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

Diagnosis: Coronary artery disease (CAD), hypertension, dermatitis, hemiplegia, benign prostatic hypertrophy (BPH), osteoarthritis (OA)

Treatment CDPAP (Consumer Directed Personal Assistance Program services), 20 hours per day, 7 days per week, for a total of 140 hours per week

The insurer denied coverage for CDPAP services, 20 hours per day, 7 days per week, for a total of 140 hours per week

The denial is overturned.

The patient has a history of coronary artery disease (CAD), hypertension, dermatitis, hemiplegia, benign prostatic hypertrophy (BPH), osteoarthritis (OA), and hypercholesterolemia. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient lives with his spouse in a one-bedroom apartment in an elevator building on the fourth floor. He reports memory problems. He is alert and oriented (A+O) x 2 (person and place). He can recall 0/5 words after 5 minutes and cannot complete the steps in boiling a pot of water without cues. Compared to the UAS (Uniform Assessment System) during which most activities were limited assistance, the UAS shows extensive or maximal assistance in most activities. The patient is bed-bound. He is totally dependent with meal preparation and ordinary housework. He requires maximal assistance with bathing, personal hygiene, dressing, toilet use, and bed mobility. He is incontinent of urine-secondary to BPH and needs to be changed almost every 2 hours as per his family. He is occasionally incontinent of bowel. The patient fell once within the last 90 days. He is fed via percutaneous endoscopic gastrostomy (PEG) tube. In sum, there has been marked deterioration over this period of time both cognitively and physically. The family is requesting Consumer Directed Personal Assistance Program (CDPAP) services, 20 hours per day, 7 days per week, for a total of 140 hours per week.

The Medical Reviewer disagrees with the opinion of the Plan and reviewers which upheld the denial of the requested Personal Assistance Services. The medical necessity of the 140 hours is supported.  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 Consumer Directed Personal Assistance Program (CDPAP) services, 20 hours per day, 7 days per week, for a total of 140 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Lower extremity deep venous thrombosis. 
Treatment: Formulary exception for Eliquis. 

The insurer denied the Formulary exception for Eliquis. 
The denial is upheld. 

The patient is a male. He was diagnosed with lower extremity deep venous thrombosis. Eliquis has been prescribed.  According to a provided prior authorization form, this patient has previously tried Plavix and Coumadin.  No other information is provided. 

No, the health plan should not cover the Formulary exception for Eliquis. 

The formulary option for this patient is Xarelto. There is limited documentation provided. There is no documentation indicating that this patient has tried and failed Xarelto. Given the provided documentation, it cannot be concluded that Xarelto is likely to be less effective for this patient or that it would be associated with a significantly increased risk of adverse events. While it is true that Xarelto has a slightly higher major bleeding risk compared to Eliquis, that is only relevant in certain circumstances given the very small increase seen with Xarelto.  Based on the very small difference in risk combined, with lack of documentation justifying why this patient would be more at risk for major bleeding, use of Xarelto cannot be considered likely to have adverse effects for this patient compared to Eliquis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Left Colonic Appendagitis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This case involves a female who presented to the emergency department complaining of numbness.  She has a past medical history that includes hypertension as well as hyperlipidemia, peripheral vascular disease (PVD), cerebrovascular accident (CVA), transient ischemic attacks (TIAs), gastroesophageal reflux disease, lupus, pulmonary embolism, and borderline diabetes.  She states she has intermittent left arm and left leg numbness for 3 days as well as constant left lower abdominal pain x3 days.  She states she had a cardiac catheterization performed where she had approximately 50 percent (%) blockage however there was no stent placed.  Per physical examination her blood pressure was 144/79.  She had a heart rate of 82 beats per minute (bpm).  There was mild left lower quadrant tenderness to palpation.  The patient had slightly diminished sensation to the left arm and posterior left knee.  She had 4+/5 strength to the upper and lower extremities bilaterally.  She was alert and oriented.  It was recommended she undergo laboratory and diagnostic studies.  Laboratory studies revealed an elevated creatine kinase at 300.  A lower extremity venous duplex revealed no evidence of diminished flow throughout the visualized deep venous system.  There was no sonographic evidence of deep vein thrombosis (DVT).  She also underwent a duplex of the upper extremity revealing no evidence of DVT.  A computed tomography (CT) scan of the head revealed no evidence of hemorrhage, mass-effect, acute infarction, or extra-axial collection.  A CT scan of the abdomen and pelvis revealed a ovoid area of fat attenuation within the left lower quadrant adjacent to the descending colon demonstrating a thin hyperattenuating rim and a thin linear central density consistent with a thrombosed vein.  The findings were consistent with an infarcted epiploic appendage consistent with acute left colonic appendagitis.  There was no evidence of mechanical bowel obstruction.  The recommendation was made to admit the patient for further monitoring and treatment.  She did receive intravenous (IV) medications and intravenous fluids.  No further adverse events were noted, and the patient was discharged the following day. This diagnosis is one of exclusion and rare and more serious and operative causes were ruled out.   Acute appendagitis can be managed with analgesics and conservative management. While treatment in the hospital may be needed for analgesics it can be done as an "Observation" status and not formal inpatient status. 

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

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

Diagnosis: Varicose Veins. 
Treatment: 36478 Left Endovenous Ablation Therapy. 

The insurer denied the 36478 Left Endovenous Ablation Therapy. 
The denial is overturned.

The patient is a female who presented with bilateral leg pain, heaviness, tiredness, and swelling. Records indicate that the patient's symptoms affect normal activities such as work. Reflux testing showed left short saphenous vein (SSV) enlargement and reflux, including at the saphenopopliteal junction. The provider performed left short saphenous vein (SSV) ablation. Coverage has been denied on the basis that the patient did not have a trial of conservative therapy. 

Yes, the proposed treatment with 36478 Left Endovenous Ablation Therapy was medically necessary. 

The patient presented with bilateral leg pain, heaviness, tiredness, and swelling. Records indicate that her symptoms affect normal activities such as work. Reflux testing showed left short saphenous vein (SSV) enlargement and reflux, including at the saphenopopliteal junction. The provider performed left short saphenous vein ablation. Coverage has been denied on the basis that the patient did not have a trial of conservative therapy. 

Under widely accepted criteria [1-7], endovenous ablation of an axial saphenous vein is medically necessary when: 
1) The patient has venous insufficiency symptoms severe enough to affect normal function. 
2) The patient has failed a trial of prescription compression stockings. 
3) The patient has duplex-proven reflux affecting the vein in question and the reflux can be reasonably construed as a cause of the patient's symptoms. 

Requirement #1 has been met. The office note states that the patient had multiple symptoms consistent with venous insufficiency and that her symptoms adversely affected normal activities, including at work. 

Requirement #2 has been met. The office note states that the patient tried and failed graduated compression stockings, which she had worn for over three months. The same note also states that oral analgesics are contraindicated because of the patient's gastrointestinal history. 

Requirement #3 has been met. The patient had a reflux study. The study showed enlargement (6.0 millimeters [mm]) and reflux (0.7 to 0.8 seconds) affecting the short saphenous vein (SSV). 

Therefore, the patient meets published, well-accepted criteria for left short saphenous vein (SSV) ablation. 

The denial letter gave the following reasons for non-coverage: "Lack of documentation of conservative therapy."  This reason for denial is not valid because the office note states that the patient failed a trial of graduated compression stockings and that oral analgesics were contraindicated for this patient. 

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: Class I occlusion.
Treatment: Braces and Monthly Office Visits.
The insurer denied Braces and Monthly Office Visits. 
The health plan's determination is upheld.

The patient in question is a male with a Class I occlusion with 3 millimeter (mm) overbite and 5-mm overjet. He has moderate maxillary and mandibular crowding. He is treatment planned for Braces and Monthly Office Visits to correct his malocclusion.

There is no medical reason to correct his malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, Braces and Monthly Office Visits are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied the Wegovy.
The denial is overturned.

The patient is a female with obesity with a body mass index of 40.14. The request for Wegovy is under review. The prior request was denied coverage by the health plan, as requests for Wegovy will not be approved until all strengths of the drug become readily available again. The physician is appealing this determination. The patient has been on Wegovy for the past 6 months using a coupon card that has expired. The patient has lost a total of 44 pounds. It is keeping her glucose levels down and away from pre-diabetes range. The patient has been enrolled in Weight Watchers for several months.

Yes, the requested Wegovy is medically necessary.

This request is for Wegovy for the treatment of obesity with a body mass index of 40.14. This patient has been successful with a 44 pound weight loss over the past 6 months. Per the Saxenda policy, requests for Wegovy will not be approved until all strengths of the drug become readily available again. The Novo Nordisk webpage indicates that the company has temporarily stopped shipments of the first two doses of Wegovy (0.25 mg [milligrams] and 0.5 mg) to deter new patients from starting Wegovy. This patient has already been on Wegovy treatment for six months. Also, the website indicates that patients who are already on Wegovy should be able to continue Wegovy. Without Wegovy, this patient will be at risk of regaining the 44 pounds of weight she has already lost, which would put her at increased risk of complications of obesity, such as type 2 diabetes. Therefore, yes, the proposed Wegovy is medically necessary.

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

The requested Wegovy is medically necessary as outlined above. The patient has already been on Wegovy for 6 months with successful weight loss.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: BRCA 2 (Breast Cancer Gene 2). 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

The patient has a history of BRCA 2 (Breast Cancer Gene 2) positive status and a family history of breast cancer. She presented to the hospital for an elective bilateral mastectomy with immediate reconstruction with acellular dermal matrix. The procedure was uncomplicated.  The patient was transferred to the floor for postoperative management. She tolerated an advanced diet, remained afebrile, and hemodynamically stable. Pain was well controlled. The patient was discharged. 

The patient underwent a bilateral mastectomy with immediate reconstruction. The procedure was uncomplicated. The patient is healthy. The blood loss was minimal. A simple bilateral mastectomy with immediate reconstruction is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. 

Multiple studies have documented the safety of this approach with no increase in readmission, infection rates, antibiotic use, emergency room visits, breakdown of the incision and/or other complications. In summary, the admission was not medically necessary.  The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

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

Diagnosis: Central Precocious Puberty. 
Treatment: Supprelin LA. 

The insurer denied the Supprelin LA. 
The denial is overturned. 

This is a female diagnosed with central precocious puberty (CPP). This request is for Supprelin long-acting (LA). As reported, the patient has needle phobia and had an adverse reaction to injection with prolonged swelling and pain. She was started on Lupron injection. Her magnetic resonance image (MRI) was normal.  The patient's estradiol was less than (<) 2.5, luteinizing hormone (LH) was 0.6, and follicular stimulating hormone (FSH) was 0.9. 

Yes, the proposed treatment with Supprelin LA is medically necessary. 

The definition of precocious puberty is children who have the onset of secondary sexual characteristics younger than age eight in girls and younger than age 9.5 in boys [1-3]. Central precocious puberty (CPP) is diagnosed using a basal luteinizing hormone (LH) of greater than (>) 0.3 or stimulation testing with a gonadotropin-releasing hormone (GnRH) analog such as leuprolide showing a pubertal response defined as an luteinizing hormone (LH) greater than (>) 10 [4]. 

Central precocious puberty (CPP) is treated with gonadotropin-releasing hormone (GnRH) agonists [5-10] such as Lupron [11] and Supprelin [12]. The Food and Drug Administration (FDA) indication for gonadotropin-releasing hormone (GnRH) agonists is for use in central precocious puberty (CPP). In addition, when used for central precocious puberty (CPP), the Food and Drug Administration (FDA) recommends discontinuation of gonadotropin-releasing hormone (GnRH) agonists before age 11 for females and before age 12 for males [11]. This is consistent with accepted recommendations for discontinuation of gonadotropin-releasing hormone (GnRH) agonist therapy at a bone age of 12 in girls and 13 years old in boys [2, 4-7]. 

The patient has a pubertal luteinizing hormone (LH) greater than 0.3.  The patient was treated with Lupron and had an adverse reaction.  The patient has needle phobia.  The patient can no longer use Lupron or other injections.  The requested medication is the only available implant that is performed one time per year.  The request is consistent with generally accepted standards of medical practice and is therefore medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient as the request is medically necessary as described above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Peripheral revascularization x1 and bilateral lower extremity angiogram
The insurer denied peripheral revascularization x1 and bilateral lower extremity angiogram.  
The denial was overturned. 

The patient is a male with multiple medical problems including diabetes, hyperlipidemia, high blood pressure, and prostate cancer who was evaluated by his provider for pins and needles, pain down both lower extremities and being only able to ambulate a few blocks before experiencing lower extremity pain. An arterial duplex of the bilateral lower extremities demonstrated hemodynamically significant stenosis in the bilateral lower extremities.

The patient was seen in follow up and was diagnosed with claudication. The patient has tried conservative measures to treat his claudication. The patient continued to have claudication and was then offered bilateral lower extremity angiogram for intervention. The patient underwent aortogram and bilateral lower extremity angiogram that demonstrated arterial disease in the bilateral lower extremities.

The issue at hand is whether or not the aortogram and bilateral lower extremity angiogram was medically necessary.

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

The requested health service/treatment of peripheral revascularization times (x) 1 and bilateral lower extremity angiogram was medically necessary for this patient.

The requested treatment aortogram and bilateral lower extremity angiogram was medically necessary for this patient. The patient had peripheral arterial disease and bilateral lower extremity claudication. He has tried conservative measures to treat his claudication. The patient continued to have claudication. The aortogram and bilateral lower extremity angiogram is the standard of care for the treatment of peripheral arterial disease and bilateral lower extremity claudication.

Therefore, the requested health service/treatment of peripheral revascularization x1 and bilateral lower extremity angiogram was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic pancreatitis.
Treatment: Emergent Inpatient admission.
The insurer denied coverage for an emergent inpatient admission.
The denial is upheld.

The patient had a history of chronic pancreatitis and presented with abdominal pain. He was undergoing a workup for chronic abdominal pains. He had splenic and portal vein thrombosis and was on Xarelto. He initially was hypertensive, but the blood pressure improved. There was no abdominal rebound or guarding. There was no leukocytosis. The amylase and lipase were normal. A CAT (computed axial tomography) scan revealed a small amount of peripancreatic fluid, splenomegaly and colitis. He was felt to have a mild pancreatitis. He requested pain medications but then signed out AMA (against medical advice) the same day.

Clinical indications for admission for pancreatitis are listed in MCG (Milliman Care Guidelines). This patient had chronic pancreatitis. Indications for admission for chronic pancreatitis include inability to maintain oral hydration, evidence of infection, severe pain, hemodynamic instability, severe vomiting, acute renal failure, altered mental status, and severe electrolyte abnormalities. The patient did not have these conditions.

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

This patient had chronic pancreatitis. The amylase and lipase were normal. IV (intravenous) hydration and pain medications could have been given with observation status. He did not meet MCG criteria for admission for Pancreatitis or far Undiagnosed Abdominal Pain. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

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

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

Diagnosis: Hidradenitis Suppurativa.
Treatment: Humira Crohn's/UC (ulcerative colitis)/HS (Hidradenitis suppurativa) Starter Pack + Humira 40 milligrams (mg).

The insurer denied coverage for Humira Crohn's/UC (ulcerative colitis)/HS (Hidradenitis suppurativa) Starter Pack + Humira 40 milligrams (mg).
The denial is overturned.

The patient is a female with a diagnosis of hidradenitis suppurativa with lesions on her breasts and thighs.  The patient has failed topical therapy with clindamycin and Benzoyl peroxide wash and oral doxycycline tablets.  The requested medication is Humira.  

Humira is medically necessary for the treatment of the patient's condition, hidradenitis suppurativa.  The patient has severe hidradenitis suppurativa affecting the breast and thighs. The patient has failed topical and oral antibiotic therapy and it is unlikely that further treatment will result in significant further improvement.     

Humira is an approved Food & Drug Administration (FDA) drug for the treatment of Hidradenitis suppurativa and is a reasonable next step in this clinical scenario based on the appeal and notes presented.  The decision is reversed and Humira is approved for the treatment of the patient's hidradenitis suppurativa.  

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 Humira Crohn's/UC/HS Starter Pack + Humira 40 mg is overturned. Medical Necessity is substantiated.