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

Diagnosis: Osteochondritis dissecans, left ankle and joints of left foot
Treatment: Consumer Directed Personal Assistance Services for A Total Amount of 30 Hours Per Week
The insurer denied: Consumer Directed Personal Assistance Services for A Total Amount of 30 Hours Per Week
The denial is upheld

The patient is an adult male. The patient has the diagnosis of osteochondritis dissecans of the left ankle and left foot. The patient has been recommended for consumer directed personal assistant services for a total of 30 hours per week. The patient had an MRI (magnetic resonance imaging) of the left ankle which showed a sclerotic subcortical cyst within the medial talar dome.

There was adjacent marrow edema. There is marked deformity of the anterior talofibular lateral collateral ligament. There is a grade 3 sprain. There is thickening and deformity of the flexor retinaculum. The patient has been recommended for home care services for 3 to 5 days for 6 hours per day. The patient was vented 10 months ago with chest pain for one day and seen in the emergency department to rule out PE (pulmonary embolism). The patient had surgery nearly a year ago for arthroscopic scraping by the podiatrist. The patient has been using crutches to ambulate. This is a review for the consumer directed personal assistant services.

The requested health service is not medically necessary.

The need for additional service hours has not been established. There is no documentation that the patient has any ambulatory dysfunction that would justify additional service hours. The patient sustained an ankle injury and is ambulating with crutches. Thus, the need for additional home services cannot be supported as medically necessary and appropriate. The patient is not bed confined and can perform activities of daily living without restrictions. There is no need for additional home services for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Moderate crowding
treatment: Braces/monthly visits
The insurer denied braces/monthly visits. 
The health plan's determination is overturned. 

The patient in question is a female with moderate crowding. She presents with a skeletal Class I malocclusion. Tooth #10 is in anterior crossbite with #22 and is pushing tooth 22 to the labial. Additionally, tooth #5 is in buccal (reverse) cross bite with its antagonists. She is treatment planned for braces/monthly visits.

Braces and Monthly Visits are medically necessary for this patient.

This patient presents with an anterior crossbite on tooth 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
Because tooth 5 is in buccal crossbite, it has no antagonist. As a result, it is extremely likely that this tooth will over erupt. Once this overeruption occurs, it is very difficult to treat.4 Buccal crossbite (also known as scissor-bite in the literature) can also negatively affect mandibular growth and should be treated as early as possible to eliminate the potential growth disturbance.

If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. If left untreated tooth 10 will keep pushing tooth 22 to the labial so that tooth 22 will develop periodontal recession. Teeth 4, 28 and 29 will also likely be compromised periodontally due to the buccal crossbite. The requested Orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is an adult male patient with type 2 diabetes mellitus who is on Lantus and Humalog insulin therapy, Januvia, and metformin. The patient was brought into the emergency department (ED) for hypoglycemia. He had been at work and felt disoriented and was slurring his speech. Emergency medical services were called. 

The patient's glucose was 25 milligrams per deciliter (mg/dL). The patient was treated with oral glucose. Glucose increased to 31 mg/dL. In the ED, the patient's glucose was 23 mg/dL. He was given two ampules of D50 [dextrose 50% (percent)] and orange juice with sugar with resolution of neurological symptoms. Repeat glucose was 238 mg/dL. The patient's blood pressure was 183/97, pulse was 96, respiratory rate was 15, temperature was 36.1, and oxygen saturation (O2sat) was 100%. The patient's white blood cell (WBC) count was 13.3, creatinine was 2.01, potential of hydrogen (pH) was 7.19, and lactate was 4.2. Repeat venous pH was 7.34 and lactate was 2.5. The patient's creatinine was 1.68 on day # (number) 2. Endocrinology was consulted. The patient was discharged home off of insulin and metformin. Januvia was continued. The inpatient hospital stay is the topic of this review.

The requested inpatient hospital stay was not medically necessary.

This patient was admitted with hypoglycemia in the setting of known type 2 diabetes on insulin, Januvia, and metformin. He was hypoglycemic on arrival to the ED. His hypoglycemia responded to dextrose infusion and oral intake and his neurological symptoms resolved. His glucose levels were stable on day #2 without recurrence of hypoglycemia. The patient was hemodynamically stable. He did not have loss of consciousness or seizures. He had a known cause of hypoglycemia. He had an elevated creatinine level indicating acute kidney injury and elevated lactate level that responded to hydration and treatment of hypoglycemia. The documentation does not support that the patient failed a lower level of care. Therefore, the patient's inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rhinitis
Treatment: Azelastine-Fluticasone
The insurer denied coverage for Azelastine-Fluticasone
The denial is upheld 

The patient is an adult. Per the treating provider on the external appeal form the patient has been treated with Azelastine, Flonase and Mometasone and "hasn't had much success with these medications." The denial letter states that approval criteria includes inadequate response or intolerance to formulary alternatives, which in this case are "Flunisolide, Fluticasone or Mometasone with Azelastine. The requirement is trial and failure of all the formulary alternatives, but not more than three." 

The documents reviewed includes a Computed Tomography of the sinus (septal deviation and right maxillary sinus posterior wall minimal thickening) and chest x-ray (normal). A progress note by the treating provider lists a diagnosis of atopic dermatitis, mild asthma and chronic rhinitis. Current medications listed include Flonase and Azelastine nasal sprays. A new medication, azelastine hydrochloride/fluticasone propionate 137-50 (micrograms) mcg/act (actuation) is noted. Another progress note by the treating provider stated in the assessments that the patient has asthma and allergic rhinitis. It is stated that the treating provider would like to switch the patient to Dymista so as to "consolidate some of the medications." The current medication list included Flonase and Patanase. A new medication is listed as Dymista 137-50 mcg/Act. Another progress note by the treating provider lists assessment of acute sinusitis and mild asthma. Current medications included Flonase and Azelastine nasal. Another progress note stated the patient had assessments of mild asthma and chronic rhinitis. Current medications included Flonase and Azelastine nasal. 

There is inadequate evidence from the documents reviewed that show that the patient met the plan requirements. The patient was not shown to fail all 3 nasal steroids combined with azelastine nasal.

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 Azelastine-Fluticasone is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Angina
Treatment: Inpatient hospital services
The insurer denied coverage for inpatient hospital services
The denial is overturned

This case involved an adult patient that presented to the hospital with complaints of chest pain. Pain radiated to the back and was relieved following treatment with sublingual nitroglycerin. Past medical history was significant for hypertension, diabetes mellitus and previous stroke. On arrival to the hospital the patient was hypertensive with blood pressure (BP) 176/103, and the pulse was 94. Physical examination revealed no significant abnormalities. 12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm without ischemic ST (wave on ECG) or T (wave on ECG) wave abnormalities and poor R (wave on ECG) wave progression across the precordial leads. Serum blood testing demonstrated no elevation in troponin level. Computed tomography (CT) angiogram demonstrated no evidence of aortic dissection. The patient was admitted to the hospital and cardiac catheterization was performed. Results revealed 90% (percent) occlusion of the left anterior descending (LAD), 95% occlusion of the right coronary artery. Drug eluting stents were placed in the left anterior descending and right coronary arteries. The patient was monitored overnight and discharged the following day.

The health plan did not act reasonably, with sound medical judgement and in the best interest of the patient. This patient presented with unstable angina and a 90% occlusion of the LAD coronary artery and a 95% occlusion of the right coronary artery. The HEART score of four put the patient in an intermediate risk category, consistent with an elevated risk of future cardiac events (Reference 1, 2). The patient was admitted and ultimately noted to have triple vessel disease on cardiac catheterization. Based on the intermediate risk score using both the HEART and thrombolysis in myocardial infarction (TIMI) risk stratification, admission for observation and cardiac catheterization was medically necessary. Risk assessment of patients presenting with chest pain and ST changes on ECG as well as negative cardiac enzymes was performed by Sanchis et al. (Reference 3). Using their risk stratification schema, this patient would have an elevated risk of future myocardial infarction or death within one year. In conclusion, acute care hospital admission was medically necessary.

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 the inpatient hospital services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent Injection 300/2ML (milliliters)
The insurer denied Dupixent injection 300/2ML.
The denial is upheld.

The patient is an adult male with atopic dermatitis of the bilateral fingers only, treated with topical steroids and Opzelura cream as well as Dupixent. The provider is requesting to restart Dupixent. The health plan requires use of topical calcineurin inhibitors or Eucrisa. The patient is noted to have bleeding and inflammation of the fingertips only.

The proposed treatment with Dupixent is not medically necessary.

The health plan requires use of topical calcineurin inhibitors or Eucrisa. These would be appropriate therapies for this patient with limited body surface area, as well as patch testing to rule out contact dermatitis. According to the recommendations provided by Simpson, et al, steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative colitis.
Treatment: Stelara.
The insurer denied the Stelara.
The determination is upheld.

This is a male patient with severe ulcerative colitis (pancolitis) and primary sclerosing cholangitis complicated by cirrhosis. He has failed azathioprine monotherapy, and azathioprine with infliximab 15 milligrams (mg) /kilogram (kg) every 4 weeks (with therapeutic infliximab level and anti-infliximab antibody level of 70 nanograms (ng) /milliliter (mL). A colonoscopy showed multiple ileal ulcers, moderate colitis from the cecum to the sigmoid colon, and mild ulcerative proctitis. The request is for Stelara 390 mg intravenously and Stelara 90 mg subcutaneously every 8 weeks for the treatment of ulcerative colitis. The request was not approved because Humira, Xeljanz, Xeljanz extended release (XR), and Entyvio have not been attempted or established as contraindicated. At issue is whether the Stelara is medically necessary.

The requested Stelara is not supported as medically necessary given that the patient has not attempted the formulary medication Xeljanz, and there is no documented contraindication to the Xeljanz.   
Xeljanz is recommended by guidelines for the treatment of Ulcerative Colitis. Stelara is recommended by American Gastroenterological Association guidelines for the induction of remission of moderate to severe Ulcerative Colitis [1]. The guidelines state that "In adult outpatients with moderate to severe Ulcerative Colitis who have previously been exposed to infliximab...he American Gastroenterological Association (AGA) suggests using Stelara (ustekinumab) or Xeljanz (tofacitinib) rather than Entyvio (vedolizumab) or Humira (adalimumab) for induction of remission" [1]. Although Humira and Entyvio would not be supported by guidelines in this case, both Stelara and Xeljanz are recommended by American College of Gastroenterology guidelines for patients who have experienced anti-tumor-necrosis factor (TNF) therapy [2]. American College of Gastroenterology guidelines for the treatment of Ulcerative Colitis also recommend Xeljanz as first-line therapy for moderate to severe disease, including in patients with prior failure of anti-tumor necrosis factor therapy such as infliximab [2]. Xeljanz is Food and Drug Administration (FDA)-approved for the treatment of ulcerative colitis [3,4]. The patient has no listed contraindications in the FDA-approved prescribing information for Xeljanz [3]. Additionally, the cardiovascular black box warnings listed in the prescribing information are based on studies in patients over age 50 and did not preclude the establishment of the above guideline recommendations for the use of Xeljanz [2,3]. There is a lack of controlled head-to-head studies to show that Stelara is safer or more effective than Xeljanz, and comparison of disparate trials is not valid; a network meta-analysis did not show notable differences in safety or efficacy [5].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Melanoma
Treatment: Personal Care Aide-Level 2 Personal Care Aide-Level
The insurer denied: Personal Care Aide-Level 2 Personal Care Aide-Level
The denial is: Overturned

The patient is a female with medical history notable for metastatic melanoma cancer. The patient and her care team requested consideration for personal care aide services, and this request was denied by the health plan. This denial is the subject under review.
The patient provided a letter of support on her own behalf for this appeal. The letter states that she has metastatic cancer and was given a 6-9 month life expectancy by her oncologist. Because of her metastatic bone pain, she has difficulty with simple tasks like putting socks on and household tasks. She does not have any informal support from her family.
In the patient's appeal request, her physician notes that she is not able to function well due to "the amount of pain she has due to metastatic cancer." The patient requests assistance for activities of daily living (ADLs) due to her pain and prognosis for decline.
Medical records were provided for review. The patient had her original melanoma removed. She had a recurrence with metastasis to the spine and spinal cord compression. She now has liver lesions and a duodenal mass. A biliary stent was placed. Given her small bowel disease, there are no curative options available to her.
A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted via video conference. The patient's cognition was intact and she is independent in directing her care. She requires total dependence for housework and maximal assistance for meal preparation and shopping. Other Instrumental activities of daily living (IADLs) are independent. All ADL's are listed as independent, stating that she had completed them 3/3 days prior. She is continent of stool and urine.

The requested health service of Personal Care Aide-Level 2 Personal Care Aide is medically necessary for this patient.
The patient has terminal metastatic cancer and deals with severe pain related to bone metastases. Her physician attests that she needs assistance with ADL's and IADL's. Her UAS was completed via teleconference and reflects what she has been doing every day given that she does not have personal care assistance. However, she is not able to safely complete all tasks independently and is expected to have worsening functional needs. She already requires assistance for housework, meal preparation, and shopping at a minimum. These personal care needs must be provided for.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligoprogressive stage four (IV) kidney cancer with enlarging metastases in the right lung and mediastinum
Treatment: Proton Beam Therapy
The insurer denied proton beam therapy.
The determination is upheld.

This is a male patient with a history of oligoprogressive stage four (IV) kidney cancer with enlarging metastases in his right lung and mediastinum. He has been recommended to proceed with a course of consolidative radiotherapy. Proton beam radiation therapy was requested and is under review for medical necessity.

The requested proton beam radiation therapy is not medically necessary for this patient. Proton radiation is not proven to yield superior outcomes in the patient's setting. The treating provider did not supply a proton/photon plan comparison to indicate that photon radiation is unable to provide adequate safety/precision (the provided plan comparison was for a case-control patient and was not specific to the patient in question). The patient has not received prior thoracic radiation in the past, nor does he have a genetic/comorbid condition that would increase his risk for normal tissue toxicity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vitiligo

Treatment: Opzelura 1.5% cream

The insurer denied coverage for Opzelura 1.5% cream

The denial is upheld 

The patient is an adult with a diagnosis of vitiligo affecting 10% of the total body surface area (TBSA), including the face, upper chest, and back. The patient has failed topical "hydrocortisone." The requested medication is Opzelura 1.5% cream.

Based on the submitted documentation, the use Opzelura is not medically necessary. The documentation provided does not provide any details of the diagnosis or the medications tried and failed other than stating that the patient has "white spots" for an unknown length of time and has failed hydrocortisone. The documentation states that the patient has failed hydrocortisone implying it is over the counter (OTC) hydrocortisone without documentation of whether it was in fact OTC hydrocortisone or a prescriptions strength steroid. There is no treatment listed on the patient's current medication and thus it is not clear when the patient used hydrocortisone and for how long or what the result was. The documentation states that the involved surface area is 10%. The use of prescriptions strength steroids, topical calcineurin inhibitors such as tacrolimus, as well as light therapy are all standard of care treatment options which can be used in this patient. The documentation provided does not support the use of Opzelura prior to documenting a failure of traditional treatment modalities to treat the patient's vitiligo. The appeal is upheld based on the provided documentation and the standard of care.

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 Opzelura 1.5% cream is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment:  Consumer Directed Personal Assistance Services (CDPAS): 24 Hours per Day, Split-Shift Services
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 24 Hours per Day, Split-Shift Services. The health plan's determination is overturned. 

The patient is a male with past medical history of dementia, bladder incontinence, bowel incontinence, insomnia, nightmare disorder, osteoarthritis, depression, obsessive compulsive disorder, and post-traumatic stress disorder (PTSD). The patient had overnight care logs documenting overnight assistance needs with activities of daily living (ADL) at least every 2 hours. 

Consumer Directed Personal Assistance Services (CDPAS): 24 Hours per Day, Split-Shift Services are medically necessary for this patient.

There is documentation from the patient's medical provider, current caregiver, and daughter of worsening functional and cognitive status. The patient has a diagnosis of dementia which is a progressive illness. The patient's medical provider documented medical necessity of 24-hour split shift services. The provider noted the patient requires frequent diaper changes in the overnight hours to prevent infection. A video assessment about 6 months prior to presentation underestimated the patient's activity of bed mobility as his caregiver documented in her letter from two months prior that the patient required assistance with bed mobility. Overnight care logs from this same timeframe documented overnight care needs with activities of daily living (ADL) that would not allow PCA (personal care aide)5 hours of uninterrupted sleep. In addition, the patient lives in a studio apartment and there is not room to accommodate a live-in PCA. The patient's increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). The requested increase in services cannot be met solely with adaptive equipment and medical supplies. 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, Consumer Directed Personal Assistance Services (CDPAS): 24 Hours per Day, Split-Shift Services are medically necessary for this patient.