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

Diagnosis: Dementia, astrocytoma, incontinence
Treatment: Home Health Care (HHC) - Level 2 Personal Care Services (PCS), per 15 Minutes Increase to 24 Hours/Day (Split Shift)
The insurer denied HHC - level 2 PCS, per 15 minutes increase to 24 hours/day (split shift).
The health plan's determination is overturned.

The patient is a female with past medical history of dementia, astrocytoma, urinary incontinence, bowel incontinence, seizures, depression, osteoarthritis, rheumatoid arthritis, hypertension, vitamin B12 deficiency, vitamin D deficiency, and gastroesophageal reflux disease (GERD) who had Home Health Care (HHC) services.

HHC - level 2 Personal Care Services (PCS), per 15 minutes increase to 24 hours/day (split shift) are medically necessary for this patient.

There is documentation by the patient's medical provider of medical necessity for turning and repositioning every 2 hours due to the need for change in body position and addressing incontinence cares. The patient is bedbound and has had progression of her medical conditions with worsening functional status. There is documentation of increased assistance needs when comparing the recent assessments despite the denial stating there had been no significant change. The patient requires more assistance than documented in the assessment as she has had a change in status since hospitalization for intractable seizures. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCS is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's overnight care needs would not allow a personal care assistant 5 hours of uninterrupted sleep. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, HHC - level 2 PCS, per 15 minutes increase to 24 hours/day (split shift) are medically necessary for this patient. PCS 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: Class I malocclusion 
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is: Overturned

The patient is a female presenting with a skeletal Class I malocclusion and minor crowding. She has a 3 millimeter (mm) anterior open bite. She is treatment planned for 30-36 months of orthodontic treatment with extraction of teeth to address the crowding and open bite. The subject under review is the medical necessity for braces, and monthly visits.

Braces and monthly visits is medically necessary for this patient. Anterior open bite patients are among the most difficult patients to treat. 1. This is not something that will self-correct without orthodontic intervention. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. 2. Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Maxillary and mandibular crowding
Treatment: Braces and Monthly Visits
The insurer denied braces and monthly visits.
The determination is upheld.

This is a female patient with maxillary and mandibular crowding and many unerupted permanent teeth. The orthodontist mentioned in the diagnosis that teeth number (#) 6 and #11 are impacted. The patient was treatment planned for 36-42 months of comprehensive orthodontics with palatal expansion and surgical canine exposure. At issue is the medical necessity of braces and monthly visits.

The patient is in the mixed dentition phase of development. Neither teeth #6 nor #11 appear to be erupting at a poor angle on the radiograph, and it is too early to determine if it will require an exposure.  There is still much time to see if the tooth will erupt successfully on its own without orthodontic intervention.

Orthodontic treatment is not medically necessary for the patient at this time. She is in the process of losing her remaining primary teeth as they are replaced with permanent teeth. Research indicates the following risk factors for impacted canines in patients over 10 years of age:

1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does not have this, as shown in the panoramic radiograph.) 2) The canines cannot be palpated and occlusal development is advanced. (Occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption.) 3) The lateral incisor is proclined and tipped distally. (Neither lateral incisor looks proclined or tipped distally.) 4) On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor. (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided.)

The patient does have maxillary crowding; however, the patient does not have enough of the criteria to suspect these canines are impacted. For this reason, orthodontic, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This adult female patient presented with the complaint of progressive right-sided flank pain and right upper abdominal pain. Vital signs were stable, and she was afebrile. Pertinent labs included white blood cell (WBC) 11.7, hemoglobin 13.4, aspartate aminotransferase (AST) 16, and alanine aminotransferase (ALT) 22. The patient's abdominal ultrasound was negative. Transvaginal ultrasound showed a left ovarian mass. The patient was in an observation level of care. Pain was managed with intravenous Toradol. The patient was tolerating clear liquids. Gynecology did not recommend interventions. Abdominal/pelvic computed tomography showed enlarge right lobe of liver, complex lobulated separated cystic lesion in pelvis, and distal esophageal wall and stomach wall thickening. Esophagogastroduodenoscopy (EGD) showed esophagitis and gastritis. The patient was tolerating diet. 
The patient was admitted on the next day for intravenous pain management of intractable pain and was continued on intravenous Toradol every six hours. Discharge was pending magnetic resonance image (MRI) and final gastroenterology report. The patient's magnetic resonance image was essentially non-diagnostic. Abdominal pain had improved. The patient was cleared for discharge. 
The appeal letter from the provider notes that the patient had an extensive work up that could not have been done in an outpatient setting.

The proposed treatment was not medically necessary.

This patient was transferred from an observation level of care to an inpatient level of care with abdominal pain of unknown etiology. The patient was hemodynamically stable and afebrile. Her diagnostic studies were unremarkable for an acute process that required an inpatient level of care. She was tolerating oral (PO) intake. She continued to receive intravenous analgesia, but the information does not indicate that oral analgesia was not tolerated or failed to control pain. Ongoing evaluation with magnetic resonance image did not require an acute inpatient level of care. The patient was discharged the next day after the magnetic resonance image was unremarkable. The inpatient admission was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: postmenopausal atrophic vaginitis
Treatment: Estring (estradiol vaginal ring)
The insurer denied: Estring (estradiol vaginal ring)
The denial is: Upheld

The patient is a female under consideration for formulary exception for Estring (estradiol vaginal ring). The patient is stated to have been stable on this medication and there is a request for consideration of a formulary exception. Formulary options for the management of estrogen replacement include estradiol vaginal cream, Imvexxy, or vagifem. The subject under review is the whether the formulary alternatives would be ineffective, or not as effective as the non-formulary drug, or would have adverse effects.

The health plan's determination is upheld.

In this case, the formulary options of estradiol vaginal cream, Imvexxy, or vagifem have not been demonstrated to be ineffective and have not been attempted as formulary alternatives for estrogen replacement for the patient. There is no evidence that these alternatives would not be as effective as the requested Estring vaginal ring. The requested non-formulary drug would not be considered to be more effective or have less adverse effects than the formulary alternatives. Clinical guidelines for the management of estrogen replacement for postmenopausal atrophic vaginitis recommend oral, topical, dermal or vaginal estrogen replacement. In this case, there has been no trial or failure of the preferred formulary agents, estradiol vaginal cream, Imvexxy, or vagifem which are all therapeutically equivalent to the requested Estring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope, fall, right leg abscess
Treatment: Continued Stay at Skilled Nursing Facility
The insurer denied: Continued Stay at Skilled Nursing Facility
The denial is upheld.

The records indicate that the patient is an adult male with a history that includes morbid obesity (with body mass index greater than [>] 50) who had a prolonged hospital stay related to syncope, fall, cholecystitis, rhabdomyolysis, renal failure, and a right leg abscess with a persistently open wound requiring wound care with packing. There was "nerve damage" below the right knee as well. He was ultimately medically stabilized and went to a skilled nursing facility for his recovery. Four months ago, the patient was acutely re-hospitalized due to concern for his right lower limb wound site. At the hospital, he was found to have a large subfascial abscess with pus, hematoma, and fat necrosis. There was no gross distal right lower limb motor or sensory function. He underwent emergent incision and drainage and was medically stabilized. Four days later, the patient returned to the skilled nursing facility for further care. The neurological dysfunction in the distal right lower extremity persisted. As of last months, the patient's right lower limb posterolateral wound was noted to be not improving. Wound care was changed to irrigation with normal saline and packing the wound with Betadine-soaked gauze twice a day. The right lower limb lateral calf wound was noted to be improving. The wound care with Silvadene with daily dressing was continued.
Recently, the patient was contact guard assist for transfers. He was ambulating 75 feet with a walker at minimal assist.
The patient was toileting at moderate assist. He was minimal assist for lower body dressing. The patient was noted to have normal strength in the upper limbs, 4+/5 strength in the left lower limb, 4+/5 proximal right lower limb strength, and 0/5 distal right lower limb strength. He was contact guard assist for transfers. He was ambulating 75 feet with a walker at minimal assist. There was scant odorless serosanguinous drainage from the surgically opened abscess. The right lower limb lateral calf wound (deemed to be a neuropathic ulcer) was noted to be improving. The same wound care for the right leg wounds was continued.
The health plan denied coverage of the service under review, indicating that the service is not medically necessary as the patient has not shown improvement with therapy.

The treatment in question (i.e., ongoing skilled nursing facility care) is not medically necessary.

The patient had plateaued functionally due to a combination of persistent neurological dysfunction at the right distal lower extremity, his chronic deconditioning, and his underlying severe morbid obesity. His right leg wounds had otherwise improved to a level where further care could have been provided at a lower level of care. The medical necessity of the ongoing skilled nursing facility level care in question is not established in the available records.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicocele
Treatment: Abdomen and pelvis computed tomography (CT) scan
The insurer denied coverage for abdomen and pelvis CT scan.
The denial is upheld.

This is an adult patient found to have a small right Varicocele. The treating physician ordered a computed tomography (CT) scan of the abdomen and pelvis to rule out any abdominal pathology (renal mass). 

As discussed in UpToDate, "Unilateral right varicoceles that are apparent on clinical examination are uncommon and should alert the clinician to possible underlying pathology causing inferior vena cava (IVC) obstruction (renal cell carcinoma with IVC thrombus, right renal vein thrombosis with clot propagation down the IVC, venous abnormalities) since the right gonadal vein directly empties into the IVC. If patients are undergoing a scrotal ultrasound to evaluate the varicocele, it would be appropriate to include the abdomen in the examination. If patients with a unilateral right varicocele are at high risk for retroperitoneal pathology, evaluation with a CT scan of the abdomen with contrast would be indicated." Similarly, for smaller moderate right Varicocele, the American Urological Association (AUA) recommends against routine imaging to rule out a tumor. CT abdominal/ pelvis is not considered to be medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for an abdomen and pelvis CT scan is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Acne
Treatment: Tazarotene 0.05% (percent) Gel
The insurer denied Tazarotene 0.05% Gel.
The denial is upheld.

The patient is an adult male diagnosed with acne, has tried and failed oral antibiotics, isotretinoin, tretinoin, clindamycin and dapsone and is requesting approval of tazarotene. The request was denied so the treating provider is appealing the denial.

The health plan should not cover the proposed treatment.

It is reasonable to not require a trial of the alternatives benzoyl peroxide and erythromycin because the patient has tried and failed other antibiotics and according to the provider, the only medication that was effective was in the retinoid class which is adapalene. The patient has tried several treatments but has not had a trial/failure of the alternative adapalene which is in the same class as the requested tazarotene. Per Rusu A, et al (2020), "Adapalene (ADP) is a representative of the third retinoids generation and successfully used in first-line acne treatment." There are no recent head-to-head studies comparing efficacy of adapalene to tazarotene for the treatment of acne vulgaris but Pariser D, et at (2008) found in their study that "Daily therapy with adapalene 0.1% [percent] gel was shown to be noninferior to tazarotene 0.1% cream in total acne lesion reductions, and during initial stages of treatment, demonstrated better tolerability with respect to erythema and scaling." There is no indication that the patient could not do well with adapalene or would have an adverse effect from this medication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain.
Treatment: Additional Physical Therapy (9 Visits).
The insurer denied: Additional Physical Therapy (9 Visits).
The denial is overturned.

The patient is an adult female with a medical history of lumbar radiculopathy and weakness. A physical therapy evaluation and plan of treatment indicated that the patient was experiencing six out of ten (6/10) pain. Her modified Oswestry Low Back Pain Disability Score was 23/50 and lower extremity motor strength was 3/5. The patient was ambulating 300 feet with a single point cane. The patient's modified Oswestry Low Back Pain Disability Score was 23/50, her lower extremity motor strength was 3+ to 4/5 and she was walking 440 feet with a single point cane. 
The physical therapy sessions were considered not medically necessary per guideline policy with the rationale that there was a lack of improvement with treatment and therefore not necessary. 
This decision is being appealed.

The proposed treatment (physical therapy) is medically necessary.

The patient is an adult female with a medical history of lumbar radiculopathy and weakness. A physical therapy evaluation and plan of treatment indicated that the patient was experiencing six out of ten (6/10) pain. Her modified Oswestry Low Back Pain Disability Score was 23/50 and lower extremity motor strength was 3/5. The patient was ambulating 300 feet with a single point cane.  According to the second evaluation the patient's modified Oswestry Low Back Pain Disability Score was 23/50, her lower extremity motor strength was 3+ to 4/5 and she was walking 440 feet with a single point cane. The patient has lumbar radiculopathy, weakness and impaired gait. The medical literature would support the use of physical therapy with these conditions. The patient was initially evaluated and then a re-evaluation indicated that the patient's lower extremity motor strength and ability to ambulate had improved; the patient demonstrated objective improvement with treatment.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/ Musculoskeletal
Pharmacy/Prescription Drugs

Diagnosis: Other - Upper limb spasticity
Treatment: Botox
The insurer denied: Botox
The health plan's determination is: upheld

The patient is a male with limb spasticity secondary to a stroke. Botox was prescribed for the treatment of upper limb spasticity. Botox was denied because the patient has not tried and failed Xeomin or Dysport. The provider appealed this determination.
At issue is the medical necessity of the requested health service/treatment of Botox.
The health plan's determination of medical necessity is upheld in whole. Botox is not medically necessary for the treatment of this patient's condition. The plan offers other botulinum toxins that are also appropriate for the treatment of upper limb spasticity following stroke. These drugs include Xeomin and Dysport. These drugs are recognized treatments for limb spasticity, and there is no compelling medical reason provided as to why the patient cannot use one of these alternatives. Both of these drugs are literature-supported for the treatment of spasticity in adults. The drugs have the same or similar mechanism of action as compared to Botox.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertension, back pain and osteoarthritis
Treatment: increase hours for Personal Care Worker 7 days/week, 10 hours/day; 70 hours/week
The insurer denied coverage for increased hours for Personal Care Worker 7 days/week, 10 hours/day; 70 hours/week
The denial is upheld
 
This is an elderly patient with chronic medical problems including hypertension, back pain and osteoarthritis. She lives with her spouse in a private home. The insurer approved 7 days/week, 4.5 hours/day; 31.5 hours/week and the request is for 7 days/week, 10 hours/day; 70 hours/week, which is currently under review.

The Uniform Assessment System (UAS) report was completed. The patient's cognition is described as modified independent. Extensive assistance is required for bathing and lower body dressing. However, she only requires limited assistance for personal hygiene, upper body dressing, eating, ambulation and toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel. Bed mobility is independent. In a letter her doctor indicates the patient has a "rapidly deteriorating mental state" and decreased functional status. However, comparing the more recent UAS to the UAS report dated three months earlier, the patient's functional ability has not significantly declined. There has been no change in activities of daily living (ADLs). She is occasionally bladder incontinent and remains bowel continent. She remains limited assistance for personal hygiene, transfer toilet and toilet use. She is independent for bed mobility and needs limited assistance for eating. She continues to walk using assistive devices. There have been no falls in the last 90 days. The patient may require additional monitoring; particularly due to her reported "mental state." However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. The patient's condition and functional needs are not at a level or unpredictable as to require the requested increase in personal care worker (PCW) services to 7 days/week, 10 hours/day: 70 hours/week. The patient's health and safety has been appropriately provided and maintained by the currently approved PCW 7 days/week, 4.5 hours/day: 31.5 hours/week.

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 increase in personal care worker (PCW) services from 7 days per week, 4.5 hours per day; 31.5 hours per week to 7 days per week, 10 hours per day; 70 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deviated Septum
Treatment: Surgery to Open the Nasal Passages
The health plan denied: Surgery to open the nasal passages
The health plan's determination is: Overturned

The patient is a female with nasal obstruction. Medical management has included nasal steroids. The exam revealed a deviated septum and nasal valve collapse along with deviated nasal bones. A computed tomography (CT) scan demonstrated a deviated septum. Photos demonstrate deviated nasal bones. Septo-rhinoplasty has been proposed.
At issue is the medical necessity of the requested health service/treatment of surgery to open the nasal passages.

The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Surgery to Open the Nasal Passages is medically necessary for this patient.
The patient has nasal obstruction refractory to medical management with noted deviated septum and nasal valve collapse. This request is consistent with good medical care and current standard of care. There are no reasonable medical or surgical alternatives available for the patient's nasal obstruction symptoms.
It appears that the patient's nasal obstruction is not just due to a deviated septum, but also due to narrow internal valves and external valve collapse. The cause of nasal obstruction can often be attributed to pathologic conditions of the nasal valve. The key physical examination finding in nasal valve compromise is inspiratory collapse of the nasal sidewall. Functional rhinoplasty encompasses the surgical techniques used to address obstruction occurring in this area. These techniques aim to increase the size of the nasal valve opening and/or strengthen the lateral nasal wall and nasal ala, preventing dynamic collapse. A narrow internal valve can only be corrected by cartilage internal middle vault grafts (spreader grafts) which are extremely difficult to place via a closed septo-rhinoplasty approach, thus the need for an open septo-rhinoplasty.
Septo-rhinoplasty is a well-accepted procedure by otolaryngologists to improve functional nasal breathing complaints in patients who have failed medical management. It is not considered an investigative procedure. The procedure in this patient is not cosmetic in nature. Although the procedure would change the external appearance of the nose, the primary goal would be to improve functional nasal breathing.