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

Diagnosis: Arthritis and coronary artery disease.
Treatment:  Increase Home Care/Personal Care - HHC (home health care) Level 2, Per 15 Minutes To 77 Hours Per Week.
The insurer denied the  Increase Home Care/Personal Care - HHC Level 2, Per 15 Minutes To 77 Hours Per Week.
The denial is overturned.

This female has medical conditions that include arthritis and coronary artery disease. She lives alone.  She is appealing denial of increase home care/personal care (PCA) to 77 hours per week. The health plan approved PCA (personal care services) 24 hours per week.  Uniform Assessment System (UAS) evaluation completed shows independent cognition and functional status: total dependence with housework, meal preparation, and shopping; maximal assistance with transportation; extensive assistance with managing medications, stairs, bathing, and lower body dressing; limited assistance with managing finances, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating.  She has a slow unsteady gait with rollator, generalized weakness and decreased range of motion.  She has bowel and bladder incontinence.  Compared to UAS (Uniform Assessment System) evaluation completed there has been decline in functional status with managing finances and medications.

A letter from a provider notes the member has gait problems with poor balance and frequent falls and with signs of dementia.  States she requires 24 hour home service to prevent falls, medication management and assistance with ADLs (activities of daily living) such as bathing, toileting, cooking, feeding, and shopping. She is incapable of being on her own.  

A letter from another provider notes the member also has hearing problems, vertigo and convulsions.  

A physical therapy note states the member would benefit from skilled therapy to improve functional dependence.  She has impaired balance and difficulty walking, abnormal gait, generalized weakness, and decreased range of motion and pain of extremities.

Yes. The proposed treatment is medically necessary.

No. The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
This member has chronic medical conditions.  She is appealing denial of increase home care/personal care (PCA) to 77 hours per week.  The health plan approved PCA  (personal care services) 24 hours per week. Uniform Assessment System (UAS) evaluation completed shows the member needs assistance with all ADLs (activities of daily living), except bed mobility and eating.  Reports show the member has weakness and an unsteady gait affecting her mobility.  Providers note the member has impaired balance and frequent falls.  It is recommended that she not be left alone.  Due to her limited mobility, she requires significant assistance with ADLs (activities of daily living) and personal care. The approved PCA (personal care services) 24 hours per week is inadequate to meets this member's need for assistance. The proposed increase PCA (personal care services) to 77 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 visits x (times) 12

The insurer denied coverage for D8080 braces and D8670 visits x 12

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class I, maxillary and mandibular crowding and anterior crossbite with gingival attachment loss (mandibular left canine) in addition to other clinical findings.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD)  index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

Upon review of the submitted documentation, (study models were not provided for review), 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 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the
gingival margins are present. 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 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 denial as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

The insurer's denial of coverage for the D8080 braces and D8670 visits x 12 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender dysphoria.
Treatment: Excision (excessive skin and subcutaneous tissue suction, assisted lipectomy, trunk and lower extremity).
The insurer denied the Excision (excessive skin and subcutaneous tissue suction, assisted lipectomy, trunk and lower extremity).
The denial is upheld.

The patient is a male-to-female transgender. She underwent vaginoplasty, revision vaginoplasty, facial feminization surgery, liposuction of the abdomen flanks and limbs  and is now requesting additional body contouring surgery (excess skin and fat of the abdomen, mons, flanks and bra line). She began hormone therapy many years prior. At an examination there was residual excess fat on the medial thighs, abdomen, flanks, lower back and skin redundancy of the lower abdomen, mons and bilateral mid-back. Her surgeon is proposing hip lifts 15834, liposuction of the trunk 15877x2 and liposuction of the legs 15879x2. There are no photos in the reviewed materials. Coverage was denied by the health plan as cosmetic.

No, the requested health service is not medically necessary.
15834,  15877 and 15879 primarily improve appearance in this case, do not reduce or resolve a physiologic impairment and are considered cosmetic. Removal of excess torso skin is only considered medically necessary for treatment of rashes, infections or sores involving the redundant skin. Liposuction of the limbs is only considered medically necessary for the treatment of Adiposis dolorosa such as dercum's or lipedema, which are not present in this case. Furthermore, unlike a vaginoplasty, liposuction of the limbs and torso and excision of excess skin are not gender-confirming procedures.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Based on the reviewed materials, it is not clear that the patient is a candidate for even cosmetic procedures, and the proposed surgery is not gender confirming. A pubmed search of liposuction and transgender only yielded articles on liposuction of the chest and fat harvest for buttock auto-augmentation, which do not apply to this case.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: vaginal bleeding
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 emergency department. She had vaginal bleeding with fatigue, lightheadedness and palpitations. She had mild anemia with a low hemoglobin. A Pelvic ultrasound showed a thickened endometrial stripe of 2.3 centimeter (cm). She was admitted as an inpatient and received a unit of blood. She had a hysteroscopic dilation and curettage procedure. She received a third unit of blood in the post-anesthesia care unit (PACU) and was discharged home. 

The Inpatient Hospital Admission is not medically necessary for this patient.
The inpatient admission was not medically necessary and could have been performed at a lower level with extended monitoring. The patient had no cardiovascular instability, and her vital signs were normal. She had no pulmonary, hepatic or renal concerns. Her procedure was without compilations and is normally considered an outpatient procedure. She had no infection or pulmonary concerns during her procedure. She tolerated anesthesia without concern. She received blood for her acute bleeding; however, there were no signs of cardiovascular collapse and she could have been monitored and discharged after the procedure without the need for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female with pseudotumor cerebri and asthma. She was seen in the emergency room approximately three days prior to her return visit to the ER (emergency room) for worsening SOB (shortness of breath) and Cough as well as fevers. 

The patient was diagnosed with acute respiratory failure due to asthma exacerbation in the ER (emergency room) and was placed on BiPAP (bi-level positive airway pressure).  The patient received frequent nebulization treatments, IV (intravenous) steroids, as well as NIV (non-invasive ventilation). The patient was admitted to acute inpatient level of care. 

The hospitalization was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed. 

No, the Inpatient admission was not medically necessary. 

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

The patient was admitted for asthma exacerbation after initial work up and treatment in the Emergency room. At the time of admission, patient was on 5L (five liters) NC (nasal cannula) oxygen and was not in any respiratory distress. By day three, patient's oxygen levels were above 90% on room air. The patient was not in any respiratory distress. The patient was feeling better. The patient was transitioned to oral prednisone. The patient was tolerating diet. 

Given the patient's signs and symptoms, it would have been reasonable to expect significant improvement within 24 hours, which was seen in this patient. The patient's medical management would not have been expected to require treatments or interventions that could not have been provided at a lower level of care. No treatment was provided or was reasonably expected to be provided that required an acute inpatient level of care. Therefore, the acute in hospital level of care was not medically necessary, as the patient could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Chest Pain
Treatment: Inpatient Hospital Stay
The health plan denied the requested inpatient hospital stay. 
The health plan's determination is upheld.

The patient is a man with a past medical history of hypertension, gout, poly-substance abuse, and depression. He initially presented to the psychiatric emergency department (ED) for detoxification. He was admitted to the telemetry unit for chest pain. Urine toxicology returned positive for cocaine and opiates. An electrocardiogram (EKG) demonstrated sinus rhythm with T-wave (interval on EKG) inversions that were unchanged from prior. His Troponins were within normal limits. His D (domain)-dimer was elevated but given that his Wells Score was 0, he was considered to have a low probability for a pulmonary embolism. Ultimately, he was discharged on Aspirin and Lipitor.

At issue is the medical necessity of the inpatient stay.

I uphold, in whole, the health plan's determination of medical necessity.

Based on the provided documentation, there is insufficient clinical data to support the medical necessity for an inpatient level of care. This patient was hemodynamically stable and afebrile. There were no significant metabolic abnormalities on his laboratory work up. Although he had chest pain, there was no evidence of ischemia and he was ruled out for acute coronary syndrome by serial troponins. His EKG was unchanged from prior. Furthermore, there was no evidence of heart failure or symptomatic arrhythmias. Although he had an elevated D-Dimer, his Wells Score was 0; therefore, he was considered to be at a low probability of having a pulmonary embolism.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal Bleeding
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of uterine fibroids and abnormal bleeding with chronic anemia. She presented to the emergency room for vaginal bleeding and abdominal pain. Her hemoglobin was 5 and a computed tomography (CT) scan showed a fibroid uterus. She was admitted as an inpatient for the anemia and provided 3 units of red blood cells. She was also provided tranexamic acid for her bleeding. She was discharged to home in good condition. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient had severe anemia and the transfusion was appropriate, however, there are no documents provided to support the need for inpatient admission. The patient had chronic anemia secondary to uterine bleeding, however, she had no other medical condition that would require acute inpatient admission. She was provided the transfusion and discharged home in good condition the following day. She could have been treated at a lower level of care. She did not require inpatient monitoring. There was no evidence of cardiovascular changes, collapse or concerns. She had chronic anemia with compensation and no loss of consciousness or neurological concerns. She had no comorbid conditions that would complicate her treatment such as hepatic, renal or pulmonary failure. There was no surgery scheduled or continued concerns.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arial fibrillation, hypertensive heart disease, coronary artery disease, congestive heart failure, hyperlipidemia, major depression

Treatment: increase in personal care aide (PCA) hours to 7 days a week 12 hours a day

The insurer denied coverage for increase in personal care aide (PCA) hours to 7 days a week 12 hours a day

The denial is upheld.

The patient has chronic medical problems including atrial fibrillation, congestive heart failure, diabetes mellitus and depression.  She lives alone and is receiving PCA services 7 days/week, 10 hours/day for a total of 70 hours.  Under review is the request for increase in PCA hours to 7 days/week, 12 hours/day for a total of 84 hours.

According to the Uniform Assessment System (UAS) report, the patient requires extensive assistance for personal hygiene, upper body dressing and toilet use.  She requires maximal assistance for bathing, lower body dressing and toilet use.  She is bowel and bladder incontinent.  She is able to ambulate and transfer with weight bearing support and a rollator.   Cognitive status is described as "modified independent."  The patient's functional and cognitive status is much the same as documented in the assessment.  The current PCA services 7 days/week, 10 hours/day for a total of 70 hours is clinically appropriate to her the ability to continue living safely at home.  

The insurer's denial of coverage for an increase in personal care aide (PCA) hours to 7 days a week 12 hours a day is upheld. Medical Necessity is not substantiated.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, the requested increase in personal care aide (PCA) hours to 7 days a week 12 hours a day is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health. 
Treatment: Mental Health Outpatient. 
The insurer denied transcranial magnetic stimulation. 
The denial is overturned. 

The patient is a male diagnosed with major depressive disorder, recurrent and severe without psychotic features and treatment refractory/resistant depression. The patient has a documented history of multiple medication treatments for depression including treatment with more than two disparate classes of medication and at least three or more trials with antidepressant medications (selective serotonin reuptake inhibitor [SSRIs] and Wellbutrin). Due to adverse effects or lack of efficacy, the patient has continued to experience severe symptoms of depression. 

Co-morbid psychiatric disorders include unspecified mental disorder best characterized as other mental health or behavioral health disorder, and the patient has no co-occurring substance use disorder.
The patient's clinician recommended treatment with a course of repetitive transcranial magnetic stimulation (rTMS) therapy that would generally include up to 36 treatment episodes/transcranial magnetic stimulation (TMS) sessions. The recommendation is in the context of the ongoing episode of depression that is treatment-resistant/refractory despite treatment with three antidepressant medications, Prozac, Celexa and Wellbutrin.
The subject under review is the medical necessity for Transcranial Magnetic Stimulation (TMS) Therapy for recurrent and severe major depressive disorder without psychotic features and treatment refractory/resistant depression.

The health plan's determination is overturned.

Yes, the requested health service/treatment of transcranial magnetic stimulation (TMS) is medically necessary, reasonable, clinically appropriate, and in the patient's best interest. The requested TMS service is backed by credible scientific study and is consistent with prevailing standards of medical practice for the condition under treatment in this case, recurrent major depressive disorder, and treatment refractory/resistant depressive disorder.
The proposed treatment can reasonably be expected to provide the patient with greater net health benefit than any other standard therapy in this case scenario. Repetitive TMS therapy as a primary or adjunctive therapy for treatment of depression has generally been evaluated in patients who have had treatment resistant or treatment refractory depression, as defined by one or more, treatment failures with or without augmentation. TMS therapy for depression is established as a safe treatment by the Food and Drug Administration (FDA), and the data as reflected in peer reviewed medical literature supports this assertion. Specifically, when treatments with antidepressant medication with or without augmentation, or electroconvulsive therapy, and/or psychotherapy (especially cognitive behavioral therapy) have failed, then TMS is clinically appropriate. This assertion is also noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid Arthritis
Treatment: Enbrel
The insurer denied the Enbrel.
The denial is upheld.

This patient is a female with stated history of rheumatoid arthritis.  The patient was started on biologic disease modifying antirheumatic drug (DMARD) Enbrel on a free patient drug program and overall has clinically been doing well.  The request for Enbrel was initially denied due to the patient not having tried and failed the maximally tolerated dose of methotrexate, leflunomide, hydroxychloroquine or sulfasalazine.

No, the proposed treatment with Enbrel is not medically necessary.

The patient is reported to have a diagnosis of rheumatoid arthritis, but there are no accompanying clinical notes to support this diagnosis.  There are no clinical notes supporting why the patient would be unable to initially start on a conventional DMARD such as methotrexate, hydroxychloroquine, sulfasalazine or leflunomide.  The American College of Rheumatology guidelines in the treatment of rheumatoid arthritis do support the use of maximally tolerated methotrexate prior to advancing to biologic DMARDs.  This patient has been on Enbrel per free patient drug program, however, it is unknown if the patient would have had good clinical disease control if the patient was started on a conventional DMARD first.  There is no indication as to why the patient had to be advanced straight to a biologic DMARD in the first place.  The use of a tumor necrosis factor (TNF) inhibitor such as Enbrel as first-line therapy does not follow the American College of Rheumatology guidelines for the treatment of rheumatoid arthritis.  Therefore, the proposed treatment is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

Requiring the patient to start treatment with a conventional DMARD does follow the American College of Rheumatology guidelines in the treatment of rheumatoid arthritis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neuromyelitis Optica Spectrum. 
Treatment: Uplizna 100mg/ 10ml IV SOLN. 

The insurer denied the Uplizna 100mg/ 10ml IV SOLN. 
The denial is upheld. 

The patient is a female with seronegative neuromyelitis optica (NMO). She had normal MRI (magnetic resonance imaging) brain, negative MOG (myelin oligodendrocyte glycoprotein) and NMO (neuromyelitis optica) antibody testing and CSF (cerebrospinal fluid) was negative for oligoclonal bands. She has been treated with rituximab, steroids and plasma exchange. The provider is requesting Uplizna. 

No, the requested Uplizna is not medically necessary. 

First, the patient does not meet the standard diagnostic criteria for seronegative NMO (neuromyelitis optica) (Borisow et al.) based on no separation in time of CNS (central nervous system) lesions and negative CSF (cerebrospinal fluid) studies. Secondly, Uplizna was not studied in persons with seronegative NMO (neuromyelitis optica) and there is no evidence to support efficacy for persons with seronegative NMO (neuromyelitis optica) (Cree et al.). Finally, Uplinza is a B-cell depleting agent, although targeting CD19 (cluster of differentiation 19), not CD20 (cluster of differentiation 20), it has the same end result as rituximab, which is depletion of B-cells. There are no clinical trials to support that targeting CD19 (cluster of differentiation 19) with Uplinza would be more effective than targeting CD20 (cluster of differentiation 20) with rituximab. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.