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

Diagnosis: Peripheral vascular disease.

Treatment: Outpatient ambulatory surgery.

The insurer denied coverage for outpatient ambulatory surgery.

The denial is overturned.

This is the case of a male with peripheral vascular disease that required left lower extremity revascularization. Past medical history was significant for hypertension, heart failure with preserved ejection fraction and concentric left ventricular hypertrophy (LVH) on echocardiography and transient ischemic attack (TIA). He was treated with guideline directed medical therapy including atorvastatin, aspirin, losartan, and amlodipine. The patient presented with complaints of leg cramping, heaviness, and fatigue after walking a few steps. In addition, he reported symptoms of numbness and paresthesia of the lower extremities while trying to sleep at night. Physical examination was significant for diminished hair on the lower extremities and bilateral weak pulses (1/4) at the posterior tibial and anterior tibial positions. Ankle-brachial index (ABI) was 0.7 for the left lower extremity and 0.8 for the right. The patient was referred for lower extremity revascularization and findings revealed 100% popliteal occlusion, mid to distal anterior tibial artery (ATA) occlusion and 100% peroneal artery occlusion. Laser atherectomy with balloon angioplasty was successfully performed.

This patient presented with signs of critical limb ischemia. This is defined by American Heart Association/American College of Cardiology (AHA/ACC) guidelines as a condition characterized by more than two weeks of ischemic rest pain. (1) This patient reported a history of claudication despite being treated with guideline directed medical therapy that included an antiplatelet agent, an angiotensin II receptor blocker, a statin drug and an antihypertensive medication. Symptoms worsened despite medical therapy and physical therapy. After presenting with lifestyle limiting claudication and persistent rest pain for more than a two-week period, he appropriately underwent revascularization.  (1, 2). In conclusion, it was medically necessary to undergo outpatient ambulatory surgery with lower extremity revascularization.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for outpatient ambulatory surgery is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness, unsteady gait and memory impairment
Treatment: Increase in Personal Care Services (PCS) Per 15 Minutes From 35 Hours To 70 Hours Per Week
The insurer denied the increase in PCS per 15 minutes from 35 hours to 70 hours per week.
The denial is overturned.

The patient is a female. She reportedly has dizziness, unsteady gait, and memory impairment. The request is to increase Personal Care Services (PCS) per 15 minutes from 35 hours to 70 hours per week.

The reason for prior denial was that request is not medically necessary.

Yes, the requested increase in PCS to 70 hours/week is medically necessary.

The patient lives with her husband, who is not able to take care of her. The patient has dizziness, unsteady gait, and memory impairment. She has significant decline in her mobility. She has history of hip replacement and cannot get out of bed by herself. She cannot dress, undress, or change her diapers. She needs help with taking her medications. She is not able to care for herself or do ADLs (activities of daily living). Increase in hours to 42 hours/week is not enough, as she needs help with frequent repositioning and diaper changes. She will need 70 hours/week to ensure enough help and safety.

The requested service is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The patient has gait instability and is a fall risk. She needs help with her ADLs. She will benefit from more hours of home care services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular tachycardia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is the case of a male with history of diabetes mellitus type 2, hypertension, and hyperlipidemia. The patient was sent via ambulance from Urgent Care to the emergency department for evaluation of supraventricular tachycardia (SVT) following conversion. On the day of admission, the patient felt palpitations, dyspnea, lightheadedness, and diaphoresis. The patient had gone to an urgent care center and was found to be in SVT at a heart rate at 180 beats per minute (bpm). He was given intravenous (IV) adenosine and converted to sinus rhythm. He was then sent to the hospital. Troponin was 0.22 (0.00-0.04). The patient had recently had a positive COVID (Coronavirus Disease 2019) test in preparation for a gastric bypass surgery although he was asymptomatic.

The patient was admitted. Metoprolol and amlodipine were started. Echocardiogram showed hypokinetic septum. Troponin peaked at 0.36. Cardiology and Endocrine consults were obtained. The patient underwent a cardiac catheterization which showed normal arteries. The patient was discharged home.

The patient had an SVT that was easily treated in an urgent care center and had an elevated troponin. It was highly likely that the elevated troponin was on the basis of the tachycardia, for example, a Type 2 myocardial infarction (MI). It was reasonable to observe the patient on an observation status with the idea that the echocardiogram and cardiac catheterization could have been performed on observation status. Note the cardiac catheter showed normal arteries. A full inpatient admission was not medically necessary. 

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Caries, consistent with a failing existing restoration

Treatment: D2740 porcelain crowns on teeth #3, 4, 8, and 10 

The insurer denied coverage for D2740 porcelain crowns on teeth #3, 4, 8, and 10

The denial is modified

Upon review of the documentation provided which includes copy of panoramic and bitewing and periapical radiographs, pretreatment intraoral clinical photos, dental treatment notes and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended full coverage crowns for teeth #3, 4, 8, and 10. The insurer has denied these services stating there is no clinical/radiographic evidence, such as traumatic injury or decay, provided to support the necessity of these services and therefore the service does not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is a copy of intraoral clinical photos, panoramic and bitewing radiographs. 

In regard to teeth #3 and #4, although there appear to be failing preexisting restorations it appears that there is no evidence of fracture or other pathology specifically affecting these teeth based on the images provided for review that would justify full coverage restorations. The clinical photos and radiographs do not substantiate the requested dental services of full coverage crowns for teeth #3 and #4 and therefore the crowns for these teeth are deemed not medically necessary. 

In regard to teeth #8 and #10, upon review of the photos and radiographs, it supports the recommended treatment. Tooth #8 which is endodontically treated exhibits a crown with open margins on both the mesial and distal aspects of the tooth as well as possible recurrent caries, consistent with a failing existing restoration. There is ample coronal structure remaining. This tooth will have adequate residual coronal structure for support of a replacement crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be replacement crown which would have an excellent long-term prognosis with the recommended treatment. 

Tooth #10 clearly exhibits extensive caries both on the clinical photos and the radiographs. There is ample coronal structure remaining. This tooth will have adequate residual coronal structure for support of a crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be a full coverage crown as requested, which would have an excellent long-term prognosis with the recommended treatment.

The health plan acted reasonably in part.

The insurer's denial of coverage for D2740 porcelain crowns on teeth #3, 4, 8, and 10  is modified. Medical Necessity is substantiated for teeth 8 and 10; however, it is not is substantiated for teeth 3 and 4.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, autism, mental retardation, osteoarthritis, gout, hyperlipidemia, and obesity

Treatment: partial denied of coverage for T1019 - Personal care services per 15 minutes, 56 hours per week 

The insurer partially denied coverage for T1019 - Personal care services per 15 minutes, 56 hours per week 

The denial is upheld

This is the case of a male with a history of hypertension, autism, mental retardation, osteoarthritis, gout, hyperlipidemia, and obesity who is being recommended for personal care services for 15 minutes, 56 hours per week. The requesting physician stated that the patient has multiple chronic conditions with limited physical capabilities due to reduced range of motion. The physician stated the patient requires constant care along with direct supervision for medication administration given profound mental retardation. The provided records indicated that upon observation, it was determined that the patient's care can be rendered in a maximum of 34 hours per week. An appeal by the treating physician reiterated the patient's multiple chronic conditions and was strongly recommending the patient receive 56 hours of personal care per week. 

According to the New York State Department of Health Guidelines for Consumer Directed Personal Assistant Services, the patient did not meet criteria for personal care services for longer than 34 hours a week. While the physician noted the patient's multiple medical problems, including the permanent mental retardation, high blood pressure, prediabetes, lack of balance, and limited range of motion along with minimal socialization, the physician did not elaborate on why the patient would require more than 34 hours of personal care per week. A visit note states for neuro- "no mood swings. No memory loss". Under a subsequent visit note it stated alert and oriented times three (A & O X3). No gait disturbance. No tremors. It also noted "fully employable".  
 
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's partial denial of coverage for T1019 - Personal care services per 15 minutes, 56 hours per week is upheld. 34 hours per week is approved and 22 hours per week continue to be denied. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-cerebral palsy.
Treatment: Durable Medical Equipment-Power wheelchair (POV).
The health plan denied the POV as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has Trisomy 21 (Down's syndrome), AV (atrioventricular) canal repair of the heart, subglottic stenosis, OSA (obstructive sleep apnea) with tracheostomy and ventilator support, hypoxic brain injury and cerebral palsy. She has a history of two cardiac arrests resulting in hypoxic brain injury. She has movement disorders with chorea (jerky involuntary movements), dystonia (muscles contract involuntarily with repetitive or twisting movements), and tremors due to her hypoxic brain injury. Her movements are often unintentional and abnormal. She has difficulty with motor planning and regulating her movement patterns. She also has impairment in mobility, balance, strength, and activity tolerance.

The requested health service/treatment of power wheelchair (POV) is not medically necessary for this patient.

In this case, the patient has mental impairment due to Down's syndrome and physical impairment: movement disorders with chorea (jerky involuntary movements), dystonia (muscles contract involuntarily with repetitive or twisting movements), tremors, unintentional and abnormal movements, and difficulty with motor planning and regulating her movement patterns due to her hypoxic brain injury. The patient would not be able to consistently operate the power wheelchair safely and effectively due to her mental impairment due to Down's syndrome and physical impairment. The physical examinations findings are inconsistent with the patient being able to safely use a joystick on a power wheelchair.
A power wheelchair (POV) is not considered standard of care and there are no well-designed well conducted studies published in peer-reviewed journals to support this device, demonstrate that this device affects health outcomes, or show that this device is equally or more effective than conventional therapies. There are many standard treatments for the diagnoses of Trisomy 21 (Down's syndrome), AV (atrioventricular) canal repair, subglottic stenosis, OSA (obstructive sleep apnea) with tracheostomy, hypoxic brain injury and cerebral palsy such as standard wheelchair operated by an assistant. The patient would not be able to consistently operate the power wheelchair safely and effectively due to her mental impairment due to Down's syndrome and physical impairment. The use of the power wheelchair (POV) is not considered medically necessary, not supported by the peer-reviewed medical literature is not considered the standard of care in United States this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pain Management. 
The insurer denied pain injections in spine. 
The denial is overturned.

The patient is a male with chronic neck pain with radiating pain to his fingers. He underwent cervical epidural injections. It was documented that the injection provided 50% pain relief for over 3 months. Unfortunately, his pain returned. He has tried physical therapy (PT), home exercise and nonsteroidal anti-inflammatory drugs (NSAIDs) without adequate improvement. The physical exam shows motor strength 5/5 bilateral upper extremities (BUE), and positive Spurling's test. Magnetic resonance imaging (MRI) revealed posterior disc protrusion at cervical (C)7-thoracic (T)1. This patient was recommended to have another cervical epidural steroid injection. The issue is whether this requested cervical epidural injection is medically necessary.

The health plan's determination is overturned.

The requested injections are medically necessary.
Based on the available medical records, this patient has a C7-T1 disc bulge with resultant neck pain and radicular pain. He has tried PT, home exercise and NSAIDs without adequate improvement. Prior cervical epidural injections provided adequate pain relief for over 3 months. Further treatments are medically necessary to improve his pain and ability to perform activities of daily living (ADL). Other treatment options including surgery and long-term use of NSAIDs, and opioid medications do not render higher success rates, but are associated higher risks and complications.
Based on current clinical evidence, cervical epidural injections are effective for neck pain and radicular pain from disc herniation. This is the most appropriate next step treatment option.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Hospital Services. 
The denial was overturned. 

The patient is a male who presents from a New York shelter to the emergency department (ED), with a past medical history of diabetes mellitus and hypertension due to an ulcer to the left 3rd digit which had wet gangrene. He had a history of ulcers to his feet. His left 3rd digit turned gangrene. He had failed outpatient therapy of Augmentin.
He was admitted into the hospital with wet gangrene of the 3rd digit, bilateral foot ulcers, and placed on intravenous (IV) vancomycin and IV cefepime. Podiatry performed an amputation of the left 3rd digit. Pathology report showed gangrenous and necrotic tissue with acute osteomyelitis with margins viable and free of acute inflammation. He was discharged to the Department of Homeless Services.
At issue is the medical necessity of Inpatient Hospital Services.

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

The requested health service/treatment of Inpatient Hospital Services was medically necessary for this patient.
Though the patient's vital signs were stable, the diagnosis of wet gangrene required immediate attention and surgical intervention to prevent unnecessary poor outcomes. The patient required prompt IV antibiotics, medical clearance/stabilization, and surgical debridement. Based on the submitted medical records and current medical literature, the patient required the inpatient medical care. The care that was provided was standard of care for this patient's diagnosis and condition. The patient is a diabetic and had wet gangrene which had already failed oral antibiotics. This is considered a medical emergency to perform an amputation. Given the patient's comorbidities, he necessitated an inpatient care for IV antibiotics, medical clearance, observation, and ultimately to undergo the amputation.
Therefore, the requested health service/treatment of Inpatient Hospital Services was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crown failure
Treatment: D2751, white glass with metal crown, tooth 10
The insurer denied coverage for D2751, white glass with metal crown, tooth 10.
The denial is overturned. 

Based on the submitted documentation, which includes copies of periapical radiographs and insurer correspondence, it appears that this patient presented to her dentist for dental care. A failing long-standing crown restoration was noted on tooth # (number) 10. The dentist is requesting replacement of the crown due to failure. The insurer has denied the full coverage crown, stating that the service is not medically necessary as the documentation did not demonstrate medical need to support the treatment, such as caries or a missing crown or damage to the existing crown and therefore the circumstance does not fulfill stated criteria for approval. The patient is appealing the decision.

Upon review of radiographs, they support the recommended treatment. Tooth #10 exhibits a crown with open margins on both the mesial and distal aspects of the tooth, as well as possible recurrent caries, consistent with a failing existing restoration. There is ample coronal structure remaining. This tooth will have adequate residual coronal structure for support of a replacement crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be replacement crown, which would have an excellent long-term prognosis with the recommended treatment.

Reverse denial and approve coverage for D2751 white glass with metal crown tooth 10 as medically necessary, as the radiographic documentation supports this service and this service would be a standard of care in general dental practice.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for D2751, white glass with metal crown, tooth 10 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque Psoriasis
Treatment: Skyrizi
The insurer denied Skyrizi.
The determination is upheld.


The patient has psoriasis. He has failed clobetasol ointment and betamethasone ointment. He is currently on Skyrizi every 12 weeks however is having an inadequate full response. The medication under review is Skyrizi 150 mg/ml syringe every 8 weeks.

The requested health treatment of Skyrizi 150 mg/ml syringe every 8 weeks is not medically necessary for this patient. The Food and Drug Administration (FDA)-approved dosing for psoriasis is Skyrizi 150 mg/ml syringe every 12 weeks. Scientific evidence has not been established via well-designed, controlled studies with adequate follow-up that demonstrate the safety and efficacy of the proposed treatment. There are no randomized-controlled studies that show the efficacy of safety of Skyrizi 150 mg/ml syringe every 8 weeks. Further studies are necessary to determine the role and utility of this non-standard dosing of Skyrizi for plaque psoriasis patients.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis

Treatment: 80 milligrams (mg) of Taltz every 2 weeks

The insurer denied coverage for 80 mg of Taltz every 2 weeks

The denial is overturned.

The patient is a female with a diagnosis of psoriasis. The patient has been treated with Taltz monthly injections; however, the patient has experienced exacerbation. The dermatologist and rheumatologist request Taltz dosing be changed to every 2 weeks to improve efficacy. The request is for Taltz 80 mg every 2 weeks as a dosing adjustment prior to changing to an alternative biologic. 

Based on the submitted documentation, Taltz dosing adjustment is medically necessary. The patient requires systemic therapy for control and management of her psoriasis diagnosis. Prior to changing to an alternative biologic, it is reasonable and within the standard of care to attempt an adjusted dosing regimen. Taltz is Food and Drug Administration (FDA) approved for treatment of psoriasis vulgaris and it is reasonable to attempt this dosing schedule.  

The joint American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines for psoriasis treatment with biologics states that Taltz is recommended for monotherapy in the treatment of psoriasis with a strength of recommendation of "A" -the highest recommendation. Bagel et al found that dose escalation was seen in 17.5% (percent) of patients on Taltz.  Based on the submitted documentation, Taltz dosing every 2 weeks is approved and the decision is overturned in whole based on the current evidence-based medical literature.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for 80 milligrams (mg) of Taltz every 2 weeks is overturned. Medical Necessity is substantiated.