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

Diagnosis: Deep bite, crowding, impacted third molars impacted mandibular canines (and over-retained primary canines).
Treatment:  Braces and Monthly Visit.
The insurer denied the  Braces and Monthly Visit.
The denial is overturned.

The patient is a male. The request is for dental benefits for braces and monthly visits (pre-service).  Per the provider's dental clinical summary---the patient presents with class II canines, mild maxillary and mandibular crowding, deep bite, moderately excessive overjet, impacted third molars, impacted mandibular canines (and over-retained primary canines).

The health plan denied the claim because the patient did not score a 26, the score necessary for approval of orthodontic therapy on the Handicapping Labio-lingual Deviation (HLD) Index Report.  The Provider appealed the claim based on the diagnoses, particularly the impacted mandibular canines.

Yes, the proposed treatment of orthodontic therapy (braces) and monthly visits are medically necessary.
As evident on the x-ray, the impacted mandibular canines do not have sufficient space to naturally erupt due to over retained primary canines.  Under these circumstances, surgical exposure of these impacted teeth coupled with orthodontic treatment is indicated as the standard of care.

No, the health did not act reasonably, with sound medical judgement and in the best interest of the patient.
Proper alignment and position of the canine in the dental arch is essential for functional guidance, chewing and aesthetics of the patient's dentition.  An untreated impacted canine can also cause damage to the adjacent teeth and cause eventual tooth loss.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment D8080 braces

The insurer denied coverage for D8080 braces

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, ectopic eruption, and anterior crowding and has recommended orthodontics. The orthodontist has completed the HLD (Handicapping Labiolingual Deviation) index attaining 21 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 13 points on the HLD index. The patient's mother is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after HLD Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 21 points to justify orthodontic
care. This reviewer concurs with the index completed by the orthodontist attaining a total of 21 points on the HLD index which is below the threshold of 26 points to support orthodontic care. Of note in this case is that the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

In this case the patient's own orthodontist completed HLD index total score of 21 points remains below threshold of 26 points to justify orthodontic care.

D8080 braces is not considered medically necessary for this patient.

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

The insurer's denial of coverage for D8080 braces is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple chronic conditions including COVID
Treatment: Long term custodial care
The insurer denied the Long term custodial care.
The denial is overturned.

The patient is an adult female who has multiple chronic conditions including COVID acute respiratory disease.  She is appealing denial of long term custodial care.  The service was denied as not medically necessary.  

Progress reports show the patient is alert with stable vital signs.  She is tolerating PO (by mouth). She requires 24-hour assistance with ADLs (activities of daily living), with the level of assistance varying depending on the time of day.  She uses a wheelchair when out of bed. She can ambulate up to 200 feet.

Yes, the long term custodial care is medically necessary.

Custodial care is care primarily for the purpose of assisting a patient in ADLs (activities of daily living) or in meeting personal rather than medical needs, and which is not specific treatment for an illness or injury. It is care that cannot be expected to substantially improve a medical condition and has minimal therapeutic value.  Such care includes assistance with walking, bathing or dressing; transfer or positioning in bed; normally self-administered medicine; meal preparation; feeding by utensil; oral hygiene; ordinary skin and nail care; using the toilet; enemas; or preparation of special diets and supervision over medical equipment or exercises or over self-administration of oral medicine.

This patient requires 24-hour assistance with ADLs (activities of daily living).  The level of assistance varies depending upon the time of day.  The proposed long-term custodial care is medically necessary, because it is standard of care for assistance with ADLs (activities of daily living) and personal needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain (s/p (status post) cystoscopy with stent placement)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This male was admitted with vomiting and right renal colic.  Vitals were 116/56-80-18.  The WBC (white blood cells) count was 6940.  The creatinine was 1.24.  CT (computed tomography) imaging demonstrated a 4 mm right distal ureteral calculus with hydronephrosis.  IV (intravenous) pain medications, nausea medications and IVF (intravascular fluid) were administered.

No, the inpatient hospital admission was not medically necessary.
An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting that did not resolve after stent placement.  Pain control, IV (intravenous) antibiotics and IVF (intravascular fluid) followed by stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism
Treatment: Occupational Therapy
The insurer denied the Occupational Therapy.
The determination is upheld.

The patient received occupational therapy with treatments focusing on improving regulation and decreasing internal distractions, improving attention/focus, and decreasing thumb sucking along with balance and coordination skills.   At issue is the medical necessity of the requested occupational therapy services.

The requested occupational therapy sessions were not medically necessary for this patient.
The patient's therapy progress note documentation does not support medical necessity for the standards of practice for occupational therapy. Occupational therapy (OT) is medically necessary when there is documentation that it is improving a patient's current condition or preventing or slowing further deterioration of the patient's condition or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition and all of the following elements of the plan are documented in the health care record: the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider; and the services including amount, frequency and duration are reasonable under accepted standards of practice.
No indication of objective measures of improvement are documented in the clinical information submitted nor is there any notation of activities which cannot be performed within the home exercise program environment.
Activities identified in the OT summary report which can be done by caregivers/parents include working with home exercise on the goals of : bear weight on upper extremities for 60 seconds, improving ball skills of throwing, catching, kicking with good force and gradation so he can participate with age appropriate ball activities, maintaining quadruped position.  Per the documentation the patient's mother is continuously involved in exercises and the treatment plan including carryover at home.  Therefore, the requested occupational therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colon carcinoma.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with colon carcinoma metastatic to the liver who underwent transarterial bland embolization (TAE). The medical note states that the transarterial bland embolization (TAE) was uneventful, without complications, and the patient had no pain or vomiting and that an overnight observation was recommended for post-embolization syndrome. The patient resumed oral (PO) food, was without complaint, and was cleared for discharge by interventional radiology.

No, the proposed inpatient hospital admission was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
The transarterial bland embolization (TAE) procedure is usually done as a short-stay/outpatient procedure or if needed a 23 hour observation. The Society of Interventional Radiology Standards of Practice Committee Quality Improvement Guidelines for percutaneous transcatheter embolization states that for minor complications requiring nominal therapy and overnight hospital stay for observation can be performed. 

This patient underwent an uneventful transarterial bland embolization (TAE) with no periprocedural complications and had an unremarkable postprocedural stay without pain. There were no "red flags" to warrant an overnight hospital admission. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle Cell Crisis

Treatment: Ketamine HCL (Hydrochloride) POW (Powder)

The insurer denied coverage for Ketamine HCL (Hydrochloride) POW (Powder)

The denial is overturned

This gentleman has a history of sickle cell disease, left shoulder avascular necrosis (AVN), cardiomyopathy, acute chest syndrome and bipolar disease. Per the Palliative Care note, the patient is followed by palliative care for chronic pain and symptom management. The patient's medications include oxycodone HCl (hydrochloride) 20 mg (milligram) tablet, ketamine 50 mg/ml (milligrams/milliliter) oral solution, clonazepam, cyclobenzaprine, gabapentin, meloxicam and methadone. Using Ketamine, the patient has been able to function better and reduce the dose of Methadone used. The request is for Ketamine powder.

Cohen et al (1) in consensus guidelines support the use of Ketamine in Sickle Cell crisis. "Evidence for ketamine in acute painful exacerbations of chronic diseases such as sickle cell disease and nonoperative trauma (eg rib fractures) is limited to mostly case reports and small case series."

Jennings et al (2) also supports the use of oral ketamine for Sickle cell crisis. The requested medication is medically reasonable and necessary.

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

The insurer's denial of coverage Ketamine HCL POW is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary inherited erythromelalgia.

Treatment: Amitriptyline HCL (hydrochloride) POW (powder) Compound (amitriptyline/ketamine compound).

The insurer denied coverage for Amitriptyline HCL POW compound (amitriptyline/ketamine compound).

The denial is overturned

The patient is a male with a diagnosis of primary inherited erythromelalgia. The patient has significant pain associated with this rare inherited diagnosis. The requested medication is amitriptyline/ketamine topical compounded.  

Based on the clinical scenario and submitted documentation, the use of amitriptyline/ketamine compounded topically is medically necessary for the treatment of the patient's condition, primary inherited erythromelalgia. The patient has a rare condition which is painful and adversely affecting his quality of life and ability to perform activities of daily living. As noted by Tham and Giles, "In a retrospective case series of 32 adults prescribed amitriptyline-ketamine topical compound, over 70% had some or substantial relief of pain, with no adverse effects." Based on the standard of care, the use of amitriptyline/ketamine topical compounded formulation is approved.  

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 Amitriptyline HCL POW Compound (amitriptyline/ketamine compound) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lewy body dementia.
Treatment: Increase Home Care/Personal Care HHC Level 2 Per 15 Minutes From 42 Hours Per Week To 24 Hours Per Day (split shift).
The insurer denied the Increase Home Care/Personal Care HHC Level 2 Per 15 Minutes From 42 Hours Per Week To 24 Hours Per Day (split shift).
The denial is overturned

The patient is a female. She reportedly has Lewy body dementia. The request is for
Increase in Home Care/Personal Care HHC Level 2 Per 15 Minutes From 42 Hours Per Week To 24 Hours Per Day (split shift).

The health plan's reason for prior denial was that they consider the increase not medically necessary.

Yes, the requested Increase Home Care/Personal Care HHC Level 2 Per 15 Minutes From 42 Hours Per Week To 24 Hours Per Day (split shift) is medically necessary.

The patient has Lewy body dementia with progressive functional and cognitive decline. She cannot take her medication and cannot organize. She cannot perform her ADLs (activities of daily living). She has progressive functional decline. She is at high risk of falls and injury. The patient needs 24/7 supervision to ensure safety.

Therefore, given the above, the requested increase is medically necessary. 

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

The patient has a progressive neurologic condition and is high risk for injury. She also has underlying anxiety and cannot perform her ADLs (activities of daily living). Her condition is likely to worsen.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type II Diabetes Mellitus, hypertensive heart disease, CHF (congestive heart failure), schizoaffective disorder, and schizophrenia. 
Treatment: Custodial Care (long term care). 
The insurer denied the Custodial Care (long term care). 
The denial is overturned. 

The patient claimant is a male with an extensive past medical and psychiatric history including: type II Diabetes Mellitus, hypertensive heart disease, CHF (congestive heart failure), schizoaffective disorder, and schizophrenia.  He was admitted to a skilled nursing and rehabilitation facility due to exacerbation of his CHF (congestive heart failure), schizoaffective disorder, and schizophrenia resulting in deficits in mobility and ADLs (activities of daily living). 

Coverage for the patient's continued at this facility was denied by the health plan, as it was deemed not medically necessary because the patient's functional level was too high. This denial is being appealed. 

Yes, the Custodial Care (long term care) was medically necessary. 

The provided care could not have been attained at a lower level of care. According to the supporting documentation provided by the patient's physical and occupational therapist he requires at least supervision with all ADLs (activities of daily living) and mobility, therefore, the patient requires long term care at a nursing home, and not home health nursing. 

Long term care is indicated for individuals who require at least minimal assistance with self-care and ADLs (activities of daily living), not just supervision. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headaches. 
Treatment: Ajovy 225mg (milligram) /1.5ml (milliliter) SC (subcutaneous) SOSY (solution prefilled syringe). 

The insurer denied the Ajovy 225mg (milligram) /1.5ml (milliliter) SC (subcutaneous) SOSY (solution prefilled syringe). 

The denial is upheld. 

The patient is a female with migraine headache disorder. She has tried and could not tolerate Emgality. The provider has requested Ajovy for migraine prevention. This was denied coverage by the health plan, as she has not tried and failed Aimovig. 

No, the requested Ajovy is not medically necessary. 

There is no documented reason the patient cannot be treated with the preferred alternative agent. Aimovig is considered a standard of care migraine preventive agent (Khan et al.). There is no evidence to support that switching to a preferred agent would jeopardize her clinical stability. The clinical trial leading to the FDA (United States Food and Drug Administration) approval of Ajovy tested efficacy against placebo (Silberstein et al.). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Ajovy relative to the preferred, Aimovig. 

Therefore, given the above, the requested Ajovy is not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: obesity
Treatment: Pharmacy/Prescription Drugs-Wegovy. 
The insurer denied Wegovy. 
The denial is upheld.

The patient is a female with a history of obesity, hypertension, gastroesophageal reflux disease (GERD), dyslipidemia, and low back pain. She is requesting coverage for semaglutide (Wegovy). Her weight was 195 pounds, the body mass index (BMI) was 33.73, and the blood pressure was 138/86. Semaglutide (Wegovy) was prescribed, along with continuation of lifestyle modification. Subsequently her weight was 191 pounds, the BMI was 33.04, and the blood pressure was 110/78. In an appeal letter the patient's provider wrote that the patient did not tolerate orlistat. The subject under review is the medical necessity for the requested Wegovy.

The health plan's determination is upheld.

Medical necessity for semaglutide (Wegovy) requires that the patient meet several criteria. Specifically, there is no evidence that the patient lost 5% of her body weight prior to when the semaglutide (Wegovy) was prescribed. In addition, although mentioned in an appeal letter that the patient was intolerant of orlistat, there is no evidence that she tried and failed courses of phentermine/topiramate (Qsymia) and buproprion/naltrexone (Contrave). The attending provider's opined that these medications were contraindicated for this patient due to hypertension. However only uncontrolled hypertension is a contraindication for the use of buproprion/naltrexone (Contrave), and the blood pressures documented in the medical record revealed excellent control of the hypertension. Hypertension is not a contraindication for phentermine/topiramate (Qsymia). In addition, there is no clear evidence that the requested medication is clearly superior and safer than the preferred medications. Therefore, based on the standard of care, as well as the peer reviewed literature  the semaglutide (Wegovy) was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for an Inpatient admission
The denial is overturned

The patient has a history of diabetes and hypertension and presented with abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The amylase was 101 and the lipase was 157 (normal to 60). An abdominal CAT (computed tomography) scan showed mild peripancreatic inflammation consistent with acute pancreatitis. IV (intravenous) fluids and pain medications were given. 

Clinical indications for admission for Pancreatitis (MCG (Milliman Care Guidelines) M-250) include having acute pancreatitis with 2 or more of the following: abdominal pain, serum lipase greater than 3 times the upper limit of normal, and imaging studies indicative of acute pancreatitis. This patient had upper abdominal pain and the CAT scan was read as acute interstitial edematous pancreatitis. These two findings met the MCG requirements for an inpatient admission for acute pancreatitis. 

The patient had pancreatitis. She was kept NPO (nothing by mouth) and given IV hydration. She met the MCG criteria for admission for Pancreatitis. The health care plan did not act reasonably or with sound medical judgment. An inpatient stay was medically necessary. 

The denial is reversed.

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

The insurer's denial of coverage is overturned. Medical Necessity is substantiated.