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

Diagnosis: Dementia, blindness, hearing loss, arthritis, and weakness
Treatment: Increase Home Care/Personal Care HHC Level 2 Personal Care Services per 15 Minutes to 80 Hours per Week
The insurer denied: Increase Home Care/Personal Care HHC Level 2 Personal Care Services per 15 Minutes to 80 Hours per Week
The denial is overturned.

This elderly female patient has medical conditions that include dementia, blindness, hearing loss, arthritis, and weakness. The denial of an increase in personal care services to 80 hours per week is being appealed. The health plan approved 44 hour per week. Uniform Assessment System evaluation completed six months ago shows modified independent cognitive skills and 
functional status: total dependence with meal preparation and housework; maximal assistance with shopping; extensive assistance with managing finances and medications, phone use, 
transportation, bathing, personal hygiene, dressing, walking, locomotion, and toileting; limited assistance with eating; and independent with bed mobility. She is continent of bowel and 
bladder. Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with meal preparation, personal hygiene, upper body dressing, walking, locomotion, toileting, and eating. 
Appeal statements have been provided. These statements indicate the patient's functioning has declined. She is homebound. She needs assistance with activities of daily living. She is a fall risk. She lives with her granddaughter who works.

The proposed treatment is medically necessary. 

Personal Assistance 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 conditions. The denial of an increase in personal care services to 80 hours per week is being appealed. The health plan approved 44 hour per week. Uniform Assessment System evaluation completed six months ago, shows the patient requires assistance with all activities of daily living, except bed mobility. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with meal preparation, personal hygiene, upper body dressing, walking, locomotion, toileting, and eating. Appeal 
statements indicate the patient is homebound and has a deterioration in level of functioning. She is at risk for falls. The information provided shows that this patient has significant limitations in functioning that have declined. The approved personal care services 44 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 80 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dental treatment

Treatment: Crowns (D2750) on tooth #s 5, 18, 19 & 31

The insurer denied coverage for Crowns (D2750) on tooth #s 5, 18, 19 & 31.

The denial is modified.

Upon review of the submitted documentation which includes narrative letter and multiple periapical radiographs, and copies of panoramic radiographs, dental charting and treatment notes, intraoral photograph and photographs of broken dental restoration, and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment. Based on the documentation full coverage crowns were recommended for teeth numbers 5, 18, 19 and 31 due to sensitivity and prior endodontic treatment on tooth number 18. The insurer has denied the services stating that these services are not medically necessary treatment as the clinical documentation does not support the requested services and does not meet required clinical criteria. 

Based on the submitted objective information for review, the radiographic documentation does not support the dental treatment on teeth number 5, 19 and 31 recommended by the dentist. It appears that there is no evidence of fracture or other pathology specifically affecting numbers 5, 19 or 31 based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested full coverage crowns for teeth numbers 5, 19 and 31. As the documentation is inadequate to support the treatment, these services are considered not medically necessary. 

As regards number 18 this tooth has already undergone endodontic therapy with placement of a temporary restoration. This tooth will have adequate residual coronal structure for support of post and core and crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice after endodontic therapy is a full coverage crown restoration which would have an excellent long-term prognosis with the recommended treatment.

Uphold denial for crowns (02750) on tooth numbers 5, 19 and 31 as the provided documentation for review is inadequate and did not support the treatment recommended. 

Reverse denial for crown (D2750) on tooth number 18 and approve as medically necessary as the clinical and radiographic documentation support this service, and this service would be a standard of care in general dental practice.

Based on the above, the insurer's denial must be modified. 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 Crowns (D2750) on tooth numbers 5, 19 & 31 services is not substantiated. However, crown for tooth number 18 is supported.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stoke, chronic kidney disease, ataxia, frailty
Treatment: Increase Home Care/Personal Care HHC Level 2 Personal Care Services per 15 Minutes to 24 Hours per Day (Live-in)
The insurer denied: Increase Home Care/Personal Care HHC Level 2 Personal Care Services per 15 Minutes to 24 Hours per Day (Live-in)
The denial is overturned.

This elderly female patient has medical conditions including stoke, chronic kidney disease, ataxia, frailty, and is wheelchair bound. The denial of an increase in home care/personal care to 
24 hours per day (live-in) is being appealed. The health plan approved 56 hour per week. Uniform Assessment System evaluation completed six months ago shows minimally impaired cognition and functional status: total dependence with meal preparation and housework; maximal assistance with managing finances, shopping, bathing, and lower body dressing; extensive assistance with managing medications, stairs, transportation, personal hygiene, upper body dressing, walking, locomotion, and toileting; and limited assistance with phone use, bed mobility, and eating. She is continent of bowel and bladder. A letter from a Provider notes the patient needs 24/7 supervision and requires assistance with activities of daily living. She lives alone and has no informal support. An appeal statement from New York State indicates the patient has evening and nighttime needs that are not met under the current authorization. She needs assistance with transferring out of the bed and toileting during the night. She uses the commode two to three times per night. She has fallen when unassisted overnight. She is not able to independently call for help in case of emergency.

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding. This patient has multiple chronic conditions and is wheelchair bound. She lives alone. The 
denial of an increase in home care/personal care to 24 hours per day (live-in) is being appealed. The health plan approved 56 hour per week. Uniform Assessment System (UAS) evaluation 
completed six months ago shows the patient requires assistance with all activities of daily living. Appeal statements support the patient needs assistance with all activities of daily living. She has 
no informal support. The patient needs nighttime assistance with transfers and toileting. She has a history of falls when attempting to use the commode without assistance. The information provided shows that this patient has significant limitations in functioning. The approved personal care services of 56 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 24 hours per day (live-in) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female who was 9-weeks post-partum when she presented to the emergency department (ED) with abdominal pain, nausea, and vomiting of 1-day duration. She had known gallstones. At the time of presentation, the patient was without fever, her heart rate was 81 beats per minute, and her blood pressure was 131/71 millimeters of mercury (mmHg). She was tender in the right upper quadrant. The white blood cell count (WBC) count was normal at 7.2. The complete metabolic panel identified elevated liver enzymes (alanine aminotransferase (ALT) of 677 and aspartate aminotransferase (AST) of 545) and bilirubin of 1.2.
The ultrasound showed a gallbladder with gallstones and the bile duct was 3 millimeters (mm) in diameter. A magnetic resonance cholangiopancreatography (MRCP) was performed showing gallstones in the gallbladder and no findings of common duct stones. She was admitted to the hospital and was initially treated with intravenous (IV) fluids and antiemetics. She was treated with a laparoscopic cholecystectomy. The operative dictation records completion of the procedure without complication with findings of acute cholecystitis. The patient was treated with post-surgical monitoring, IV (intravenous) fluids, IV analgesia, antibiotics, and antiemetics. The immediate post-surgical recovery was uncomplicated. She had a normal temperature and normal vital signs. The diet was advanced, and her pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting.

An inpatient level of care was not medically necessary in this case. The treatment plan in this case included surgery that was performed. The progress notes state that the patient was stable for discharge from the hospital on the first post-surgical day. The ultrasound showed a gallbladder with gallstones and the bile duct was 3 millimeters (mm) in diameter. A magnetic resonance cholangiopancreatography (MRCP) was performed showing gallstones in the gallbladder and no findings of common duct stones. She was admitted to the hospital and was initially treated with intravenous (IV) fluids and antiemetics. She was treated with a laparoscopic cholecystectomy. The operative dictation records completion of the procedure without complication with findings of acute cholecystitis. There were no peri-operative complications or other clinical issues. She remained stable and was suitable for discharge from the hospital on the first post-surgical day. In this case, the patient's presenting condition, laboratory data and imaging, and her clinical course did not justify an inpatient level of care. The care provided during this period of time could have appropriately been rendered with an alternate level of care.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Beta Thalassemia
Treatment: Deferasirox 
The insurer denied the request for Deferasirox.
The health plan's determination is upheld.

The patient is female for whom there is little primary clinical documentation. The patient is stated to have beta thalassemia. Deferasirox has been recommended and is under review. The patient has not tried and failed any of the formulary alternatives (Deferiprone and Ferriprox). The patient does not have a documented inadequate response or adverse reaction to the formula alternatives and the patient has no documented contraindication to the formulary alternatives.

The authors of UpToDate state "... There is no current consensus on which agent to choose when initiating chelation therapy. The age of the patient, presence or absence of comorbidities, side effects of the available agents, and patient preferences will determine which agent is chosen. ..". Given the available information, there is no evidence that the formulary alternative would be more toxic, less well tolerated, or less effective than Deferasirox. Lacking phase III data or evidence in literature or recommendations in guidelines, the superiority of the requested agent over the formulary alternative cannot be established.

The health plan's determination is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Alopecia areata
Treatment: Xeljanz
The insurer denied Xeljanz.
The determination is overturned.

The patient is a male with alopecia areata (AA). The alopecia areata was severe with complete scalp hair loss and loss of eyebrows. He has been on Xeljanz with near remission. The medication under review is Oral Xeljanz (10 mg tablets).

The proposed health treatment Oral Xeljanz (10 mg tablets) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient is in remission, and there are no other standard of care treatments that would be appropriate for this patient.

Based on the current peer-reviewed literature and accepted standards in the specialty's medical community, the treatment with Xeljanz is considered medically necessary for this particular individual.

In support of the use of Xeljanz for alopecia, Liu et al writes "Ninety patients met inclusion criteria. Of 65 potential responders to therapy, defined as those with alopecia totalis or alopecia universalis with duration of current episode of disease of 10 years or less or alopecia areata, 77 percent (%) achieved a clinical response, with 58% of patients achieving greater than 50% change in severity of alopecia tool (SALT) score over 4 to 18 months of treatment. Patients with AA experienced a higher percent change in the SALT score than did patients with alopecia totalis or alopecia universalis (81.9% vs 59.0%). Tofacitinib was well tolerated, and there were no serious adverse events" [1].

Given this patient's positive response to Xeljanz, continued treatment with Xeljanz is warranted.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Alopecia areata
Treatment: Xeljanz
The insurer denied Xeljanz.
The determination is overturned.

This is a male patient with alopecia areata (AA), treated with topical and intralesional steroids, topical janus kinase (JAK) inhibitors and minoxidil. The provider is requesting Xeljanz as continuation as the patient has had dramatic improvement on Xeljanz. The health plan denied the request and the Xeljanz is under review.

A wide range of treatments have been used for the management of alopecia areata, most of which are not highly effective. Treatments include topical or intralesional corticosteroids, topical minoxidil (2 percent (%) or 5%), topical anthralin, systemic corticosteroids, cyclosporine, and other immunosuppressants. A dependable and safe treatment for extensive disease (totalis or universalis) has yet to be found. Given the rarity of the disease, large randomized controlled trials are extremely difficult.

Alopecia areata and its variants is an extremely distressing disease. With further case reports of "off-label" uses of medications such as Xeljanz, more treatment options can become available. Xeljanz is currently Food and Drug Administration (FDA)-approved for rheumatoid arthritis and undergoing approval trials for psoriasis and psoriatic arthritis. It is known to be safe and effective in the conditions for which it is FDA approved. Biologic medications as a whole have many off label uses, leading to better outcomes in rare diseases for which large randomized trials are not readily available.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache and vision changes during pregnancy
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay.
The determination is upheld.

This is a female patient who presented with an intractable headache for one week and dark spots distributed throughout the visual field. The headache was described as strong pressure with severe intensity with pain from top of head and radiation to the occipital/neck area. The headache was also associated with tinnitus, photosensitivity, nausea and vomiting and was described as being worse in the morning when she first woke up and she also felt dizzy. 
The patient reported that her blood pressure had been in the 160s to 170s at home and particularly at night. The patient was admitted for a headache evaluation and chronic hypertension with superimposed preeclampsia without severe features. She was also under evaluation for an intracranial mass versus pseudotumor cerebri. The patient's plan for admission was to labor and delivery for monitoring with twice per day nonstress test, and labs. The patient was also to have a consultation with maternal fetal medicine, neurology, and ophthalmology. 

During the hospitalization, the patient underwent an MRI (magnetic resonance of imaging) of the brain that showed no acute changes. She had no evidence on MRA (magnetic resonance angiography) or MRV (magnetic resonance venography) of a clot. The patient was noted to be recommended for magnesium for headache. She was also prescribed Tylenol as needed for pain. She had a resolution of the vision symptoms. Fetal testing was reassuring. The patient's symptoms improved with treatment, and she was discharged to home. At issue is the medical necessity of an inpatient stay.

Based upon a review of the medical records and the peer reviewed medical literature, there was no medical necessity for acute inpatient care.
The patient presented with a headache and known chronic hypertension. She was evaluated and found to have a normal neurologic exam and normal vital signs with normal MRI (magnetic resonance of imaging). She was monitored for any changes. The fetal status was reassuring. There was no acute range blood pressure. The patient was noted to have mild range blood pressures without any hypertensive emergency. There was no evidence of end organ damage in this case. There was no evidence of a cerebral infarction or intracerebral hemorrhage. MRI was normal of the central nervous system (CNS) and spine. There was no evidence of vision loss or unstable angina.  Fetal status remained reassuring. Based upon this information, the patient would not meet criteria for an acute inpatient admission. The patient required no antihypertensive therapy or magnesium. Given the absence of any change in her status and normal laboratory values with a total protein not significantly changed from baseline, there was no suspicion of preeclampsia in this case, and this would not require treatment with magnesium sulfate, which was deferred. Thus, care in this case could be provided at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Hyperglycemia
Treatment: Inpatient level of care
The health plan denied: Inpatient level of care
The determination is: Overturned

The patient is a female with known type 1 diabetes. She had blood sugars greater than 600. The patient was assaulted 24 hours prior to coming to the emergency department (ED). X-rays were done which did not show any fractures. She had pain and hyperglycemia. Her blood glucose in the ED was 438, with a bicarbonate of 18, an anion gap of 16, and a beta hydroxybutyrate of 4.52. The patient was diagnosed with diabetic ketoacidosis (DKA) and was treated with an insulin infusion.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of the inpatient level of care is medically necessary for this patient. Hospitalization for DKA is universally medically necessary[1-9]. Patients with diabetes and DKA initially generally require the intensive care unit (ICU) level of care[1,3,4,5] until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring the ICU level of care[10 ,11]. Most hospitals admit patients with DKA to the ICU due to rules regarding level of service with every 1-hour blood draws and nursing rules. The patient was admitted for treatment of diabetic ketoacidosis. The patient met all criteria for diabetic ketoacidosis as the patient had type 1 diabetes, hyperglycemia, ketosis, and acidosis. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who was admitted for acute onset vertigo with nausea and vomiting. This occurred after having eight days of fever and upper respiratory symptoms. Neurological examination was concerning for unidirectional right-sided nystagmus. Computed tomography (CT) of the head was unremarkable. The patient did not improve despite fluids and Zofran. She required standing meclizine. Despite this, symptoms were not improved, and she required an increase in the meclizine dose, Reglan, scopolamine, diazepam, lorazepam and Compazine.

The inpatient admission was not medically necessary.

The patient had vertigo with unidirectional nystagmus. This would not be considered a severe neurologic deficit as indicated by the Milliman Care Guidelines (MCG) 26th Edition -
Neurology. In addition, management of this patient's symptoms could have been done in an outpatient or observation setting. None of the patient's symptoms were considered severe enough on neurologic examination to warrant inpatient admission. Therefore, the proposed inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Endocrine/Metabolic/Nutritional/obesity
Pharmacy/Prescription Drugs/Ozempic Pen Injector
The health plan denied the requested medication, Ozempic Pen Injector as not medically necessary. The health plan's determination is upheld.

This is a case review for a male being prescribed Ozempic pen injectors for the diagnosis of obesity.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has obesity with a body mass index (BMI) of 33.91. The patient had been taking Ozempic for 3 months and successfully lost 2.2 kilograms (kg). The physician states that although the medication is not approved for weight loss, the side effect of therapy with semaglutide (the active ingredient in Ozempic) is weight loss. Office visit notes were provided for review. The patient lost significant weight with Weight Watchers but experienced a plateau. He does not have any documented diagnosis of type 2 diabetes.
At issue is the medical necessity of Ozempic Pen Injector.

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

The requested health service/treatment of Ozempic Pen Injector has not been demonstrated to be medically necessary for this patient.
Ozempic is Food and Drug Administration (FDA) approved for the treatment of type 2 diabetes mellitus, and the patient does not have this diagnosis. The medication was prescribed off-label for the treatment of weight loss. There are other medications in this class (Glucagon-like peptide-1 (GLP-1) receptor agonists) that are FDA approved for the indication of weight loss. Because the patient does not have type 2 diabetes, it has not been clearly demonstrated that there is medical necessity for treatment with Ozempic.