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

Diagnosis: Overjet

Treatment: D8080 braces

The insurer denied coverage for D8080 braces

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, and insurer correspondence, this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to excessive overjet among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required stating the patient exhibits the automatically qualifying condition of overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater than 3.5mm with reported masticatory/speech difficulties to support orthodontic necessity. 

Upon review of the submitted documentation, it is evident that the patient exhibits a significant 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 Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation 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 claims an automatic qualifying condition of overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition met and supports comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology; this has been determined to represent an appropriate approach for assessing orthodontic need. 

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 D8080 braces is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, hypertension, hyperlipidemia, chronic renal failure, and osteoarthritis.

Treatment: Increase in personal care services, 24 hours a day, 7 days a week (split shift).

The insurer denied coverage for increase in personal care services, 24 hours a day, 7 days a week (split shift).

The denial is upheld. 

According to the documentation submitted, this is a patient with a history of coronary artery disease, hypertension, hyperlipidemia, chronic renal failure, and osteoarthritis. According to the most recent Uniform Assessment System (UAS), the patient lives alone and is alert and oriented (A&O) x (times) 2, is able to direct care, is forgetful, sometimes disoriented, and the short-term memory is impaired. The patient is blind on the right eye, has diminished vision on the left eye, and requires total dependence for ordinary housework and locomotion. Maximal assistance is needed for meal preparation, managing medications, bathing, personal hygiene, dressing upper body, dressing lower body, walking, transfer toilet, and toilet use. No falls were reported in the last 90 days. The patient's physician is requesting an increase in personal care services to prevent further complications in the patient's health.

The records show no recent events. There were no falls, ER (emergency room) visits nor hospitalizations in the last 90 days. The Universal Assessment Comments describe no specific change in medical conditions. There was no report of the need to be fed frequently or any condition that would require turning, repositioning or frequent toileting. The Health Assessment report shows no new medical conditions, and the same level of support would be required. The patient is currently approved for 84 hours per week, 12 hours a day for 7 days per week. The physician letters of appeal describe medical conditions without specific change. Correspondence does not provide objective worsening to substantiate additional service.

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 an increase in personal care services, 24 hours a day, 7 days a week (split shift) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: D8080 Braces.
The insurer denied: D8080 Braces.
The denial is upheld.

The patient is a teenage male. The request is for comprehensive orthodontic treatment. The health plan denied the request on the basis of medical necessity. The denial is being appealed.

The requested braces are not medically necessary.

The health plan's initial review denied coverage of the treatment due to the patient not having any automatic qualifying conditions and did not meeting a score of 26 on the HLD (Handicapping 
Labio-Lingual Deviation) index. A review of the clinical information submitted does not indicate the patient has a handicapping malocclusion. The criteria for handicapping malocclusion include, but are not limited to, deep impinging overbite with palatal impingement causing tissue trauma; true anterior open bite, more than two teeth in anterior crossbite with gingival stripping; impacted incisors or canines that will not erupt into the arches without orthodontic or surgical intervention; overjet in excess of 9mm (millimeters); negative overjet greater than 3.5mm (millimeters); cleft lip/palate deformities and 
other significant craniofacial anomalies; malocclusions requiring a combination of orthodontic and orthognathic surgery for correction. The HLD (Handicapping Labio-Lingual Deviation) Index is also used as a basis for determining whether a patient qualifies for orthodontic treatment. A patient must score a minimum of 26 points to qualify for coverage. The initial review gave a score of 20 points. This review scores the patient with 22 points. The provider gave a score of 26 points, but this score is inconsistent with the provided records. The provider gave a score of 7mm (millimeters) on the labio-lingual spread. There 
is no tooth in either arch that is displaced 7mm (millimeters) from the normal arch. Therefore, given the above, and based on the information in the appeal file, intraoral and facial photographs, case photographs, and radiographic images, the requested braces are not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Asthma. 
Treatment: Dulera. 

The insurer denied: Formulary exception for Dulera. 
The denial is overturned. 

The patient is an adult female with asthma. She is being treated with Dulera. The patient has tried and failed Advair HFA (hydrofluoroalkane-134a), Advair diskus, Symbicort and Breo. The patient has been doing well on Dulera. The request for Dulera was denied coverage by the health plan for not meeting formulary requirement. This denial is being appealed. 

The health plan should cover the Formulary exception for Dulera. 

The patient has asthma. The formulary drug has been ineffective. The patient has tried and failed Symbicort, Advair, and Breo. The patient has been stable on Dulera. Not continuing Dulera is likely to worsen the patient's asthma symptoms, with worsening quality of life. The continuation of treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pain/decreased mobility.
Treatment:  Skilled nursing facility.
The insurer denied Admission to Skilled Nursing Facility. The health plan's determination is overturned.

The patient is a male with obesity, obstructive sleep apnea (OSA), venous insufficiency, chronic back and leg pain on gabapentin. He was recently discharged from subacute rehabilitation where he was ambulating with a RW (rolling walker). He lives alone. He was admitted to acute care after syncopal episode. Physical therapy (PT) evaluation showed CG (contact guard) /supervision bed mobility, transfers and ambulation 20 feet.

The admission to a Skilled Nursing Facility (SNF) is medically necessary for this patient. He requires CG/S (contact guard supervision) for functional mobility as he has back and leg pain that is limiting his ability to function. He lives alone and is a safety risk if he is discharged to home alone. He is below his baseline level of function and would benefit from strength and endurance training to improve his safety.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic migraines
Treatment: Botox
The insurer denied Botox.
The determination is overturned.

This is a female patient who is prescribed treatment with Botox for chronic migraine. The drug was denied because there is not clear documentation that the member has a 50 percent (%) improvement in migraine frequency with Botox treatment. At issue is the medical necessity of Botox injection.

The patient has chronic migraine. Botox is Food and Drug Administration (FDA) approved for prevention of chronic migraine. The patient experienced decreased migraine intensity with Botox. When used in combination with Ajovy, the patient experienced a cumulative treatment effective with further improvements in migraine frequency and severity. However, Ajovy has since been discontinued as the patient is attempting to become pregnant. As a result, the patient is requesting continued use of Botox for management of headaches. The continued use is reasonable as the patient has intractable migraines and has failed numerous oral preventative therapies. The use is on-label and both the patient and neurologist have determined that there is benefit to the treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis Vulgaris and Psoriatic Arthritis.
Treatment: Cosentyx Pen (2 pens) 150mg/ml Pen Injector.
The insurer denied: Cosentyx Pen (2 pens) 150mg/ml Pen Injector.
The denial is overturned.

The patient is an adult male with severe psoriasis and psoriatic arthritis for over a decade. This has been well controlled on Cosentyx. Before using Cosentyx he had tried and failed numerous treatments including Enbrel, desonide, and fluocinonide. Since 2018 his disease has been in remission on Cosentyx.

The requested Cosentyx is medically necessary.

The patient has been on Cosentyx for the past four years with excellent results (complete remission). It is medically appropriate and necessary to continue treatment with this medication as continuity of care. It is not medically appropriate to switch to another class of medications to satisfy step criteria, as this may cause a flare and loss of control over the patient's disease. Therefore, Cosentyx is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Female to Male Transgender
Treatment: Triptodur
The insurer denied: Triptodur
The denial is: Overturned

The patient is a female to male transgender. His luteinizing hormone (LH) was 6.5, estradiol was 58, follicle-stimulating hormone (FSH) was 7.1, and testosterone was 16. This request is for Triptodur. The subject under review is the medical necessity for Triptodur.

The treatment with Triptodur is medically necessary. Gonadotropin-releasing hormone (GnRH) agonists such as Eligard, Lupron, Fensolvi, and Supprelin are only Food and Drug Administration (FDA)-approved for central precocious puberty [3, 4] and prostate cancer. They are not FDA-approved in patients with gender dysphoria. This would be off-label use of the medication. The Endocrine Society Clinical Practice Guidelines do support the use of GnRH analogs to suppress isosexual hormone production in patients with gender dysphoria either during puberty or as adults when other medications are not successful. [5, 6] The patient has gender dysphoria and is in puberty. The request for Triptodur is consistent with generally accepted standards of medical practice including guidelines from the Endocrine Society, as well as the World Professional Association for Transgender Health. The patient meets the standard of care for use of Triptodur.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Respiratory syncytial virus (RSV).
treatment:  Inpatient hospital.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male infant who presented to the emergency department (ED) with a four-day history of cough, one episode of non-projectile vomiting, and tactile temperature. He was feeding at baseline with baseline urine output. Vital signs included temperature 37.8 degrees C, heart rate 168, respiratory rate 46, and oxygen saturation 98% in room air. Examination was significant for no acute distress, non-toxic appearance, moist mucous membranes, minimal subcostal retractions, diffuse crackles, and non-focal neurologic exam. Rapid testing revealed negative influenza, negative Covid, and positive respiratory syncytial virus (RSV). He was admitted with RSV bronchiolitis for apnea monitoring. While awaiting bed availability, he was treated with nebulized saline and suction.

The inpatient stay was not medically necessary.

This term male infant developed worsening cough as a result of RSV infection. He was not having apneic episodes, but because of his age, was at risk. He was also at risk for decompensation with worsening respiratory distress. While it was reasonable to monitor him in the hospital for possible decompensation, he was overall hemodynamically stable without oxygen requirement, without apnea, and tolerating feedings. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Full Inpatient Hospital Admission
The insurer denied the full inpatient hospital admission.
The denial is upheld.

This patient is an adult male who was hospitalized for shortness of breath. He presented to the emergency department for evaluation of dyspnea on exertion with palpitations. The patient's vitals were stable: oxygen saturation was 100% (percent) on room air, blood pressure was normal. However, the patient was tachycardic; the patient's heart rate was 123. His electrocardiogram (EKG) was negative for any ischemia. The patient's troponin was negative. Chest computed tomography angiogram (CTA) was negative for pulmonary embolism. Workup was significant for very low thyroid stimulating hormone (TSH) and elevated thyroxine (T4) consistent with hyperthyroidism. Treatment included initiating a beta-blocker in the form of metoprolol 25 milligrams (mg) twice a day (BID) and he was discharged to home. The request for coverage for inpatient hospitalization was denied and the patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient hospitalization are not met, including respiratory distress, pulmonary edema, hemodynamic instability, acute myocardial infarction, pulmonary embolism, aortic dissection, pneumonia, or hyperthyroid crisis. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay and this would not be considered the standard of care. The care the patient received, including evaluation and management of uncomplicated hyperthyroidism, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine cancer
Treatment: Personal Care Aide (PCA) Services: Live-In per Diem, 1 Day x 7 Days per Week - Total of 7 Days per Week
The insurer denied Personal Care Aide (PCA) Services: Live-In per Diem, 1 Day x 7 Days per Week - Total of 7 Days per Week.
The health plan's determination is overturned. 

The patient is a female with past medical history of bilateral knee osteoarthritis, Graves' disease, hypothyroidism, angina, chronic anticoagulation, hypertension, glaucoma, hyperlipidemia, and uterine cancer who underwent a video assessment as a first assessment for PCA (personal care assistant) services. The patient was assessed at total assistance with all tasks except for bed mobility for which she was assessed at Limited assistance. Notes from the assessment stated the patient was wheelchair-bound, had moderately impaired cognitive skills, had private aide services prior to the assessment, had a decline in activities of daily living (ADL) status over the last 90 days, and a deterioration of overall self-sufficiency in the last 90 days.

Personal Care Aide (PCA) Services: Live-In per Diem, 1 Day x 7 Days per Week - Total of 7 Days per Week are medically necessary for this patient.

There is documentation from the plans own assessment that the patient requires total assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) except for bed mobility. The patient therefore has unpredictable and unscheduled care needs has been to continue with time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient takes a diuretic which increases urinary output and frequency. In addition, the patient's medical provider documented medical necessity of increased PCA services. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IDLs. 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, Personal Care Aide (PCA) Services: Live-In per Diem, 1 Day x 7 Days per Week - Total of 7 Days per 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: Formulary Exception
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Oxycontin (oxycodone ER)
The insurer denied: Oxycontin (oxycodone ER)
The determination is: Upheld.

The patient is a female with widely metastatic breast cancer. The patient has severe pain. The patient had a severe allergic reaction to morphine during which she experienced swelling and hives. The patient is currently receiving a regimen that includes OxyContin 20 milligrams (mg) every 8 hours; this is under review as a non-formulary drug.

The health plan's determination is upheld in whole.

This patient had an allergic reaction to morphine, and codeine is stated to also be contraindicated in this patient. However, this is not a contraindication to fentanyl, hydromorphone, methadone, or Nucynta. Further, it should be noted the patient is currently receiving Oxycontin. Extended-release oxycodone is the generic equivalent to this. There is no evidence that this patient would have an adverse outcome with these agents based on recommendations from the National Comprehensive Cancer Network (NCCN), the peer-reviewed literature, nor from the authors of UpToDate.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Type 2 Diabetes.
Treatment:  Mounjaro.

The insurer denied Mounjaro.  The determination is overturned.

This is a male patient with type 2 diabetes, chronic kidney disease, hyperlipidemia, obesity, and hypertension treated with Basaglar insulin, Jardiance, metformin, and Mounjaro. He has tried and failed Ozempic. A request for continuation of Mounjaro is under review.

This request is for the continuation of Mounjaro for the treatment of type two diabetes. The prior request was denied, as the patient has not tried and failed or had an intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. All of the formulary alternatives are glucagon-like-peptide-1 (GLP-1) agonists. Mounjaro has been shown to be superior to Ozempic, the most potent GLP-1 receptor agonist [1]. The mean change from baseline in the glycated hemoglobin level was 2.01 percentage points, 2.24 percentage points, and 2.30 percentage points with 5 milligrams (mg), 10 mg, and 15 mg of Mounjaro, respectively, and 1.86 percentage points with Ozempic; the estimated differences between the 5 mg, 10 mg, and 15 mg Mounjaro groups and the Ozempic group were 0.15 percentage points (95% confidence interval [CI], 0.28 to 0.03; probability [P] equals (=) 0.02), 0.39 percentage points (95% confidence interval (CI), 0.51 to 0.26; P less than 0.001), and 0.45 percentage points (95 percent (%) confidence interval (CI), 0.57 to 0.32; P less than 0.001), respectively. This is of clinical importance as this patient has tried and failed Ozempic. He can therefore reasonably be expected to fail Rybelsus, Trulicity, and Victoza. It is not appropriate to trial these less potent glucose lowering medications in this patient who is stable on Mounjaro and who is requiring multiple medications, including insulin, for his diabetes management. Without Mounjaro, this patient will remain at high risk of uncontrolled hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy.