Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: dysphagia

Treatment: Lansoprazole Orally Disintegrating Tablets (ODT)

The insurer is denied coverage for Lansoprazole Orally Disintegrating Tablets (ODT)

The denial is upheld. 

This male patient has a history of gastroesophageal reflux disease and eczema that developed dysphagia with solids but not liquids.

This patient has dysphagia in the setting of previous gastroesophageal reflux disease and known atopic dermatitis. His difficulty with solids and not liquids is concerning for a fixed anatomical obstruction (peptic stricture, eosinophilic esophagitis with or without stricture or foreign body). In a review of proton pump inhibitors (PPIs) use and adverse effects from UpToDate the authors conclude the following regarding the various available agents:
1)	Pharmacokinetics - PPIs are similar in structure and mechanism of action, but PPIs differ in their pKa [ a number that shows how weak or strong an acid is], bioavailability, peak plasma levels, and route of excretion. The magnitude of these differences are small and their clinical relevance has not been established.
2)	PPIs are most effective when the parietal cell is stimulated to secrete acid postprandially, a relationship that has important clinical implications for timing of administration.
3)	In most individuals, once-daily dosing is sufficient to produce the desired level of acid inhibition, and a second dose, which is occasionally necessary, should be administered before the evening meal 
4)     Selecting a PPI - The choice of a specific oral PPI and whether over-the-counter (rather than prescription) PPIs are prescribed are often determined by patient preference and payer coverage. A systematic review of 12 randomized trials examining the relative effectiveness of different PPI doses and dosing regimens found no consistent difference in symptom resolution and esophagitis healing rates. 
5)     In patients unable to swallow pills or capsules, options include an oral suspension of lansoprazole and a powder formulation of omeprazole-sodium bicarbonate for oral suspension.
 The underlying is the inability of the patient to swallow a pill. The obvious solution is offered by the available liquid/suspension versions of PPIs.

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

The carrier's denial of coverage for the Lansoprazole Orally Disintegrating Tablets (ODT) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who was discharged after being admitted for dizziness and diagnosed with benign vertigo. He then presented several days later with the complaint of dizziness. At presentation, the patient's neurological examination and repeat neuro-imaging was negative for new changes. He was admitted and treated with benzodiazepines (lorazepam and then diazepam) with improvement in his symptoms.

No, the proposed inpatient admission was not medically necessary.

The patient presented with a chronic neurological condition for which an extensive work-up had already been completed and diagnosis established. At presentation, there were no significant neurological examination abnormalities and the repeat neuro-imaging did not demonstrate any new findings. Therefore, no further diagnostic tests were necessary and the monitoring and treatment of his condition could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Periodontal Disease

Treatment: D5213 - partial upper denture

The insurer denied coverage for D5213 - partial upper denture.

The denial is upheld.

Based on the submitted documentation which includes copies of periapical radiographs of the patients remaining dentition, dental chart notes from the treating clinician and insurer correspondence, it appears that this patient exhibits extensive moderate to severe periodontal disease and oligodontia in the maxilla upon initial presentation tor treatment. Based on these clinical/radiographic findings, the clinician recommended a maxillary removable prosthesis to address/restore function in the edentulous maxillary spaces. The insurer has denied the partial denture, claiming the remaining dentition are not healthy enough to support the recommended prostheses due to extensive caries and severe periodontal disease. 	

Based on the radiographic findings it is clear that this patient exhibited dental neglect with evidence of severe periodontal disease, generalized, in addition to carious teeth. Significant periodontal disease is noted affecting the remaining maxillary teeth, especially number (#) 6 and #11, which exhibit circumferential severe alveolar periodontal bone loss. Based on the radiographic findings, the remaining maxillary teeth do not appear to be periodontally sound to serve as support/abutment teeth for a maxillary partial removable denture.

The insurer's denial of coverage for D5213 - partial upper denture is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right obstructing ureteral calculus with right hydronephrosis 

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with past medical history of asthma, diabetes, and hypertension (HTN) who presented to the Emergency Room (ER) complaining of abdominal pain. Computed Tomography (CT) scan revealed right obstructing ureteral calculus with right hydronephrosis. The patient was afebrile, with stable vitals in the ER. The patient was admitted. She was taken to the Operating Room (OR) by Urology for cystoscopy/stent placement. The patient improved thereafter and was discharged home on Keflex/Flomax.  

Per Milliman Care Guidelines (MCG) Health (24th Edition) Renal Colic and Kidney Stones, the patient fails to meet clinical indications for admission to inpatient care. These include urinary tract infection (UTI), acute renal failure, hemodynamic instability, bilateral obstruction, obstruction in a transplanted kidney or in a patient who has only one functioning kidney, et cetera. This patient had negative urinalysis, negative urine/blood cultures also. The patient is also noted to meet the OR discharge parameter within 24 hours post procedure. This is considered an ambulatory surgical procedure.

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

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

Diagnosis: Hyperlipidemia. 
Treatment: Repatha. 

The insurer denied Repatha. 
The health plan's determination is upheld. 

The patient is a woman with morbid obesity (body mass index (BMI) 53.12), hypertension, hyperlipidemia and prediabetes. Her father had a myocardial infarction; however, the records provided do not document a family history of premature atherosclerotic cardiovascular disease. The patient's coronary artery calcium score was 0. Recently, her low-density lipoprotein (LDL) cholesterol level was 185. She has had joint pains attributed to multiple statins, including pravastatin, rosuvastatin, pitavastatin, atorvastatin and simvastatin. The doses of these medications that were tried were not provided. She has also been intolerant to Welchol and ezetimibe. 

Repatha is not medically necessary for this patient. 

This patient has hyperlipidemia and has been intolerant to multiple statins. However, since the doses of statins tried were not provided, nor is there documentation of symptom resolution upon drug discontinuation, and symptom recurrence with re-challenge, complete statin intolerance cannot be confirmed. There is no documentation that the patient has atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia. At the present time, Repatha is Food and Drug Administration (FDA) approved and recommended for use only in patients with established ASCVD or those with primary hyperlipidemia, including familial hypercholesterolemia. These indications were selected since these subgroups have the highest risk of future cardiovascular events, and were previously studied in phase II and III lipid-lowering trials. While there have been several trials examining the use of PCSK9 (Proprotein convertase subtilisin/kexin type 9) inhibitors in other patient subgroups, the data regarding their use in these lower risk groups are limited. 

Given the paucity of published data on the use of Repatha in patients, such as this woman, without a documented diagnosis of familial hypercholesterolemia (or other primary hyperlipidemia), a baseline LDL cholesterol level of 190 or greater, or clinical ASCVD, use of this drug in this situation cannot be determined to be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol abuse. 
Treatment: Long-Term Care Rehabilitation and Nursing. 

The insurer is denied coverage for Long-Term Care Rehabilitation and Nursing. 

The denial is upheld. 

This male patient has a history of essential hypertension, chronic obstructive pulmonary disease (COPD), alcohol abuse, and benign prostatic hyperplasia. 

Medicare Part A (hospital insurance) covers skilled nursing care. In certain conditions for a limited time if all of the following conditions have been met: 
1. Patient has Part A and have days left in their benefit period to use 
2. Patient has a qualifying hospital stay 
3. Physician decided that the patient will need daily skilled care. It must be given by, or under the supervision of, skilled nursing or therapy staff. 
4. Patient receives these skilled services in a Skilled Nursing Facility (SNF) that is certified by Medicare. 
5. Patient needs these skilled services for a medical condition that is either a hospital related medical condition treated during the qualifying 3-day inpatient hospital stay or a condition that started while you were getting care in the SNF for a hospital related medical condition. 

Residential long term care at Rehabilitation and Nursing was not medically necessary since the patient was independent in all functional mobility and ADLs. Minimum Data Set (MDS) showed that the patient had no limitations in range of motion of the arms or legs. He did not require rehab nursing care. He did not require restorative physical therapy, occupational or speech therapy services. He was able to tolerate a regular diet and oral medications. He was not in any pain nor did he have any pressure ulcers. 

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

The carrier's denial of coverage for the Long-Term Care Rehabilitation and Nursing is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autosomal dominant polycystic kidney disease.
Treatment: Jynarque.

The insurer is denied coverage for Jynarque.  The denial is upheld. 

This female patient has a history of autosomal dominant polycystic kidney disease (ADPKD) and anemia.

There is inadequate evidence-based literature to support efficacy and safety in treating polycystic kidney disease in patients with glomerular filtration rate (GFR) less than 25 ml/min. This patients' most recent GFR was 22 ml/min (milliliters/minute); therefore, per evidence-based literature, Jynarque is not medically necessary.

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

The carrier's denial of coverage for the Jynarque is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: loss of function.
Treatment: level 2 personal care services of 8 hours per day, 7 days per week for a total of 56 hours per week.
The insurer is denied coverage for level 2 personal care services of 8 hours per day, 7 days per week for a total of 56 hours per week.
The denial is overturned. 

This female patient has a history of cerebrovascular disease with dysphagia, neurodegenerative disorder, vascular dementia, depression, osteoarthritis of both knees, lower back pain, gait dysfunction, high falls risk and spondylosis.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 note:
"(a) Definitions and scope of services.
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse."
Also:
"As previously advised, social services districts are NOT required to allot time for safety monitoring as a separate task as part of the total personal care services hours authorized (see GIS 99 MA/013, GIS 99 MA/036). However, districts are reminded that a clear and legitimate distinction exists between "safety monitoring" as a non-required independent stand alone function while no Level II personal care services task is being provided, and the appropriate monitoring of the patient while providing assistance with the performance of a Level II personal care services task, such as transferring, toileting, or walking, to assure the task is being safely completed." 

The patient has lost functional capacity in multiple areas, now needing at least limited assistance (hands on) in walking, locomotion and toilet transfer and use. She also has dementia, with poor score on mini mental status exam (MMSE). She demonstrates problems with situational memory. In view of the cognitive deficits and the need for assistance, services provided to her are not for safety only. 


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

The carrier's denial of coverage for the level 2 personal care services of 8 hours per day, 7 days per week for a total of 56 hours per week is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pulmonary fibrosis

Treatment: pre-elective hospital admission

The insurer is denied coverage for pre-elective hospital admission

The denial is overturned. 

This female patient has a history of progressive lung disease.

Based upon the records provided this patient meets all the criteria for lung transplant. The insurer denied her because of lack of dental clearance, Pap smear and mammogram. She did have them done and therefore met even the insurer's criteria. As noted by Milliman Care guidelines (MCG) Care Guidelines Inpatient and Surgical Care 25th Edition Lung transplant ORG: S-1300 (ISC) clinical Indications for Procedure is indicated for ALL of the following: End-stage lung disease appropriate for transplant is present, as indicated by pulmonary fibrosis as well as other conditions; Alternative to lung transplant is not available or not appropriate (e.g., lung volume reduction surgery or bronchoscopic lung volume reduction for chronic obstructive pulmonary disease (COPD), pulmonary thromboendarterectomy for patient with chronic pulmonary thromboembolic disease); Medical therapy for condition does not exist or has failed; no contraindications to lung transplant present.

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

The carrier's denial of coverage for the pre-elective hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a female who presented to the emergency department (ED) with chest tightness and shortness of breath. The patient ran out of her albuterol. The patient also was short of breath with walking. She believed her symptoms were more consistent with her asthma. In ED, the patient was not in acute distress. Her blood pressure (BP) was 155/65, her heart rate was 86 beats per minute (BPM), her temperature was 36.9, and her oxygen (O2) sat on room air was 100%. Her pulmonary and cardiovascular exam was normal, based on ED attending notes. Her right knee had decreased range of motions and swelling, and she had pitting edema of her lower extremities. The patient was consulted by vascular surgery for severe carotid stenosis, based on carotid duplex done two months prior. The test revealed 80-99% stenosis of her left internal carotid artery. The patient was recommended revascularization. It was noted that the patient did not have any signs or symptoms of stroke, however, her risk of stroke within next two years was estimated to be 20%. The patient was transferred to vascular surgery service. The patient had a contrast allergy, and she was prepared with prednisone and Benadryl prior to the procedure. The patient underwent arch angiogram, diagnostic carotid angiogram, left vertebral and cervococerebral carotid angiogram. Also, left internal carotid stenting with anti-embolic protection. After surgery, the patient was transferred to post-anesthesia care unit (PACU) overnight. Her condition remained stable. Her BP was elevated, the rest of her vitals were normal. The patient was transferred to surgical unit. She was discharged home.

The health plan's determination is upheld.

The patient presented with dyspnea, worsened since she did not use her inhalers. The patient has history of CHF (congestive heart failure) and asthma. She also suffers from hypertension. At presentation to ED, the patient was not in major distress. During her admission, the patient remained stable, her BP was elevated, but her respiratory status was stable. She had mild CHF exacerbation. Her BNP (Brain Natriuretic Peptide) was elevated, but it was not clear, how different it was from her baseline BNP. The patient was treated mostly with oral medications. Her troponin remained negative. Cardiology consult did not plan any additional diagnostic or therapeutic procedures.
The patient has had an abnormal carotid study. She did not have any acute neurologic symptoms which could have been caused by carotid stenosis during this admission. The procedure, carotid stent, which was performed, was an elective procedure. It was not clear why the procedure was done based on the finding of carotid duplex which was performed two months prior to this presentation. 

Inpatient level of care was not medically necessary. The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep bite
Treatment:  Braces (Pre-service)
The insurer denied the  Braces (Pre-service)
The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits. The patient has a deep bite, class II canines and impacted second molars.

Yes, the proposed treatment was medically necessary. Based on the documentation submitted, the patient has a 27 score on the Handicapping Labio-Lingual Deviation (HLD) index. Ectopic eruption - 12 points, anterior crowding - 5 points, labio-lingual spread - 2 points, overbite - 4 points and overjet - 4 points; for a total of 27 points which is above the 26-point threshold needed for benefits.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine Adenocarcinoma.
Treatment inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient is a female with a history of uterine adenocarcinoma status post total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO) and tumor debulking.  The patient went to the emergency room for evaluation of wound dehiscence/drainage and lower abdominal pain. The wound had been cleaned by the gynecology (GYN)/oncology (ONC)'s office and appeared clean without induration or foul odor.  The patient noted that her oncologist told her to come to the emergency room for an incision site infection. The midline incision had opening with redness. The cystostomy incision on the left side of the hypogastric area had a tube in place draining straw-colored urine, which was hooked up to a Foley catheter. The patient was admitted for wound site dehiscence. The computed tomography (CT) scan reported a peripherally enhancing fluid collection within the central pelvis at the site of drainage catheter which communicated with the anterior pelvic wall at the site of wound dehiscence. The patient underwent wet-to-dry dressing changes with packing. A Urology consultation was placed, and it was recommended that the patient continue to undergo conservative management. The patient was stabilized and discharged.

This is a complex patient from a medical and surgical standpoint who underwent a TAH/BSO and tumor debulking for ovarian cancer. Surgery was complicated by a cystogram showing urinoma which required a subsequent bladder repair and indwelling Foley catheter 2 weeks after the initial surgery. The patient then developed a wound separation and a CT showed a wound dehiscence and a fluid collection in the pelvis.

Although the management ended up being conservative in nature, the patient required a high degree of complex decision making. Due to the concern on an abscess, recent surgery, an injured healing bladder and a wound dehiscence it is reasonable to closely monitor for acute worsening of her condition. The physician and team acted reasonably in treating this patient. 

There was sufficient evidence to support that the inpatient admission was considered medically necessary treatment for the patient's condition.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.