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

Diagnosis: Plaque

Treatment D4341 Deep Gum and Root Cleaning on all Four Quadrants

The insurer denied coverage for D4341 Deep Gum and Root Cleaning on all Four Quadrants.

The denial is overturned.

Upon review of submitted documentation which includes copies of full mouth series radiographs, dental/periodontal probing depths, narrative letter and insurer correspondence and member guidebook, it appears that this patient presented to the dentist for periodontal disease in all four quadrants.  Recommended treatment was four quadrants of scaling and root planing given multiple areas of 5 mm (millimeters) pocketing. The insurer denied scaling and root planing as requested stating in summary that the information provided does not offer sufficient basis for the requested services such as bone loss or radiographic calculus indicative of periodontal disease. 

In this case, as regards documentation of the periodontal status, in particular the periodontal charting and radiographs, it is evident that there is a level of periodontal disease when there is root surface exposure and alveolar bone loss. All four quadrants exhibit multiple areas of 5 mm pocket depths and radiographic calculus is noted particularly in the molar areas. Appropriate treatment would be the recommended scaling and root planing to address any ongoing periodontal issues.  This would be the standard of care given the alveolar bone loss and level of periodontal disease as documented on the clinical and radiographic findings.  As such these services are considered dentally necessary.

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

Based on the above, the medical necessity for the D4341 Deep Gum and Root Cleaning on all Four Quadrants is substantiated. The insurer's denial is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atrial Fibrillation. 
Treatment: Eliquis. 

The insurer denied coverage for Eliquis. 

The denial is upheld. 
 
This patient was diagnosed with atrial fibrillation. He was prescribed Eliquis 5 milligrams (mg) twice daily. His insurance company denied coverage stating that the patient had not failed any of the alternative therapies listed on formulary.  These medications included Xarelto (rivaroxaban) and warfarin.  The patient's doctor requested approval of non-formulary medication based on side effects caused by the formulary medications.  No specific side effects were noted in the records provided. 

The formulary drug, Xarelto is not likely to cause the patient an adverse reaction.  The formulary drug has not been ineffective, and no documentation is provided to support that the patient has ever been treated with the formulary drugs. Both Eliquis and Xarelto therapies have been found to be non-inferior to warfarin.  The American Heart Association, American College of Cardiology and Heart Rhythm Society Guidelines provide a Class I (level of evidence A) recommendation for treatment with novel oral anticoagulant regimen instead of warfarin.  This recommendation was based on several randomized clinical trials that enrolled thousands of patients.  The direct thrombin inhibitor medications and the Factor Xa inhibitor medications (including Xarelto/Rivaroxaban) were at least non inferior and in some cases superior to warfarin therapy.  When Xarelto was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated non-inferiority to warfarin in preventing stroke or systemic embolism (Reference 2). In conclusion, the patient should be treated with Xarelto. There is no evidence provided to demonstrate intolerance to the formulary medications. 

The insurer's denial of coverage for Formulary Exception for Eliquis is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ANCA (autoantibodies)-associated vasculitis 
Treatment: Tavenos
The insurer denied Tavenos. 
The health plan's determination is upheld. 

The patient is a male with a history of ANCA (autoantibodies)-associated vasculitis and that has involved the eye, sinuses, and kidneys. His scleritis was initially treated with intravenous (IV) cytoxan or rituximab and improved. Sinus symptoms started and he was started on prednisone and remains on 20 milligrams (mg) daily. Creatinine was noted to be elevated as well at that time in addition to nephrotic range proteinuria. He has been treated with corticosteroids which has been complicated by weight gain and worsening hypertension. The patient's provider has prescribed Tavneos (Avacopan) in order to allow for reduction in his steroid dosing and improved disease control. He has received two doses of Truxima with solumedrol. The health plan has determined that Tavneos is not medically necessary at this time.

The use of Tavneos is not medically necessary in this case.
Tavneos is a complement 5a inhibitor that has recently been Food and Drug Administration (FDA) approved as an adjunctive treatment of ANCA (antineutrophil cytoplasmic antibodies) associated vasculitis in conjunction with glucocorticoids. Importantly, it does not eliminate steroid use and is recommended to be used with other standard therapy. The patient has a history of an ANCA associated vasculitis and had responded to standard therapies in the past. He was recently started on oral prednisone and in addition was given two doses of truxima/rituximab with solumedrol over the past two months. The patient requires a 3-6 month trial on standard therapy with documentation of a failed response. There is no documentation of such a trial or of a failed response to therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This is the case of a patient that was sent to the hospital by his cardiologist after an episode of syncope that occurred three days prior to presentation. A 12-lead electrocardiogram (EKG) at his cardiologist's office revealed sinus rhythm, right bundle branch block, atrial premature complexes (APCs) and terminal notching of the QRS (interval on EKG) complex in the inferior leads. Past medical history was significant for diabetes, hypertension, and severe depression. Upon arrival to the hospital vital signs were stable with blood pressure (BP) 161/86, and pulse 74 beats per minute. Physical examination revealed no abnormality.  A 12-lead EKG revealed normal sinus rhythm without ST (interval on EKG or T (interval on EKG wave abnormalities. Serum blood testing revealed no elevation in troponin. Echocardiogram demonstrated a normal left ventricular ejection fraction (60 percent) with mild concentric left ventricular hypertrophy. Head computed tomography (CT) demonstrated no significant abnormality. The patient was admitted to telemetry for further observation and released the following day. 

This patient presented with syncope that occurred three days prior to presentation. Physical examination and serum blood testing revealed no major abnormalities. His 12-lead EKG demonstrated sinus rhythm with right bundle branch block and atrial premature beats. Echocardiography revealed a structurally normal heart with a normal left ventricular ejection fraction. This patient falls into a low to intermediate risk group for syncope. According to American Heart Association/ American College of Cardiology/ Health Rhythm Society (AHA/ACC/HRS) guidelines such patients should be managed utilizing a structured Emergency Department (ED) observational protocol (1). In a study of individuals presenting to the ED, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (2). 

In this case, the patient had a normal echocardiogram and an abnormal 12-lead EKG (right bundle branch block and atrial premature beats). However, the clinical presentation was consistent with an etiology of orthostasis. Acute inpatient admission was not medically necessary for this patient. 

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

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

Diagnosis: Bariatric surgery
Treatment: Wedge Liver Biopsy
The insurer denied the Wedge Liver Biopsy
The denial is upheld

The patient is a male. He underwent bariatric surgery (laparoscopic sleeve gastrectomy and concomitant liver biopsy) performed. The records support that he had a BMI (body mass index) of 40.31. The operative dictation states that the surgeon noted a fatty liver and obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provides the diagnosis of mild fatty change.

The surgeon submitted code 47379 (liver biopsy, wedge). The health plan rationale for denial of coverage for liver biopsy per the letter is that there is no documentation of objective signs or symptoms of liver disease to warrant liver biopsy. Per this letter guidelines on the use of liver biopsy in clinical practice do not mention routine biopsy of the liver with bariatric surgery. The health insurance denial letters indicates that the surgeon submitted code 47379 (laparoscopic procedure liver). Appeal material is provided by another surgeon.

No, the Wedge Liver Biopsy was not medically necessary.
In this case, the patient is morbidly obese with a body mass index of 40.31. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology. [1, 2, 3]

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The health plan acted reasonably with the determination of medical necessity regarding liver biopsy in this case. Accepted indications for liver biopsy include Documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case, there is no such documentation to warrant wedge liver biopsy (47379 liver biopsy, wedge or 47100). Routine liver biopsy is not an accepted or standard aspect of bariatric surgery. [1]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Odontogenic Infection

Treatment: Hospital admission

The insurer denied coverage for the hospital admission.

The denial is upheld.

The patient has a past medical history significant for asthma who presented to the Emergency Department (ED) with complaints of right-sided facial swelling and pain after a cat scratch. The patient was afebrile and had both an elevated blood pressure (BP) 151/92 and pulse of 94 beats per minute. Her white blood cell (WBC) count was 10.8.

The patient was empirically started on intravenous (IV) antibiotics (vancomycin, ceftriaxone, and metronidazole) for possible odontogenic infection. A computed tomography (CT) scan of the sinuses showed mucosal thickening and fluid in the right maxillary sinus, soft tissue swelling in the right side of the face and right periorbital region, consistent with facial cellulitis. No fluid collection or abscess. Infectious Disease service recommended a transition to oral antibiotics. Ophthalmology service recommended application of ice packs. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral antibiotics as an outpatient. 

According to the documentation, the patient presented with localized facial cellulitis following a cat scratch. Otherwise, she was afebrile, stable hemodynamically with no evidence for systemic toxicity. Laboratory results were unremarkable. CT scan did not reveal any drainable collection and no surgical intervention was required. Based on the above findings, the patient did not meet criteria for acute inpatient admission. 

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

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

Diagnosis: Central Nervous System/Neuromuscular Disorder/multiple sclerosis.
Treatment: Pharmacy/Prescription Drugs/Panzyga.

The insurer denied Panzyga intravenous immunoglobulin. 
The denial is upheld. 

The patient is a male with relapsing remitting multiple sclerosis. The patient was treated with rituximab. During the most recent neurologic follow up, the neurologist chose to change rituximab to natalizumab. During this transition, the patient was diagnosed with a "secondary immunodeficiency" and intravenous immunoglobulin (Panzyga) was prescribed. The drug was denied by the plan. The subject under review is the medical necessity for the Panzyga intravenous immunoglobulin (IVIG).

The health plan's determination is upheld in whole. 

The requested Panzyga intravenous immunoglobulin is not medically necessary. The drug was prescribed for treatment of "secondary immunodeficiency". This secondary immunodeficiency is presumably due to treatment with rituximab. However, it is not the standard of care to treat with intravenous immunoglobulin during or after treatment with rituximab. Following cessation of rituximab, immune reconstitution starts usually after six months with recovery to normal between nine to twelve months. Extended rituximab treatment results in a prolonged recovery of B-cells without an increase of clinically relevant infections. If there is concern for infection, patients should receive close monitoring and appropriate infection prophylaxis rather than intravenous immunoglobulin.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine
Treatment: Ajovy

The insurer denied Ajovy. 
The health plan's determination is overturned.

The patient is a female who has been diagnosed with chronic migraine without aura.
The patient's headaches started 3 years ago and became worse 2 years ago. She is having daily, constant headaches which are frontotemporal, throbbing in nature, and rated as 9/10 in severity 1-2 times a week. Typically, the severity is 6-7/10. Photophobia and phonophobia are present, together with nausea but no vomiting. Triggers include bright lights, and physical activity may aggravate the headache. She has motion sickness. The patient has tried ibuprofen, acetaminophen and ondansetron as abortive medications, and has been prescribed naproxen. Prophylactic medications which have been ineffective have included Lexapro, propranolol (not tolerated at higher dosages due to dizziness and poor exercise tolerance), nortriptyline, and the Cefaly device. Her current medications include Abilify, vitamin D, Lexapro, propranolol and ondansetron.

The requested Ajovy Auto Injector 225 milligram (mg) is medically necessary for this patient. 

The patient is having constant, severe migraine headaches which have not remitted despite several prophylactic medications from different classes, taken at appropriate doses. Frequent migraine and chronic migraine have been shown to cause significant adverse impact on quality of life of children and adolescents. Ajovy is an appropriate next medication step to try to improve her headache frequency and severity. Given her history of anorexia nervosa, a trial of topiramate is inappropriate, as the drug tends to cause appetite suppression and weight loss. Valproic acid is teratogenic, can cause hair loss and polycystic ovary syndrome and its use is generally avoided in adolescent females.
The patient is adult-sized. There is no physiological reason why Ajovy should not be effective for her.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Current Procedural Terminology (CPT) code 72197 - Magnetic resonance (eg, proton) imaging, pelvis
The insurer denied the Current Procedural Terminology (CPT) code 72197 - Magnetic resonance (eg, proton) imaging, pelvis
The denial is upheld

This is a female. She was seen in clinic for chronic abdominal pain. She has had a sensitive stomach with worsening abdominal pain and increased gassiness and flatulence. She did not have other gastrointestinal symptoms. Her doctor requested stool tests, blood tests, abdominal ultrasound, upper endoscopy/colonoscopy/capsule endoscopy, and magnetic resonance enterography (MRE), or magnetic resonance imaging (MRI) of the intestine. The reason for prior denial was that the requested magnetic resonance imaging (MRI) was not indicated because the patient did not have red flag symptoms.

No, the proposed treatment is not medically necessary.
As documented in clinic note, this patient has had sensitive stomach. The patient had worsening abdominal pain with gassiness and flatulence. There was no documentation for any "red flag" symptoms such as persistent diarrhea, bloody stools or weight loss. The initial assessment included infection, inflammation, celiac disease, pancreatitis and functional abdominal pain.

The patient had normal stool and blood tests including inflammation markers and celiac screening. Thus, infection, inflammation, celiac disease and pancreatitis were unlikely. The patient likely had functional abdominal pain. Magnetic resonance enterography (MRE), or magnetic resonance imaging (MRI) of the intestine, is usually performed to check for intestinal inflammation. Since this patient did not have "red flag" symptoms and had normal stool and blood tests and likely has functional abdominal pain, the requested magnetic resonance imaging (MRI) is not medically necessary (1-2) as it is not clinically appropriate and considered effective for the patient's illness and not in accordance with generally accepted standards of medical practice.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Since this patient did not have "red flag" symptoms and had normal stool and blood tests and likely has functional abdominal pain, the requested magnetic resonance imaging (MRI) is not recommended based on current literature. Thus, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care/ consumer directed personal care services (CDPAS) 57 hours a week.
The insurer denied consumer directed personal care services 57 hours a week. 
The denial is overturned.

The patient is a female with past medical history of osteoporosis, hypertension, traumatic brain injury (TBI) with cognitive deficit, spinal stenosis with neurogenic claudication, subdural hematoma, bladder incontinence, bowel incontinence, hearing loss, anxiety, and Benign positional vertigo (BPV) who had a fall with traumatic brain injury with bleeding, neck fracture, and shoulder fracture.  The patient was discharged to rehabilitation. Then the patient was discharged to home. There was a request to increase Consumer Directed Personal Assistance Services (CDPAS) hours. The subject under review is the medical necessity for the requested increase in hours to 57 hours per week.

The health plan's determination is overturned.

The requested services for 57 hours per week are medically necessary for this patient. The patient's PCP has documented the patient's past medical history with noted decline in physical and cognitive functioning. The patient's denial letters from the insurer noted decision based on assessment even though patient had 2 other assessments assessing the patient at a higher need for assistance with most tasks. The requested increase in CDPAS is not solely for safety and supervision but to assist the patient with safe completion of ADLs (Activities of daily living) and IADLs (Instrumental activities of daily living ). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS for 57 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Coronary Artery Disease/CAD
Treatment: Home Health Care
The health plan denied the requested increase in personal care worker hours as not medically necessary. 
The health plan's determination  is overturned.

The patient is a male with past medical history significant for coronary artery disease, hypertension, end-stage kidney disease, diabetes, hyperlipidemia, anemia, and syncope.
The patient has been approved for personal care worker (PCW) services 7 days a week 6 hours a day for a total 42 hours a week.
At issue is the medical necessity for an increase in PCW services to 12 hours per day 7 days a week for a total of 84 hours a week.

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

Yes, the requested health service of an increase in Personal Care Worker (PCW) services from 7 days per week, 6 hours per day, 42 hours per week to 7 days per week, 12 hours per day, 84 hours per week is medically necessary for this patient.
The patient is a male with multiple medical problems with progressive weakness and disability secondary to chronic conditions such as heart disease, hypertension, and end-stage kidney disease. He lives alone without any specific informal support. The patient has been getting weaker secondary to his underlying medical conditions. His cognitive ability appears intact. Maximal assistance for instrumental activities of daily living (IADLs) is noted. He is able to ambulate with limited assistance, use toilet and transfer with assistance. The patient has durable medical equipment (DME) supplies which include a cane, shower chair, Rollator walker and grab bars. The patient's physician stated that the patient is having progressive physical decline secondary to his multiple medical problems. This decline has resulted in anemia and congestive heart failure (CHF) which limits his mobility and is not expected to improve. The Uniform Assessment System (UAS) State of New York was noted.
The patient has scheduled services 6 hours per day 7 days a week. He has unscheduled needs that cannot be scheduled during the allotted time, including ambulation, eating and toileting requiring significant assistance. These unscheduled activities of daily living (ADLs) cannot be appropriately counted for in the time allotted. I recommend additional service hours to meet these needs.