately provided and maintained at home with the currently approved CDPAS 24 hours a day, 7 days a week (live-in).

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.

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 consumer directed personal assistance services (CDPAS) 7 days per week 2-12 hours split shift services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Rinvoq ER (extended release) 30mg (milligrams). 
The insurer denied: Rinvoq ER (extended release) 30mg (milligrams). 
The denial is overturned. 

The patient is an adult female with moderate to severe Crohn's disease. She has failed mesalamine, sulfasalazine, 6-MP (mercaptopurine), Remicade, Stelara and Humira. She started Rinvoq 45 mg (milligrams) daily earlier this year and did well. Recently Rinvoq was decreased to 30 mg (milligrams) daily. She continues to do well. Colonoscopy revealed her to be in endoscopic remission. Her provider is requesting continuation of Rinvoq. 

The requested Rinvoq is medically necessary. 

Rinvoq is a JAK (janus kinase) inhibitor that is FDA (United States Food and Drug Administration)-approved for use in ulcerative colitis, rheumatoid arthritis and psoriatic arthritis. In a phase 2 trial of patients with Crohn's, Rinvoq induced endoscopic remission in a significant proportion of patients compared with placebo. Most drugs FDA (United States Food and Drug Administration)-approved for ulcerative colitis eventually are approved for use in Crohn's, and it is standard of care to use such drugs for both conditions. When the patient started on Rinvoq, she had no other available treatment options for Crohn's, and she has done remarkably well. Discontinuing Rinvoq at this time would not be clinically appropriate or accepted standard of medical care. Therefore, continuation of the proposed Rinvoq is clinically appropriate, accepted standard of medical care, and is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anaphylaxis.
Treatment: Inpatient admission.
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a female with a history of hypertension (HTN), hyperlipidemia (HLD), hypothyroidism and angioedema who presented to the emergency department (ED) with tongue swelling that started few hours prior to presentation. She had similar symptoms in the past, her Lisinopril was stopped and she was switched to Irbesartan. She was also on Hydralazine. She had no associated itching, rash, shortness of breath (SOB) or chest pain. However, she had significant tongue swelling. Her exam was notable for a swollen tongue and her Mallampati score was 4. She was given Epinephrine, Benadryl, a proton pump inhibitor (PPI), Histamine H2-receptor antagonists (H2 blockers) and was admitted to the intensive care unit (ICU). She was placed on telemetry and observed in the ICU. Her angiotensin II receptor blocker (ARB) was stopped and she continued on Hydralazine. She remained hemodynamically stable and her tongue continued to improve slowly. She was subsequently discharged with an EpiPen and with a plan to follow up with her primary care physician (PCP).

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 patient had angioedema, significant tongue swelling and a high Mallampati score. She needed an inpatient admission, management and monitoring.

The patient was admitted to the ICU. She was meeting criteria for inpatient admission due to the acuity of her presentation and severity of the angioedema. She has a Mallampati score of 4 that is the highest score with high risk intubation and high risk of compromise if the patient needs intubation. This high score was from significant tongue edema [1]. She also had stage 3 tongue swelling from the angioedema and the ICU admission is recommended in such situations [2,3]. Moreover, the patient most likely has bradykinin mediated angioedema that can have a waxing and waning course and can worsen after initial improvement. Bradykinin mediated angioedema can have a more unpredictable course compared to allergic or anaphylactic angioedema. The patient most likely had ARB associated angioedema. Despite the patient's quick recovery and hemodynamic stability, the patient was a high-risk patient and needed inpatient management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female. She was admitted to the hospital with exam and CT (computed tomography) findings of acute appendicitis. She was admitted for IV (intravenous) hydration and IV (intravenous) antibiotics. She underwent a laparoscopic appendectomy, which confirmed acute infection of the appendix. Postoperatively, after she was stable, tolerating a diet and managed with oral pain medications. She was subsequently discharged. 

The inpatient admission was denied coverage by the health plan, stating that based on MCG (Milliman Care Guidelines) Criteria-Surgery, admission to the hospital was not medically necessary. 

The Inpatient Hospital Admission was not medically necessary. 

The hospital's appeal letter notes that the patient was ASA (American Society of Anesthesiologists) class 3, making her higher risk. However, per the provided anesthesia records, the patient was classified as ASA (American Society of Anesthesiologists) class 2. 

Appendectomy without abscess or peritonitis can be performed as an ambulatory status or extended stay. This patient was first triaged in the Emergency room late at night. She was evaluated by anesthesia early the next morning and had surgery right away. She was discharged from the hospital the same day after surgery. The patient was in the hospital for less than 12 hours. The patient's vitals were stable throughout the entire stay, not requiring any extra or additional management. 

Therefore, given the above, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flank pain, nausea and vomiting
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult female with history of recent ESWL (Extracorporeal Shock Wave Lithotripsy) and stent placement for renal calculus status post stent removal. She presented with worsening flank pain, nausea and vomiting. The pain refractory to Tylenol, ibuprofen and oxycodone at home.

Noted were several episodes of hematuria after stent removal. CT (computed tomography) abdomen/pelvis demonstrated right hydronephrosis and hydroureter proximal, no stones UPJ (Ureteropelvic Junction) obstruction was suspected. The patient was noted to be afebrile. Vital signs were stable. She had steady gait. Abdomen was soft non-tender, non-distended. The patient was alert and oriented on presentation. White blood cell count was elevated at 13.7, creatinine was normal at 0.72, urinalysis was negative for leukocyte esterase, nitrite, 4 WBC (white blood count) and 207 red blood cells. The patient was admitted inpatient for pain control and hydration.

The inpatient hospital admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The requested inpatient hospital admission was not medically necessary.

This patient presented with flank pain, nausea, and vomiting after stent removal after treatment for a stone. At the time of presentation, she was alert and oriented, had stable vital signs, and her creatinine was normal. She had no documentation of acute kidney injury stage 2 or 3, and there were no signs of pyelonephritis on her CT scan. Her urinalysis was nitrite negative, leukocyte esterase negative, only 4 WBC and no bacteria. She had no indwelling prosthetic device. She was not noted to be pregnant. She had not been managed with observation management, and there was no notation of impaired bladder emptying. The patient was placed on antibiotics empirically without vital signs, urinalysis or CT to support the presence of pyelonephritis, emphysematous pyelonephritis or pyelitis.

Thus, the patient did not meet the criteria for inpatient hospital admission and could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult male with a history of schizoaffective disorder who presented to the emergency ward with aggressive behavior. At presentation he had a normal neurological examination. He was admitted for possible seizure. Subsequent MRI (magnetic resonance imaging) and EEG (electroencephalogram) were negative.

The acute inpatient level of care from was not medically necessary.

The patient presented with spells of agitation and aggressive behavior. There was no tonic clonic activity, tongue bite, rhythmic motor activity, incontinence or post-ictal confusion to support he was having seizure activity. Given the pre-existing diagnosis of schizoaffective disorder, the likely diagnosis was not seizure (Shellhaas, 2019). The diagnostic studies and treatment for these spells could have been safely and effectively completed at a lower level of care (Schomer, 2021).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple medical conditions - Obesity, memory deficits, hypertension, osteoarthritis, asthma, depression, sleep apnea and has chronic pain
Treatment: Additional 19-24 Hours Personal Care Services 
Per Week for a Total of 25 to 30 Hours Per Week
The insurer denied: Additional 19-24 Hours Personal Care Services Per Week for a Total of 25 to 30 Hours Per Week
The denial is upheld

The patient is an adult female. The patient is morbidly obese. She has memory deficits, hypertension, osteoarthritis, asthma, depression, sleep apnea and has chronic pain. Denial of an additional 19-24 hours personal care services per week for a total of 25 to 30 hours per week is being appealed. The health plan approved 6 hours per week.

The Personal Care Service Time-Tasking Tools shows functional status: extensive assistance with environmental care, meal preparation, and shopping; minimal assistance with bathing and dressing; and independent with eating, grooming, toileting, transferring, mobility/ambulation. An appeal statement from the patient's provider notes the patient's multiple medical appointments. She has limited mobility and difficulty with household chores and personal care. The provider recommends additional hours.

The requested Additional 19-24 Hours Personal Care Services Per Week for a Total of 25 to 30 Hours Per Week is not medically necessary.

Personal Care Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. 

This patient has multiple chronic medical conditions. The Personal Care Service Time-Tasking Tools shows she needs assistance with environmental care, meal preparation, shopping, bathing, and dressing. An appeal statement notes the patient needs additional hours for assistance with household chores and personal care. The information provided does not support that the patient's level of functioning and need for assistance with ADLs (activities of daily living) requires more than 6 hours per week to be accomplished. She has limited needs for assistance with ADLs (activities of daily living). The requested additional 19-24 hours personal care services per week for a total of 25 to 30 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Leg Weakness
Treatment: Physical Therapy 2 visits
The health plan denied the requested physical therapy, 2 visits, as not medically necessary. 
The health plan's determination is overturned.

The patient has a past medical history (PMH) of a cerebrovascular accident (CVA) with residual left upper extremity (LUE) coordination deficits and transverse myelitis, (initial onset combined with a Covid infection) with significant residual right lower extremity (RLE) weakness. She has been receiving physical and occupational therapy to assist with her gait impairments and activities of daily living (ADLs). She had a cervical magnetic resonance imaging (MRI) which demonstrated findings consistent with cervical myelitis as well as multilevel cervical spondylosis and central canal stenosis. On her most recent physical therapy (PT) visit, it was documented that the patient had made gains with lower extremity (LE) strength, ambulation, standing tolerance, and sit to stand testing. Ongoing PT was recommended, as she has ongoing short term and long-term goals.
At issue is the medical necessity for the requested physical therapy visits.

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

Based on her most recent medical assessments and physical therapy assessment, it would be medically sound to consider further physical therapy.
Further physical therapy is medically necessary for this patient. On her PT assessment, there was an overall improvement in bilateral lower extremity (BLE) strength, ambulation, standing tolerance and sit to stand. As outlined by her physical therapist, she still had both short- and long-term goals to consider prior to discharging her from PT.