Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Tinea Unguium
Treatment: Formulary exception for Jublia
The insurer denied the Formulary exception for Jublia
The denial is overturned

The patient is a male. He suffers from onychomycosis and has undergone treatment with various topical agents without success. This included clotrimazole, in line, as well as several other antifungals including ketoconazole.  He was then prescribed and efinocozole which he began using and saw improvement in his onychomycosis.  He has confirmed onychomycosis by biopsy.

Yes, the health plan should cover the Formulary exception for Jublia.
The health plan should cover the Formulary exception for Jublia, as it has already been effective for the patient. It does meet FDA (United States Food and Drug Administration) guidelines for use and he has tried all the alternative topical medications.  Alternative to medical treatment is laser therapy, which is not covered by insurance. The formulary drugs have not been effective for the patient, as he has already tried and failed them. Multiple high-level clinical trials have shown success in the treatment of onychomycosis (1, 2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: porcelain crown for #14, and core buildup for #14.
The insurer denied a porcelain crown for #14, and core buildup for #14.
The determination is upheld.


The patient presented for the treatment of tooth number (#)14. Provided for review are a single periapical film, single bitewing film, multiple dental claim forms, as well as previous denials and health plan language.
Previous denials have been on the basis that the tooth does not appear to have decay or injury.
At issue is the medical necessity of the treatment of porcelain crown (2740) for #14, and core buildup (2950) for #14.

No, based on the provided documentation there is no evidence of medical necessity for the treatment of porcelain crown (2740) for #14, and core buildup (2950) for #14.
There is no provided diagnosis, no evidence of decay, no evidence of the presence of decay that requires a restoration beyond that of a direct restoration. There is no radiographic or clinical evidence of decay, nor any decay that would require a buildup or crown. There are also no clinical notes with any diagnosis of any decay to necessitate any treatment.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II Diabetes Mellitus
Treatment: Formulary Exception for Januvia
The insurer denied the formulary exception for Januvia.
The denial is upheld.

This is a male patient with type II diabetes. The request for Januvia is under review. The prior request was denied as the patient has not tried and failed Tradjenta. The attending physician is appealing this determination, as the patient has not been controlled on other medications and has experienced nausea, vomiting, diarrhea, frequent urination, dizziness, and fatigue.

No, the health plan should not cover the proposed treatment, Januvia.

The request is for Januvia for the treatment of type II diabetes. The preferred formulary alternative is Tradjenta. Tradejnta is expected to be equally safe and effective for the treatment of type II diabetes as Januvia. The American Diabetes Association clinical guidelines do not recommend the use of Januvia over Tradjenta. Therefore, the health plan should not cover the proposed Januvia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild Gastritis and IBS (irritable bowel syndrome).

Treatment: inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented with abdominal pain, nausea, and diarrhea. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A CAT (computed axial tomography) scan of the abdomen was negative for bowel obstruction or an acute inflammatory process. An ultrasound showed a distended gallbladder but no gallstones. A HIDA (hepatobiliary iminodiacetic acid) scan was negative. She was treated with Protonix and Carafate. An endoscopy revealed mild gastritis. She was started on Bentyl for IBS. Her symptoms improved.

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG (Milliman Care Guidelines) M-05) include hemodynamic instability, peritoneal signs, bacteremia, inability to maintain oral hydration after observation care, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

Clinical indications for admission for Gastroenterology (MCG MG-GAS) include a suspected acute intra-abdominal process, ascites requiring acute treatment, severe diarrhea with complications such as acute renal failure, severe dysphagia, and gastroparesis associated with renal failure. The patient did not have these conditions.

This patient required a workup for abdominal pain. However, she was stable for an outpatient workup including the endoscopy and radiology scans. She was diagnosed with mild gastritis and IBS. She could have been treated with a PPI(proton pump inhibitors), Carafate, and Bentyl as an outpatient. She did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Gastroenterology. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

The denial is upheld.

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

Diagnosis: Orthopedic/Musculoskeletal/Bone Fracture/Break
Treatment: Inpatient Hospital
The health plan denied the inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a past medical history of diabetes, obesity, hypertension, and hyperlipidemia who presented to the emergency room (ER) after being in a motorcycle accident with a severe injury to the left foot and ankle. The patient had a full trauma work-up and was found to be stable. The patient sustained multiple fractures to his ankle and foot. He was told he would need surgery but did not want to undergo surgery while out of town.
One day later, he presented to the ER at another facility. He was then seen by a podiatrist and orthopedist. He was noted to have multiple tarsal fractures, a navicular fracture, and a cuboid with dislocation of the anterior posterior tibial tendon. The orthopedist recommended to delay in surgery for 1 week to allow the swelling to subside and decrease wound complications. The podiatrist recommended admission to be set up for surgery. He underwent an open reduction internal fixation (ORIF) of his left navicular and cuboid with repair of the posterior tibial tendon with allograft. He was placed into a cast and was to be non-weight bearing (NWB). He was discharged home after surgery. He would follow up with the orthopedist for his ankle fracture and with his primary care physician.
At issue is the medical necessity for the inpatient stay.

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

No, the requested health service/treatment of an inpatient stay was not medically necessary for this patient. The patient was initially seen in a hospital after a motor vehicle accident and had a full trauma work up and was discharged in stable condition and was recommended to follow up with an orthopedist, podiatrist, and his primary care physician. The patient then presented to an ER at another facility and was admitted into the hospital. He underwent surgery and was discharged home. There is no clear reason/documentation on why the patient needed this level of care. The patient had foot surgery that could have been performed in an outpatient setting.
Based on the review of submitted records, there is no documentation to support the level of care of an inpatient. The patient sustained an injury and was discharged home on the same day of injury in a stable condition. There was no documentation to support the inpatient level of care. The patient was stable and even though he presented to another emergency room the following day, this is not enough to support the level of care. He would have been treated with a similar outcome and quality of care in an outpatient basis. The patient needed surgery; however, the surgery was not considered an emergent surgery that required inpatient status. The patient was stable to be discharged home with no requirements necessitating hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This is a male who presented to the hospital complaining of chest pain and shortness of breath. Past medical history was significant for hypertension, end stage renal disease, congestive heart failure and atrial fibrillation. Upon arrival he was hypertensive with blood pressure (BP) 174/103 and tachycardic with heart rate 120. No other abnormalities were noted on physical examination. Serum blood testing revealed an elevated high sensitivity troponin level (124), an elevated brain natriuretic peptide (BNP) level 2344, and anemia with a hemoglobin of 9. A 12-lead electrocardiogram (EKG) revealed atrial fibrillation with a rapid ventricular rate. The patient was treated with atrioventricular (AV) nodal blocking agents and diuretics and admitted to the hospital for treatment of atrial fibrillation, congestive heart failure and acute coronary syndrome. He ultimately signed out against medical advice.

This patient presented with chest pain and congestive heart failure. EKG on admission revealed atrial fibrillation with rapid ventricular rate. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic atrial fibrillation. (2) In addition to atrial fibrillation, this patient had chest pain and a high pretest probability of significant coronary artery disease. (3) This patient had an elevated HEART (History, EKG, Age, Risk factors, and troponin) score and appropriately was admitted to the hospital. (4) In conclusion, acute inpatient admission was medically necessary in this case.

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 an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer.
Treatment:  Proton Radiation Therapy, pre-service.
The insurer denied the  Proton Radiation Therapy, pre-service.
The denial is overturned.

The patient is a female with a diagnosis of bilateral breast cancer status post breast conserving surgery and chemotherapy. Adjuvant radiation therapy to bilateral breasts and regional nodes was recommended, and proton therapy was requested.

The initial request for proton therapy was denied coverage by the health plan, because it was not considered medically necessary. This denial is being appealed.

Yes, the requested Proton beam therapy is medically necessary.
The requested proton therapy is considered medically necessary because it is safe and effective; a generally accepted national standard of medical practice; not provided primarily for convenience of the patient or the practitioner; the least intensive and/or most appropriate alternatives among diagnostic and treatment options; provided in the most effective setting.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
In this case, a dosimetric comparison with a photon-based plan was performed, and the proton therapy plan significantly reduces radiation dose to the heart and lung. The mean heart dose was 10.1Gy (Gray), which exceeded tolerance, and 0.57Gy (Gray) with proton therapy (within tolerance).  The V5 (volume receiving 5 Gray) and V20 (volume receiving 20 gray) left lung dose was also significantly lower with the proton therapy plan.

A study from the University of Florida performed a comparative analysis and evaluated patients with breast cancer treated with proton therapy.  Median cardiac V5 (volume receiving 5 Gray) was 0.6% with PT (proton therapy) and 16.3% with conventional radiation). Median ipsilateral lung V5 (volume receiving 5 Gray) and V20 (volume receiving 20 Gray) were improved with PT (proton therapy) (median V5 [volume receiving 5 Gray] 35.3% vs 60.5%; and median V20 [volume receiving 20 Gray], 21.6% vs 35.5%).  The authors concluded that proton therapy "significantly improves cardiac dose, especially for left-sided patients, and lung V5 [volume receiving 5 Gray] and V20 [volume receiving 20 Gray] in all patients without excessive acute toxicity."

Proton beam radiation is the best technique for this patient that can provide adequate tumor coverage and normal tissue sparing and in this case, it is an appropriate treatment. Therefore, it is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervicalgia and Cervical Radiculopathy

Treatment: Procedure to place wires on the spinal cord

The insurer denied coverage for procedure to place wires on the spinal cord.

The denial is overturned.

This woman has a history of hypertension, cervicalgia, and cervical radiculopathy. She presented to the Physical Medicine and Rehabilitation physician's office for a follow up visit for neck pain. The patient reported pain at a level of 9 out of 10. The patient took Percocet without relief. She has also tried physical therapy (PT), acupuncture, massage therapy, and home exercise for more than three months without relief. The patient was recently seen by a Spine Surgeon. The surgeon recommended a cervical spinal cord stimulator trial to relieve pain

Chivukula, et al conducted a survey and found "Of 121 patients identified that underwent at least trial SCS [spinal cord stimulator], 100 underwent permanent lead implantation. Indications for cervical SCS included brachial plexus lesions (8), complex regional pain syndrome (33), degenerative disc disease (4), failed neck surgery syndrome (23), chronic radiculopathy (6) and post-herpetic neuralgia (PHN) (1); for CMJ [cervicomedullary junction] SCS, indications included trigeminal deafferentation pain (10), trigeminal neuropathic pain (4), PHN (4) and occipital neuralgia (7). Pain relief was greater along the extremities than axially, and less in the occipital area than in the head or face. Mean pain reduction averaged 56.6% [percent] at a mean follow-up of 4.2 years. Of 24 revision surgeries required, 8 were for presumed lead migration or fracture. Complications included 4 CSF [cerebrospinal fluid] leaks, 5 wound infections, and 4 cases of persistent numbness or pain. Pain relief lasted an average of 3.6 years." (1)

They concluded: "Cervical and CMJ SCS are safe and efficacious and may provide greater relief along the upper extremities than axially, and in the head rather than in the occipital region." (1)

According to Baranidharan, et al, a "Systematic literature search was performed for studies reporting outcomes for cervical 10 kHz [kilohertz] SCS using date limits ... The study results were analyzed and described qualitatively. Additionally, when feasible, meta-analyses of the outcome data, with 95% confidence intervals (CIs), were conducted using both the fixed-effects (FE) and random-effects (RE) models." (2)

They concluded that the Findings suggest 10 kHz SCS is a promising, safe, minimally invasive alternative for managing chronic upper limb and neck pain. (2)

The SCS is medically reasonable and necessary for this patient.

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 a procedure to place wires on the spinal cord is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, age related debility, blindness in the right eye, hypertension, pruritus, glaucoma, osteoarthritis and urinary incontinence.

Treatment Personal Care Aide Level 2: services of 12 hours per day, 7 days per week for a total of 84 hours per week.

The insurer denied coverage for Personal Care Aide Level 2: services of 12 hours per day, 7 days per week for a total of 84 hours per week.

The denial is overturned.

This is a female patient with a history of dementia, age related debility, blindness in the right eye, hypertension, pruritus, glaucoma, osteoarthritis and urinary incontinence. As per her physician, she is legally blind. Per the video telephonic conference New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, her daughter and personal care aide were present. The patient lives with her child. She is totally dependent for ordinary housework. The patient needs maximum assistance with meal preparation, managing finances, managing medications, phone use, shopping, transportation and bathing. She needs extensive assistance with dressing her lower body, walking, toilet transfer and locomotion. The patient uses an assistive device for locomotion. Her ability to walk and transfer has deteriorated due to severe hip pain. The patient needs limited assistance with dressing her upper body, bed mobility, eating and toilet use. She is frequently bladder incontinent but has complete bowel control. It was noted that she had multiple periods of unscheduled toileting needs amounting to 6 times during the 3.5 hrs (hours) in the evening when alone. The patient's son, daughter and daughter-in-law are all very supportive in all aspects of her care. It was noted the patient had one fall in the last 30 days. An increase to Personal Care Aide Level 2: services of 12 hours per day, 7 days per week for a total of 84 hours per week is being requested.

The calculation of the number of hours recommended was reviewed along with the adjustments that were made.

Based on the professional findings and recommendations, the medical necessity for the requested 84 PCA hours is supported.   

Personal Care Aide Level 2: services of 12 hours per day, 7 days per week for a total of 84 hours per week is considered medically necessary for this patient.

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 Personal Care Aide Level 2: services of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, heart disease, and hearing impairment
Treatment: Increase in Personal Care Aide (PCA) services for a live-in per diem, 24 hours per day
The insurer denied the increase in PCA services for a live-in per diem, 24 hours per day.
The denial is overturned.

The patient is a male. His conditions include dementia, heart disease, and hearing impairment. Denial of increase in personal care aide (PCA) services for a live-in per diem, 24 hours per day, is being appealed. The health plan approved 56 hours per week.

Uniform Assessment System (UAS) evaluation competed shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, bathing, personal hygiene, dressing, and toileting; extensive assistance with phone use, walking, locomotion, bed mobility and eating. The patient has frequent bowel and bladder incontinence.

An appeal letter from the patient's provider notes the patient's dementia has been worsening. He has abruptly lost the ability to stand and walk. He has fallen several times when there is no assistance. He is unable to perform ADLs (activities of daily living) without extensive assistance.

The patient's log sheets show frequent awakening and transfer for toileting during the nighttime.

Yes, the increase in PCA services for a live-in per diem, 24 hours per day, is medically necessary.

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

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs, including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase in PCA services for a live-in per diem, 24 hours per day, is being appealed. The health plan approved 56 hours per week.

This patient has progressive dementia. UAS evaluation competed shows the patient requires extensive assistance to total dependence with all ADLs. He has frequent bowel and bladder incontinence. The appeal statement from his provider notes that he has progressive dementia and has lost the ability to stand and walk. Log sheets show frequent awakenings and assistance with transfers and toileting during nighttime. This patient has significant limitations in functional status. The information provided demonstrates that he needs both daytime and nighttime assistance. The approved PCA 56 hours per week is inadequate to meet the patient's needs for assistance with ADLs and personal care. The proposed increase in PCA for a live-in per diem, 24 hours per day, is medically necessary.