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

Diagnosis:  Psoriasis.
Treatment: Otezla.
The insurer denied Otezla.
The determination is upheld.

The patient is a female with psoriasis. She has failed Zoryve and betamethasone. She is on Otezla and Tremfya. The medication under review for medical necessity is Otezla.

The requested health service/treatment of Otezla is not medically necessary for this patient.
Based on the evidence-based literature, the Otezla is not medically necessary. 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 or safety of Otezla when administered concomitantly with Tremfya. There are no psoriasis guidelines that support the use of these medications given together (1-2). There is very limited data on prescribing Otezla as a biologic medication, and they are limited to only a few small studies (1-2). Tremfya is not Food and Drug Administration (FDA)-approved for treatment with Otezla.
Further studies are necessary to determine the role and utility of co-administration of these medications for plaque psoriasis patients.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is an adult male who was hospitalized for heart failure. The patient presented to the ED (emergency department) for evaluation of persisting headache x2 (times two) days, accompanied by dyspnea and orthopnea. His past medical history included known HFpEF (Heart Failure with preserved Ejection Fraction), hypertension, CAD (coronary artery disease), AFib (atrial fibrillation) treated with Apixaban, OSA (obstructive sleep apnea), stage 4 (four) chronic kidney disease, diabetes, and cystic fibrosis. The patient's initial blood pressure was reported as elevated, with blood pressure readings of 190/90's, followed by 160/105 and 131/94. A performed exam showed coarse breath sounds bilaterally. An EKG (electrocardiogram) revealed atrial flutter, and chest film showed pulmonary fibrosis with bronchiectasis. Treatment included IV (intravenous) Furosemide, and IV (intravenous) Hydralazine, followed by the patient's oral medications. Ophthalmology was consulted for management of scleritis, and the patient was provided with topical treatments. By day (number) #4, the patient was deemed medically stable for discharge to home. The requested coverage for the Inpatient Hospital Admission was denied as not medically necessary based on the patient's health plan policy. The denial is being appealed. 

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

Based on the peer reviewed medical literature, including the MCG (Medical Coverage Guidelines) titled: Heart Failure (ORG: M-190), the requested inpatient admission was not considered medically necessary, as the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. The criteria for an inpatient stay are not met, this criteria includes documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism (PE), aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs that would require acute inpatient management. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital care. The care this patient received for mildly decompensated chronic LV (left ventricular) diastolic HF (heart failure), is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
Treatment: D8080 Braces, D8670 Monthly Visit, D8680 
Retainer
The insurer denied: D8080 Braces, D8670 Monthly Visit, D8680 
Retainer
The denial is overturned.

This is a teenage male patient. The request is for orthodontic benefits, monthly visits, and a retainer. The patient has a Class I malocclusion. The prior denial was due to a revised handicapping index score of 18.

The requested health service is medically necessary.

The patient has multiple anterior teeth in crossbite with attachment loss and gingival recession. Each one of these is an automatic qualifier for benefits and the patient has multiple teeth in crossbite. The patient also has the upper right canine (tooth #6) "blocked out", meaning it is stuck in the jaw, not erupting into its proper position. With this upper canine out of position and the 
upper left canine (tooth #11) also out of position, there can be no "canine guidance". This is when during the chewing cycle, the lower canines glide along the backs of the upper canines and 
disclude (open up the bite) on the posterior teeth so they do not touch. Without canine guidance, all the patient's teeth will bang into each other causing trauma and fracturing over time. 
Orthodontic treatment is needed to correct all these problems and the monthly visits are needed to make sure the treatment progresses properly. The requested retainer is to prevent relapse after the treatment is done.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptoms of a stroke
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female who presented to emergency room with right-sided weakness, numbness, and dizziness. She was seen at a different hospital prior with negative computed tomography (CT) scan. Magnetic resonance imaging (MRI) of the brain was done and showed acute punctate infarct of the posterior limb of the left internal capsule. She was admitted for stroke management that includes frequent neurologic checks and telemetry. 

The requested health service is medically necessary. 

The patient had an acute stroke and acute stroke management requires measures including permissive hypertension and prolonged cardiac monitoring via telemetry unit. This cannot be done in the outpatient setting. Discharging her when she had a stroke without neuromonitoring could potentially lead to larger strokes and lead to significant morbidity and mortality. Therefore, 
the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

 
Diagnosis: Urinary Tract Infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a past medical history significant for rheumatoid arthritis, migraines, common variable immunodeficiency (CVID), and cerebrovascular accident (CVA) who presented to the emergency department with complaints of upper respiratory symptoms and dysuria.

Vitals on presentation included: Temperature 98.1 Fahrenheit, blood pressure (BP) 153/107, pulse (P) 119, respiratory rate (RR) 35, and oxygen saturation 100%.

Laboratory results included the following: white blood cell (WBC) 21.7, hemoglobin (Hgb) 12.3, hematocrit (Hct) 37.4, creatinine 0.77, and glucose 156.

The patient was started on intravenous fluids and empiric antibiotics (ceftriaxone) for possible urinary tract infection (UTI). A computed tomography (CT) scan of abdomen/pelvis was unremarkable. Blood cultures were negative and urine culture grew >100 thousand gram negative rods. The patient remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient follow-up on oral antibiotics (Augmentin). 

According to documentation, patient was admitted for urinary tract infection. The patient remained afebrile. Initial vitals in triage showed hypertension and tachycardia, which soon normalized while in emergency department. The patient was described as "overall well appearing." The decision to admit patients with acute complicated UTI should be individualized. The decision is usually clear when patients are septic or otherwise critically ill. Otherwise, general indications for inpatient management include significant pain, marked debility, or inability to maintain oral hydration or take oral medications. Additionally, inpatient management is warranted when urinary tract obstruction is suspected or there are concerns regarding patient adherence. Generally, outpatient management is acceptable for patients with acute complicated UTI of mild to moderate severity who can be stabilized, if necessary, with rehydration and antimicrobials in the emergency department or observation unit. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Impacted teeth
Treatment: Surgical Extraction (D9243 IV (intravenous) Sedation each 15 minute; D7240 Extraction of Impacted Tooth Covered by Bone Tooth, 16, D7240 Extraction Impacted Tooth Covered by Bone, Tooth 1, D9243 IV Sedation each 15 Minutes; D7240 
Extraction of Impacted Tooth Covered by bone, Tooth 1; D720 Extraction of Impacted Tooth Covered by Bone, Tooth 16; D9243 IV Sedation each 15 minutes x 2)
The insurer denied: Surgical Extraction (D9243 IV (intravenous) Sedation each 15 minute; D7240 Extraction of Impacted Tooth Covered by Bone Tooth, 16, D7240 Extraction Impacted Tooth Covered by Bone, Tooth 1, D9243 IV Sedation each 15 Minutes; D7240 Extraction of Impacted Tooth Covered by bone, Tooth 1; D720 Extraction of Impacted Tooth Covered by Bone, Tooth 16; D9243 IV Sedation each 15 minutes x 2)
The denial is Partially Overturned.

The patient is a teenage male. He presented for evaluation for extraction of his third molars. Upon examination, the patient has impacted teeth #1, 16, 17, 18, 31, and 32. The provider requested extraction of teeth #1, 16, 17, and 32, and surgical access of impacted teeth #18 and 31 with intravenous sedation. The plan approved extraction of teeth #17 and 32 with 40 minutes of intravenous sedation. According to the denial letter, teeth #1 and 16 were denied because, according to the plan, in order for the tooth to be extracted, the tooth must have severe pain or must be in a position that will not let it break through the gum by itself. The plan also denied the additional units of intravenous sedation. The denial is being appealed.

The requested health service is medically necessary, in part.

Code D7240 for teeth #1 and #16 is indicated. Based on AAOMS (American Association of Oral and Maxillofacial Surgeons) recommendations, "When removal of an impacted tooth is 
indicated, it is surgically prudent and cost beneficial that other impacted teeth be considered for treatment at the same surgical session. This reduces the need for additional anesthetic and 
surgical procedures." Thus, extraction of teeth #1 and 16 is indicated. As for IV (intravenous) sedation (D9243 x1), 1 unit total of 15 minutes is indicated in this case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Treatment: Qulipta 60mg Tablet
The insurer denied: Qulipta 60mg Tablet
The denial is upheld.

The patient is a teenage female with migraine headache disorder. She has tried and failed topiramate for migraine prevention. The provider has requested Qulipta for migraine prevention. This was denied coverage as she has not tried and failed three preferred formulary medications for her condition.

The health plan should not cover the proposed treatment.

There is no reason the patient cannot be treated with preferred formulary medications for her condition. All of the preferred agents are considered first line, standard of care, oral migraine preventive agents (Burch, 2021). The documented blood pressure and heart rate in the medical record do not preclude the use of any preferred medication including beta-blockers or antihypertensive medications. The clinical trial leading to the Food and Drug Administration (FDA) approval of Qulipta tested efficacy against placebo (Ailani et al., 2021). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Qulipta relative to the preferred medication.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: apical variant hypertrophic cardiomyopathy.

Treatment: Bystolic (nebivolol).

The insurer denied coverage for Bystolic (nebivolol).

The denial is overturned.

Asked to review the case of an adult with a history of apical variant hypertrophic cardiomyopathy. Physical examination revealed no abnormality. Cardiac magnetic resonance imaging (MRI) demonstrated no evidence of outflow tract obstruction. Exercise tolerance was within normal limits. The patient was treated with nebivolol therapy after developing side effects of erectile dysfunction and fatigue on metoprolol and carvedilol therapy.

The formulary drugs are likely to cause the patient an adverse reaction. The patient's physician noted that the patient had an adverse reaction to metoprolol and carvedilol. Nebivolol (Bystolic) is a beta 1 receptor selective and can cause less erectile dysfunction than less selective agents (Reference 1,2). The release of nitric oxide triggered by nebivolol therapy can allow for endothelial relaxation and arterial vasodilation, while less selective agents can prevent vasodilation. (Reference 1) 

His doctor provided historical evidence of intolerance to the formulary drugs. All are not beta 1 selective or less selective than nebivolol. The requested drug will be more effective than the formulary drugs because it will treat the patient for hypertrophic cardiomyopathy without causing side effects of fatigue and erectile dysfunction.

The formulary drugs are expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Bystolic (nebivolol) to treat essential (primary hypertension) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines
Treatment: Nurtec 75mg ODT Tablet (every other day dosing)
The insurer denied: Nurtec 75mg ODT Tablet (every other day dosing)
The denial is upheld.

The patient is an adult female with migraines. She has 14 migraine days per month. She has tried sumatriptan and ibuprofen. The provider wishes to prescribe Nurtec every other day for migraine prevention. The request was previously denied as the patient has not tried and failed two different oral preventative medications for migraines.

Nurtec every other day is not medically necessary.

The patient has not tried two oral preventative migraine medications. The American Headache Society anti-calcitonin gene-related peptide (CGRP) guidelines recommend initiation of anti-Calcitonin gene-related peptide when one has tried and failed at least 2 different oral preventative medications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home Care/Personal Care Consumer Directed Personal Assistance Services (CDPAS) increase to 77 hours/week 
The insurer denied home care/personal care CDPAS increase to 77 hours/week. 
The health plan's determination is overturned. 

The patient is a female with a history of hypertension, hyperlipidemia, heart failure, atrial fibrillation, dementia, anxiety, depression, hypothyroidism, knee osteoarthritis, lumbar stenosis, unsteady gait, and bladder and bowel incontinence. 

Home care/personal care consumer directed personal assistance services (CDPAS) increase to 77 hours/week is medically necessary for this patient.

There is documentation in the Uniform Assessment System (UAS) of the patient requiring limited assistance with toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the plan failed to document a plan to meet these unscheduled and unpredictable care needs.

The patient has increased assistance needs with bathing, personal hygiene, dressing upper and lower body, toilet use, transfer toilet, walking, locomotion, and bed mobility as compared to the previous UAS. The patient lives alone and does not have informal support for the entire time outside of the previously assigned CDPAS hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS hours is not solely for safety and supervision but to assist the patient with activities of daily living (ADLs).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain behind the knee
Treatment: Vascular procedure [36470 x (times) 1, 36471 x1]
The insurer denied vascular procedure (36470 x1, 36471 x1).
The denial is upheld.

The patient is an adult female. The patient has pain behind the knee without any complications associated with the varicosities.

The requested health service is not medically necessary.

The patient does not meet the medical necessity criteria for the requested procedure since there is no specific documentation that patient has persistent pain, swelling, itching, burning, or other symptoms associated with varicose vein disease with symptoms significantly interfering with mobility. In addition, the patient has not failed conservative management including compression therapy and leg elevation which has not improved the symptoms. The patient does not have active ulceration, bleeding, phlebitis, or size of vein being greater than 3 millimeters.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Intractable epilepsy.
Treatment:  Epidiolex.

The insurer denied Epidiolex.  The determination is overturned.

This is a male patient with intractable epilepsy. Treatment with Epidiolex is the subject of this review. The patient has previously tried and failed many anticonvulsants, including levetiracetam, lamotrigine, zonisamide, topiramate, and valproate. 
Epidiolex 100 milligrams/milliliter (mg/ml) solution is medically necessary for this patient. The patient has intractable epilepsy as defined by poor seizure control on optimal doses of two or more medications. The patient has tried and failed many anticonvulsant medications from different classes. The use of Epidiolex has been shown to be safe and effective for the treatment of refractory seizures. In multiple clinical studies, the drug has been shown to decrease seizure frequency by approximately 50 percent. The drug has limited safety issues in adults and is Food and Drug Administration (FDA)-approved for the treatment of children. The use of this drug is appropriate and consistent with the standard of care for patients with intractable epilepsy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Aide (PCA) Services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week  (split-shift) - a total of 168 hours per week. 
The insurer denied Personal Care Aide (PCA) Services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week  (split-shift) - a total of 168 hours per week.  
The health plan's determination is overturned. 

This is a female patient with a history of hypertension, progressive dementia, anxiety, insomnia, anemia, pain in low back and legs, urinary incontinence, urinary frequency, muscle weakness, unstable gait, and fatigue. She lives alone in a 2-bedroom apartment. The patient and her care team requested Personal Care Aide (PCA) Services. 

Personal Care Aide Services of 12 hours per day, 7 days per week + 12 hours per day, 7 days per week (total of 168 hours per week, split-shift) is medically necessary.
There is documentation in the UAS (Uniform Assessment System) of the patient being totally dependent for tasks of transfer toilet and toilet use and requiring limited assistance with tasks of walking and locomotion. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient lives alone and does not have informal support for the entire time outside of the previously assigned PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL). The recent UAS shows a decline in function and increase in assistance needs as compared to prior UAS. 

Per NY (New York) Codes, Rules, and Regulations section 505.14, a live-in personal care aide must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. An aide to this patient would be unable to receive five hours of uninterrupted sleep for two reasons. First, the patient's PCP (primary care physician) documented the need for the patient to be turned and positioned every 2 hours, which is typically recommended for the purpose of preventing pressure injuries. As noted in "Pressure Injuries: Prevention, Evaluation, and Management", prevention measures in patients at increased risk of pressure injuries including keeping skin clean (particularly following incontinence events) and encouraging patients to change positions often, with assistance if necessary. Secondly, the overnight care logs provided by the patient's aide show that the patient requires assistance with walking, toileting, or positioning every 1-2 hours. Therefore, split-shift care is required to meet the patient's frequent care needs.