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

Diagnosis:  Osteoporosis, hypertension and osteoarthritis.
Treatment:  Personal Care Aide (PCA) Level 2: 8 hours per day - 7 days per week - a total of 56 hours per week.

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 8 hours per day - 7 days per week - a total of 56 hours per week.  The denial is modified.

This is an elderly female with chronic medical problems including osteoporosis, hypertension and osteoarthritis.  She lives with her spouse in a private residence.   However, her spouse is in a skilled nursing facility at this time.  The patient's son is reportedly supportive and involved in her care.  The insurer approved personal care aide (PCA) level 2: 4.5 hours/day, 5 days/week (22.5 hours/week), and the request is for 8 hours/day, 7 days/week (56 hours/week), which is under review.

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as modified independent.  She is reportedly totally dependent to maximal assistance for completing much of her instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She reportedly requires extensive assistance for bathing and lower body dressing.  Limited assistance is reportedly needed for upper body dressing, bed mobility, locomotion, toilet transfer/use and ambulation.  She is independent with personal hygiene and eating.  She is occasionally incontinent of bladder and continent of bowel.  

The patient's self-sufficiency and activities of daily living (ADL) status have reportedly declined over the prior 90 days.   The patient's clinical condition and functional ability are not at a level or unpredictable as to require the requested PCA level 2: 8 hours per day, 7 days a week, for a total of 56 hours per week.   However, her declining functional ability supports PCA services 7 days/week.  As such; her clinical condition and functional ability support increasing PCA level 2: 4.5 hours per day, 7 days a week, for a total of 31.5 hours per week.   The patient may require additional monitoring; particularly due to her cognitive status and falls risk.  Safety monitoring under PCA does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   Based on the enclosed documents reviewed, attention to the patient's physical needs can be appropriately provided and maintained by increasing PCA services to 4.5 hours/day, 7 days/week, totaling 31.5 hours/week.  

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Aide (PCA) Level 2: 8 hours per day - 7 days per week - a total of 56 hours per week services is not substantiated. However, increasing PCA level 2: 4.5 hours per day, 7 days per week for a total of 31.5 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: obesity
Treatment: Gastric Restrictive Procedure; Sleeve Gastrectomy by Laparoscopy
The insurer denied Gastric Restrictive Procedure; Sleeve Gastrectomy by Laparoscopy. The health plan's determination is overturned. 

This patient is a woman under consideration for bariatric surgery. The recent telehealth surgical consultation documents that she is 68 inches tall and weighs 245 lbs (pounds). This corresponds to a body mass index (BMI) of 37.3. She has no documented weight related comorbid health conditions. The patient has attempted weight loss with conventional weight loss programs without significant sustained weight reduction.

Given this patient's diagnosis, her current health condition, and the accepted guidelines for the care and treatment of bariatric surgical patients, the proposed laparoscopic sleeve gastrectomy operation is medically necessary for this patient.
This patient has a BMI in excess of 35. She has successfully completed a multidisciplinary bariatric evaluation. She has had appropriate dietary counseling and has been cleared for the proposed surgery from a medical and psychological standpoint.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal obstruction

Treatment: For repair of nasal valve collapse with low energy temperature-controlled remodeling.

The insurer denied coverage for for repair of nasal valve collapse with low energy temperature-controlled remodeling.

The denial is overturned.

The patient is presenting with a diagnosis of bilateral nasal congestion. Prior treatment with Flonase and over-the-counter allergy medications failed. Patient has a history of prior septoplasty and endoscopic sinus surgery. Examination with endoscopy notes nasal septal swell bodies, inferior turbinate hypertrophy, nasal valve stenosis, and positive Cottle maneuver. Review is for CPT 30469 radiofrequency nasal valve repair.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. 

This patient has a diagnosis of bilateral nasal congestion and prior treatment with Flonase and over-the-counter allergy medications. Patient has a history of prior septoplasty and endoscopic sinus surgery. Examination with endoscopy notes nasal septal swell bodies, inferior turbinate hypertrophy, nasal valve stenosis, and positive Cottle maneuver. Based on the failed therapies and current exam findings the request for radiofrequency nasal valve repair is medically appropriate and supported by current peer reviewed literature.

Nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) does have final approval from the appropriate regulatory bodies for this diagnosis.     

Based on the submitted medical record, this patient is a good candidate for nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction).     

Based on the submitted medical record, nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) is the best available treatment for this patient at this time.     

Based on the submitted medical record, the adverse risks are not increased over standard treatment/services.      

Based on the submitted medical record, the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.                                                    

In summary, the denial of repair of nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal obstruction

Treatment: for repair of nasal valve collapse with low energy temperature-controlled remodeling

The insurer denied coverage for repair of nasal valve collapse with low energy temperature-controlled remodeling

The denial is overturned

The patient has a history of chronic sinusitis, sinus surgery, and deviated nasal septum. The patient presented to the Otolaryngologist's office for a routine sinus follow up. The patient underwent a nasal endoscopy. There was stenosis of the nasal valve bilaterally, 3-4+ turbinate hypertrophy bilaterally, 4+ septal swell bodies, polyploidy changes of middle turbinate. The physician recommended nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction).

There are many peer-reviewed scientific papers that support improvement in health outcomes for those suffering nasal valve collapse.  

The patient has failed medical management which is standard first line treatment; so in office procedure is the next step to achieve resolution of nasal obstruction. Therefore, the nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) is approved.

The VivAer received Food and Drug Administration (FDA) approval in 2020 for treatment for nasal valve collapse.     

The patient has failed medical management for nasal obstruction due to nasal valve collapse and is a good candidate for nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction).     

The patient has failed medical management for nasal obstruction due to nasal valve collapse and nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) is the best available treatment for this patient at this time.     

The adverse risks are not increased over other standard treatment/services.

The patient has failed medical management, so the risks of in office procedure are still less than general anesthesia.     

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The patient has failed medical management which is standard first line treatment so in office procedure is the next step to achieve resolution of nasal obstruction.                                                    

In summary, the denial of repair of nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Nasal obstruction

Treatment: for repair of nasal valve collapse with low energy temperature-controlled remodeling

The insurer denied coverage for repair of nasal valve collapse with low energy temperature-controlled remodeling

The denial is overturned

According to the medical records, the patient presented with nasal obstruction. She was noted to have collapse of the nasal valves bilaterally, turbinate hypertrophy, and large septal swell body. She has tried oral antihistamines and decongestants in addition to steroid sprays. The request for this review is to determine the medical necessity of radiofrequency ablation procedure for the nasal valves.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes. 

The patient has failed conservative treatment and medical management. The requested nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) is less invasive, safe, and effective. Therefore, the nasal valve collapse with low energy temperature-controlled remodeling is beneficial for this patient. 

Nasal valve collapse treated with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) does have final approval from the appropriate regulatory bodies for this diagnosis. 

Per Food and Drug Administration (FDA) approval (2020), "The VivAer Stylus is indicated for use in otorhinolaryngology (ENT) surgery for the coagulation of soft tissue in the nasal airway, to treat nasal airway obstruction by shrinking submucosal tissue, including cartilage in the internal nasal valve area."     

The patient is a good candidate for nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction).     

Nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) is the best available treatment for this patient at this time.     

The adverse risks are not increased over standard treatment/services.     

This service is likely to be more beneficial than any of the standard treatments/procedures for this patient. The patient has failed conservative, and medical management. Surgical options such as functional rhinoplasty have more risk associated. This option, nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) is less invasive, safe, and effective.                                                    

In summary, the denial of repair of nasal valve collapse with low energy temperature-controlled remodeling (a procedure to treat nasal airway obstruction) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer- Breast Cancer
Treatment: Radiation Therapy-Proton Beam Therapy
The health plan denied the treatment of Proton Beam Therapy as not medically necessary for this patient. The reviewer has overturned in whole the health plan's determination.

This is the case of a patient who presented with locally advanced Left breast cancer. The patient was treated with chemotherapy followed by a lumpectomy. The plan is to treat the patient comprehensively with radiation to the breast and lymph nodes using proton beam therapy (PBT). This is the subject of review.

The requested health service/treatment of Proton beam therapy is medically necessary for this patient.
This is a young patient with curable disease. The disease is on the Left side and the tumor bed is just above the heart. In order to treat the patient's disease comprehensively with all lymph nodes, the patient's heart and lungs are getting unacceptably high doses of radiation. In order to avoid high dose of radiation to the heart and lung, proton beam therapy (PBT) is medically necessary.
The attending physician provided a dose-volume histogram (DVH) comparison of proton beam therapy (PBT) and intensity modulated radiation therapy (IMRT). The Mean heart dose was 7.8 Gy from IMRT vs 0.7 Gray (Gy) from PBT. This is Quantitative Analysis of Normal Tissue Effects in the Clinic (Quantec) violation if IMRT photons are used. This will increase cardiac morbidity and mortality in this young patient with curable disease. PBT can avoid this serious morbidity and mortality. Left lung V5 (5 Gray) is 34% (percent) from PBT vs (versus) 98% from IMRT. Left lung V20 (metric used for normal lung tissue dose) is 8.6% from PBT vs 57% from IMRT. Thus, PBT will reduce lung morbidity.
PBT reduces radiation to the opposite breast and thus avoids cancer developing in the opposite breast. PBT is known to reduce second cancer development compared to photon IMRT.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo

Treatment: Photochemotherapy, tar and ultraviolet b

The insurer denied coverage for Photochemotherapy, tar and ultraviolet b.

The denial is overturned.

 
The patient is a child with vitiligo of the trunk. The patient has failed therapy with triamcinolone and tacrolimus ointment. The request is for continuation of excimer light therapy treatment.  

Based on the information provided, the use of excimer light therapy laser is medically necessary for the treatment of the patient's condition, vitiligo, affecting the trunk.  The patient has failed topical therapy with triamcinolone, a topical steroid as well as tacrolimus.  Light therapy with excimer laser allows for localized treatment of the affected area without the need for systemic light exposure from light box therapy.  The patient has experienced clinical improvement without documented side effects from the treatment with excimer XTRAC laser light therapy.  References are noted below documenting the clinical benefit of excimer light therapy in the treatment of vitiligo.  The request is reversed and the use of excimer light therapy to treat the patient's vitiligo is approved under the supervision of the treating dermatologist.  

Based on the above, the insurer's denial must be reversed. 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 Photochemotherapy; tar and ultraviolet b services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I occlusion
Treatment: Braces
The insurer denied braces.
The health plan's determination is overturned. 

The patient in question is a young female with a Class I occlusion. She is crowded and has a 4-millimeter (mm) overjet. She has a 6-mm overbite causing wear on her mandibular incisors. Tooth 11 has erupted ectopically on the palate and tooth H is retained. She is treatment planned for orthodontics (braces) to correct her malocclusion.

Braces are medically necessary for this patient. The patient has wear on her lower anterior teeth, particularly visible on teeth 23-26 in the photographs. If left untreated, this will worsen and cause restorative problems. A deep bite on its own is not a reason to treat with orthodontics. However, at the patient's age, she is already causing wear to the incisal edges of her mandibular anterior teeth. This will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive and difficult to correct than the orthodontic problem she currently has. Therefore, braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Sotyktu. 
The insurer denied: Sotyktu. 
The denial is upheld. 

The patient is an adult male with psoriasis to the nails and possible psoriatic arthritis, treated with Ibuprofen. Provider is requesting Sotyktu. The health plan requires use of formulary agents Otezla, Cimzia, Enbrel, preferred Adalimumab product, Skyrizi, Tremfya, Cosentyx, or Stelara. 

The requested health service is not medically necessary. 

The patient has no contraindications to the formulary agents, which are widely used, safe and effective therapies. While Sotyktu is one possible agent for psoriasis, the formulary agents are likely to be more effective. In the POETYK trial, at week 16, response rates were significantly higher with deucravacitinib versus placebo or apremilast for PASI (Psoriasis Area and Severity Index) 75 (194 [58.4%] versus 21 [12.7%] versus 59 [35.1%]; P < .0001) and sPGA (Static Physician's Global Assessment) 0/1 (178 [53.6%] versus 12 [7.2%] versus 54 [32.1%]; P < .0001). Efficacy improved beyond week 16 and was maintained through week 52. Adverse event rates with deucravacitinib were similar to those with placebo and apremilast.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic back pain. 
Treatment: Personal Care Aide 56 hours/week, consumer direct, 1 client. 
The insurer denied coverage for Personal Care Aide 56 hours/week, consumer direct, 1 client. 
The denial is upheld. 
 
This is an adult male with chronic back pain who underwent thoracic spine surgery. He lives alone in a 1 bedroom apartment with elevator access. The patient is approved for Consumer Direct Personal Care Aide (CDPCA) services 21 hours/week and requested 56 hours/week, denied by the insurer; which led to an external review. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as independent. The patient's ability to perform Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping; varies from total dependent to independent. The patient reportedly required limited assistance for lower body dressing. He is otherwise independent with bathing, personal hygiene, upper body dressing, eating, bed mobility, locomotion, toilet transfer/use and ambulation. The patient is reportedly infrequently incontinent bladder and bowel. 

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require CDPCA services 56 hours/week; as he is essentially independent with activities of daily living. According to the more recent clinical records, the patient underwent thoracic spine surgery. A hospital progress note recommended transfer to acute rehabilitation. Subsequent clinical notes were not available for review. A new assessment for CDPCA services should be performed in order to determine the patient's appropriate level of CDPCA services at this time. However, based on the information submitted for review, the requested 56 hours CDPCA services are not medically necessary. 

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 Personal Care Aide 56 hours/week, consumer direct, 1 client services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Premature ventricular complexes
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the hospital for an elective catheter ablation for frequent symptomatic premature ventricular complexes (PVCs) with a PVC burden of approximately 15 percent (%). His medical history was remarkable for diabetes, hypertension, coronary artery bypass graft surgery, aortic valve, aortic root and partial aortic arch replacement, obstructive sleep apnea and morbid obesity. Electrophysiologic testing mapped the origin of the PVCs to the moderator band. The focus was successfully ablated and the procedure was uncomplicated. Post-procedure, the patient was admitted to the hospital. He remained stable overnight and was discharged. The medical necessity for an inpatient admission is at issue.

Based on the documentation provided an inpatient level of care was not medically necessary.
Catheter ablation for frequent premature ventricular complexes (PVCs) is a safe and effective treatment option for patients with significant symptoms or PVC-induced cardiomyopathy. This patient underwent a successful, uncomplicated procedure. The safety of same-day discharge after catheter ablation of a variety of arrhythmias has been well documented. While it was reasonable to monitor this patient overnight post-procedure, no specific therapy was required. An inpatient level of care was not medically necessary. A lower level of care would have been appropriate.