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

Diagnosis: Parkinson's disease
Treatment: Consumer Directed Personal Assistance Services, 48 Hours over 4 Days
The health plan denied Consumer Directed Personal Assistance Services, 48 Hours over 4 Days. The denial is overturned.

The patient is an elderly female. She has depression and Parkinson's disease. Denial of consumer directed personal assistance services, 48 hours over 4 days is being appealed. The health plan approved 29 hours over 4 days.

The patient's Uniform Assessment System (UAS) evaluation completed this year shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, phone use, shopping, bathing, personal hygiene, dressing, walking, locomotion, and toileting; and extensive assistance with managing finances and medications, bed mobility, and eating. The patient has bladder incontinence.

A letter from the patient's provider notes the patient needs assistance with ADLs (activities of daily living). She needs physical assistance with bed mobility to be repositioned. She needs to be fed.

A statement from Caring People notes that the patient is unable to perform ADLs (activities of daily living). She cannot differentiate night and day. She needs frequent change of clothes due to incontinence of bladder. She needs around-the-clock care - some of which her family can provide.

Appeals statements support the patient's need for assistance with all ADLs (activities of daily living). The statements also note the patient needs assistance with repositioning in the bed and frequent care related to urinary incontinence. The information provided shows that this patient has significant limitations in functioning. The approved consumer directed personal assistance services 29 hours over 4 days is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase to 48 hours over 4 days is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Orthopedic
Pharmacy/prescription drug

Diagnosis: osteoporosis
treatment: Teriparatide
The insurer denied Teriparatide. The health plan's determination is overturned. 

The patient is a male with osteoporosis at high risk for fracture and a history of multiple fractures whom initiated Teriparatide. Additional history included long term steroid use for Allergic bronchopulmonary aspergillosis. 

A formulary exception is indicated in this case.
Based on the clinical documentation provided, evidence based literature and standards of care, teriparatide is clinically appropriate and effective for the treatment of osteoporosis associated with sustained glucocorticoid therapy.
The patient has severe high-risk osteoporosis in the setting of long term corticosteroid use. Teriparatide is approved by the Food and Drug Administration (FDA) for the treatment of men and women with osteoporosis associated with sustained glucocorticoid therapy at high risk for fracture or who have failed or are intolerance to other available osteoporosis therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: atopic dermatitis and severe alopecia areata
Treatment: Cibinqo 100 milligram (mg) tablets
The insurer denied coverage for Cibinqo 100 milligram (mg) tablets.
The denial is overturned.
 
The patient is a teenager with a diagnosis of atopic dermatitis and severe alopecia areata.  The patient has failed intralesional steroids, topical steroids, as well as tacrolimus ointment.  The patient has failed treatment for alopecia areata with oral minoxidil.  As the patient has concomitant atopic dermatitis which has failed topical therapy, the physician is recommending Cibinqo for treatment of the atopic dermatitis in the hopes that it may also assist in the improvement of the alopecia areata given its mechanism of action.  The request is for Cibinqo.  

Based on the information provided, the use of Cibinqo is medically necessary in the treatment of the patient's atopic dermatitis.  The patient has severe atopic dermatitis with significant body involvement.  He has failed intralesional steroids, topical steroids, and tacrolimus.  The patient requires systemic therapy.  Janus kinase (JAK-STAT) inhibitors like Cibinqo have been shown to improve atopic dermatitis.  Additionally, JAK-STAT inhibitors can improve alopecia areata.  This patient has severe alopecia areata which has failed standard therapies.  The use of Cibinqo offers the possibility of significantly improving both disease states.  In head-to-head trial of abrocitinib (Cibinqo) and dupilumib (Dupixent) Reich et al reported "Compared with dupilumab (Dupixent), a larger proportion of patients treated with abrocitinib reached the primary outcomes..."

The use of Cibinqo is approved for the use in the treatment of this patient's skin conditions.  

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 Cibinqo 100 milligram (mg) tablets is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Mitochondrial Myopathy. 
Treatment: Coenzyme Q-10 (powder compound). 

The insurer denied the Coenzyme Q-10 (powder compound).  The denial has been upheld. 

The health plan should not cover the proposed treatment. 

The patient has a diagnosis of mitochondrial myopathy. An unsigned and undated letter with pages of limited legibility noted that the patient has a history of multiple sensitivities to colors, dyes, gluten, dairy, and artificial ingredients. Pure powder form was recommended. However, there is insufficient supporting evidence that the patient has a true allergy or contraindication to non-powder or non-compounded forms of Coenzyme Q-10.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: enlargement of the Adam's apple on the left side

Treatment: Computed tomography (CT) neck

The insurer denied coverage for Computed tomography (CT) neck

The denial is overturned

 
This case involves an adult patient regarding computed tomography (CT) of the neck.  Records noted that an ultrasound noted that the thyroid was slightly heterogeneous with a small cyst in the upper pole of the right thyroid.  Laboratory reports noted increased albumin at 5.4 and increased bilirubin at 1.2.  The patient reported feeling well.  He was positive for enlargement of the Adam's apple on the left side during physical examination.  The impression was of localized swelling, mass and lump with hypothyroidism.  He was recommended for a CT scan of the neck with and without contrast.  He was denied coverage for CT of the neck with claims that this was not medically necessary.  The document sent claimed the patient had neck swelling and that results from ultrasonography should confirm why additional testing is needed.  This review pertains to the denial of coverage for neck CT.

Literature states that the purpose of any imaging examination is to answer a clinical question raised by appropriate and complete history and physical examination.  Neck masses are often seen in clinical practice, and the family physician should be able to determine the etiology of a mass using organized, efficient diagnostic methods. The first goal is to determine if the mass is malignant or benign; malignancies are more common in adult smokers older than 40 years. Etiologies can be grouped according to whether the onset/duration is acute (e.g., infectious), subacute (e.g., squamous cell carcinoma), or chronic (e.g., thyroid), and further narrowed by patient demographics. If the history and physical examination do not find an obvious cause, imaging and surgical tools are helpful.  Contrast-enhanced computed tomography is the initial diagnostic test of choice in adults.  While it was noted that ultrasonography initially identified abnormalities of the thyroid, the requested CT is to define the diagnosis which can help direct treatment planning.  Given that the primary concern in adults with a persistent neck mass is malignancy, and with the patient having a history of smoking, proceeding with the CT of the neck would be within the standard of care.  As such, the neck CT is 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 neck CT (computed tomography - pictures of inside neck) visits/units requested: 1 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic short stature
Treatment: Genotropin
The insurer denied coverage for Genotropin.
The denial is upheld.

This is a male child diagnosed with idiopathic short stature (ISS). This request is for Genotropin.  His bone age was 11 years at calendar age (CA) 10y(years)6m(months). His height velocity is reported to be 4.2 centimeters/year (cm/yr). His insulin-like growth factor (IGF1) was 217; insulin-like growth factor binding protein (IGFBP3) was 4910. His testes were 2 cc (craniocaudal) bilaterally and pubic hair was at Tanner 1. 
His weight was 26.4 kilograms (kg), his height at 10.33 years old was 129.19 cm (centimeters) (-1.65 standard deviation score (SDS)). Height at 10.83 years old was 131.3 cm (-1.65 SDS) with height velocity over 6 months of 4.2 cm/yr.  His mid parental height is 175.26 cm (-0.22 SDS). His predicted adult height is 161.036 cm (-2.20 SDS)
The patient did not meet biochemical criteria. Growth hormone stimulation testing is not reported. 

The patient did not have pretreatment height less than or equal to -2.25 standard deviation (SD). The patient therefore does not meet idiopathic short stature criteria.

The request does not meet any nationally accepted criteria for use of growth hormone. 

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 Genotropin services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack
Treatment: Hospital Admission
The health plan denied Hospital admission.
The determination is Upheld.

The patient is a male with past medical history of hypertension (HTN), diabetes mellitus type 2 (DM2), coronary artery disease (CAD), erectile dysfunction (ED), and hyperlipidemia (HLD) who was admitted with complaints of left arm weakness, which resolved in less than one hour. His vital signs were notable for significant HTN (hypertension) of 238/140 millimeters of mercury (mmHg). The physical exam notable for no apparent distress and normal extremity strength throughout. He had a National Institute of Health Stroke Scale (NIHSS) of 2. The lab work was unremarkable. A computed tomography (CT) scan of the head showed small vessel ischemic changes, a transthoracic echocardiogram (TTE) was within normal limits (WNL), and computed tomography angiography (CTA) of the head/neck showed severe atherosclerotic plaque in the right carotid bulb with left vertebral artery focal narrowing. The magnetic resonance imaging (MRI) showed findings consistent with multiple small sub-acute infarcts. An electrocardiogram (EKG) showed sinus bradycardia with premature ventricular contractions (PVCs). The patient was diagnosed with a transient ischemic attack (TIA) and was treated with blood pressure control, dual antiplatelet therapy (DAPT), and statin. The patient was discharged in stable condition.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of left arm weakness, which resolved in less than one hour. The patient's NIHSS (National Institute of Health Stroke Scale) score was 2, indicating that the patient on presentation, at most, had suffered a minor stroke, but was eventually found to have a negative CT (computed tomography) scan and MRI (magnetic resonance imaging) negative for acute findings. Further suggesting that this patient was appropriate for an alternate level of care is that the patient did not have a crescendo TIA (transient ischemic attack), head CT (computed tomography)/MRI (magnetic resonance imaging) was negative for acute ischemia, there was no known extracranial embolic source such as atrial fibrillation or artificial heart valve, known carotid stenosis, disabling stroke, altered mental status, or hypertensive encephalopathy. Finally, the patient was diagnosed with a TIA (transient ischemic attack), and the patient did not have a high-risk age, blood pressure, clinical features, duration, and diabetes (ABCD2) score. The patient remained hemodynamically stable during the stay, was treated with standard medications for TIA (transient ischemic attack) and was discharged in stable condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: wheelchair dependence, hypertension, Friedreich ataxia, and tremors

Treatment: PCA services 12 hours per day, 7 days per week, a total of 84 hours per week

The insurer denied coverage for PCA services 12 hours per day, 7 days per week, a total of 84 hours per week

The denial is overturned

This is an elderly patient with chronic medical conditions including Friedreich's ataxia.  She lives alone in a 1-bedroom apartment.  The insurer approved personal care assistance (PCA) service 8 hours/day, 7 days/week (56 total).  The request is for PCA services 12 hours/day, 7 days/week (84 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 can verbalize an emergency plan, activate her Personal Emergency Response System (PERS) or call 911 during an emergency. The patient reportedly requires maximal assistance for much of her instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She also reportedly requires maximal assistance for bathing, personal hygiene, dressing, and toilet use.  Extensive assistance is reportedly needed for toilet transfer and bed mobility.  She reportedly requires limited assistance for bed mobility and eating.  The patient is reportedly frequently incontinent of bladder and continent of bowel.   The patient's functional ability has significantly declined when compared to the prior UAS.  Her clinical condition and functional ability are at a level or unpredictable as to require the requested PCA level 12 hours per day, 7 days a week, for a total of 84 hours per week.   The combination of the patient's continued functional decline, underlying medical condition and review of enclosed nighttime treatment logs support the requested  increase PCA services 12 hours/day, 7 days/week, totaling 84 hours/week.  

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 personal care assistance (PCA) services 12 hours per day, 7 days per week, a total of 84 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems. 
Treatment: Deep gum and root cleaning, Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant, and Upper Right Quadrant. 
The health plan denied: Deep gum and root cleaning, Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant, and Upper Right Quadrant. 
The determination is Upheld. 

A male patient presented for a scaling and root planning procedure in all four quadrants. The initial request was denied due to no evidence of bone loss. 
At issue is the medical necessity of the deep gum and root cleaning, lower left quadrant, lower right quadrant, upper left quadrant, and upper right quadrant. 

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

The requested health service/treatment of D4341 deep gum and root cleaning, lower left quadrant, lower right quadrant, upper left quadrant, and upper right quadrant is not medically necessary because there is no explicit proof of periodontal illness. The panoramic radiograph does not demonstrate evidence of bone loss. While pocketing is noted on the periodontal charting, there is no marked bone loss on the imaging.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hepatocellular carcinoma. 
Treatment: Professional services (outpatient procedure (37243 x 2, 37242 x 1). 

The insurer denied coverage for professional services (outpatient procedure (37243 x 2, 37242 x 1). 

The denial is overturned. 

The patient is an adult being recommended for the Y90 procedure.  The patient underwent a liver scan that noted 7.5% shunting from the hepatic artery to the lungs.  The patient underwent a magnetic resonance imaging (MRI) of the abdomen that revealed a new peripheral nodular enhancement. There were 4 lesions identified. The provider stated that the patient had been treated with thermal ablation and chemoembolization for multifocal hepatocellular carcinoma.  However, the patient had recurrent disease.  The provider noted that the patient had been previously approved for Y90. 

Current scientific literature demonstrates the safety and efficacy of Y90 for the treatment of patients with hepatocellular carcinoma (HCC) that is unresectable pathology. The patient has a history of HCC despite thermal ablation and chemoembolization. Treatment plan includes potential transplantation. 

There is scientific evidence in peer-reviewed literature to support a result of improvement in health outcomes. 

The patient is a good candidate for professional services (outpatient procedure (37243 x 2, 37242 x 1). 

The requested treatment is the best available treatment for this patient at this time. 

The adverse risks are not increased over standard treatment/services. In addition, the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

In summary, the denial of professional services (outpatient procedure (37243 x 2, 37242 x 1) and coverage for the requested treatment should be reversed. 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: Hepatocellular carcinoma. 
Treatment: Professional services (outpatient procedure (37243 x 2, 37242 x 1). 

The insurer denied coverage for professional services (outpatient procedure (37243 x 2, 37242 x 1). 

The denial is overturned. 

This case involves an adult with hepatocellular carcinoma (HCC).  The liver scan noted 7.5% shunting from the hepatic artery to the lungs.  The magnetic resonance imaging (MRI) of the abdomen revealed four lesions to include a new peripheral nodular enhancement associated with mild restricted diffusion. This was more pronounced compared to prior study. An appeal letter stated the patient had undergone thermal ablation as well as chemoembolization.  There was recurrent disease of the segment 6 lesion. The patient was being recommended for treatment with Y90 in discussion with the patient's transplant surgeon and hepatologist.  The patient had previously undergone half of the Y90 procedure. 

YO90 radioembolization has become an essential therapy in the treatment of HCC and is supported by National Comprehensive Cancer Network guidelines. 

There is scientific evidence in peer-reviewed literature to support a result of improvement in health outcomes. 

The patient has persistent HCC despite previous treatment. The patient is a good candidate for professional services (outpatient procedure (37243 x 2, 37242 x 1). 

The requested treatment is the best available treatment for this patient at this time. 

The adverse risks are not increased over standard treatment/services. In addition, the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

In summary, the denial of professional services (outpatient procedure (37243 x 2, 37242 x 1) and coverage for the requested treatment should be reversed. 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: Hepatocellular carcinoma. 
Treatment: Professional services (outpatient procedure (37243 x 2, 37242 x 1). 

The insurer denied coverage for professional services (outpatient procedure (37243 x 2, 37242 x 1). 

The denial is overturned. 

This case involves an adult under review for outpatient procedure.  Nuclear medicine liver scan revealed there was 7.5% shunting from the hepatic artery to the lungs.  Magnetic resonance imaging (MRI) of the abdomen revealed no significant change in lesion #3 with persistent nodular arterial enhancement.  There was a new peripheral nodular enhancement with lesion #2 as well as 5 millimeter (mm) pulmonary nodule in the right lower lobe.  Letter reported prior request for Y90 was denied.  It was noted the patient had undergone multiple locoregional therapies for multifocal hepatocellular carcinoma including thermal ablation.  Patient also underwent chemoembolization. The patient continued to have recurrent disease.  It was noted the patient was previously approved for Y90 and had completed half of the procedure. 

Current literature supports that Y90 radioembolization can be safely used to bridge patients to resection or transplantation, induce future liver remnant growth, and select for less aggressive tumor biology prior to surgery. In this case, the patient has persistent liver cancer despite treatment to date. The procedure was planned in consultation with transplant surgeons. 

There is scientific evidence in peer-reviewed literature to support a result of improvement in health outcomes. 

The patient is a good candidate for professional services (outpatient procedure (37243 x 2, 37242 x 1) and this is the best available treatment for this patient at this time. 

The adverse risks are not increased over standard treatment/services and the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

In summary, the denial of professional services (outpatient procedure (37243 x 2, 37242 x 1) and coverage for the requested treatment should be reversed. 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.