Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pompe Disease. 
Treatment: Lumizyme (dosed at 40mg (milligrams)/kg (kilograms) weekly. 

The insurer denied: Lumizyme (dosed at 40mg (milligrams)/kg (kilograms) weekly. 
The denial is overturned. 

The patient is an adult male with Pompe Disease. He was diagnosed with this as an infant. He is dependent on a PEG (percutaneous endoscopic gastrostomy) tube. He is currently on Lumizyme and was previously in a clinical trial for this. He most recently has had right arm weakness that is worsening. His provider wishes to continue Lumizyme. The request was previously denied coverage by the health plan, as it was considered experimental/investigative. The denial is being appealed. 

The health plan should cover the requested Lumizyme. 

Continuation of Lumizyme is medically appropriate. The patient is currently on it. This medication is not Experimental/Investigative. A meta-analysis by Khan and colleagues in 2020 noted that Lumizyme improves gross motor outcomes, lingual strength, pulmonary function measures, and biochemical markers in early-onset Pompe disease. A study by Van Gelder and colleagues in 2016 noted that a majority of those on Lumizyme were ventilator free at the end of the study.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
This adult patient presented to the hospital complaining of short periods of intermittent chest pain and palpitations. Past medical history was significant for diabetes mellitus and hypertension. On arrival to the hospital, vital signs were stable (Blood pressure (BP) 145/85, Pulse 71).  Physical examination revealed no major abnormality. A 12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST (interval on an ECG) or T wave (interval on an ECG) abnormalities. Serum troponin levels were not elevated. The patient was admitted to the hospital for monitoring and testing.  Exercise stress electrocardiography revealed no evidence of ischemia after reaching a maximally predicted heart rate of 87% (percent). The patient was deemed to have non cardiac chest pain and discharged home with follow up.

This patient presented with chest pain and a past medical history of hypertension and diabetes mellitus. His pretest probability of coronary artery disease was low. Utilizing the HEART (cardiac risk measure) score he was considered low risk (Score of 2- age/2 cardiac risk factors). Utilizing the TIMI (cardiac risk score) he also had a low risk of developing major adverse cardiac events in the subsequent 30 days. Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.

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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Encounter for screening for dental disorders
Treatment: Porcelain Crown on Teeth/Quads #20 and #21
The insurer denied: Porcelain Crown on Teeth/Quads #20 and # (number) 21
The denial is upheld.

The patient is an adult female. The request is for benefits for crowns on teeth #'s 20 and 21. The prior denial was due to there not being decay and/or fractures present in the teeth (necessitating crowns over composite restorations).

The proposed treatment is not medically necessary.

There is no tooth structure missing due to decay and/or complete fractures in either of these teeth in the x-ray presented. Therefore, crowns are not warranted, as no restoration of the teeth is needed.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: 0275T - Percutaneous Laminotomy /Laminectomy
The insurer denied: 0275T - Percutaneous Laminotomy /Laminectomy
The denial is upheld

The patient is an adult male with low back pain radiating into the right hip and right lower extremity with occasional coccydynia. Past treatment for the patient's pain includes sacroiliac joint injection, physical therapy, NSAIDs (nonsteroidal anti-inflammatory drugs) and epidural steroid injections. MRI (magnetic resonance imaging) of the patient's lumbar spine shows multilevel degenerative disc disease, L3-4 (lumbar three to four) severe right and moderate to severe left foraminal stenosis, and L4-5 (lumbar four to five) severe central canal stenosis. MILD (minimally invasive lumbar decompression)
procedure at levels L3-4 (lumbar three to four) and L4-5 (lumbar four to five) secondary to intermittent neurogenic claudication due to central lumbar stenosis was requested. The request was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested health service.

There is not adequate valid scientific evidence to show that the expected health benefits from the procedure are clinically significant and will have a greater chance of benefit, without a 
disproportionately greater risk of harm or complications, than other possible treatments. The available evidence for MILD (minimally invasive lumbar decompression) has been continuously debated. Overall, it is considered that while the procedure is likely safe, there is only modest evidence for effectiveness. The available studies are limited in patient size and/or duration. A 2021 publication of a prospective study does show efficacy and lack of adverse reactions at 6 months with 155 patients aged 50-80. Based on a 2021 review of the available current scientific literature, the novel interventions for symptomatic lumbar spinal stenosis, such as the MILD (minimally invasive lumbar decompression) procedure and the
Superion interspinous spacer, are generally evidenced to be safe and effective. There is a possibility in the future that these interventions could disrupt current treatment algorithms for lumbar spinal stenosis. However, more studies need to be done. As such, at this time, MILD (minimally invasive lumbar decompression) is not medically appropriate, and alternative treatments are acceptable and available. The requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease. Other standard treatment options may include non-opioid medications (i.e., other NSAIDs [non-steroidal anti-inflammatory drugs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., repeat physical therapy, home exercise program, chiropractor
treatments), and interventions (i.e., repeat epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions, which is the accepted treatment in cases of severe canal stenosis).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: 0275T - Percutaneous Laminotomy /Laminectomy
The insurer denied: 0275T - Percutaneous Laminotomy /Laminectomy
The denial is upheld

The patient is an adult male with chronic low back pain. The patient attempted HEP (home exercise program) and walking, as well as nerve blocks. The patient's exam reveals no focal deficit.
MRI (magnetic resonance imaging) shows L3-4 (lumbar three to four) severe right, and moderate-to-severe left foraminal narrowing. The patient was recommended a L3-5 (lumbar three to five) MILD (minimally invasive lumbar decompression)
procedure. 

The health plan should not cover the requested health service.

This reviewer is in agreement with the denial letter. There is limited long-term outcomes data and large studies on percutaneous procedures. The patient is being recommended a percutaneous procedure that does not have the same outcomes or long-term follow up as gold-standard procedures. Therefore, in this setting, the surgery is not medically appropriate and would not be considered warranted for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: 0275T - Percutaneous Laminotomy /Laminectomy
The insurer denied: 0275T - Percutaneous Laminotomy /Laminectomy
The denial is upheld

The patient is an adult male with severe spinal stenosis neurogenic claudication and sacroiliac joint pain. He has undergone injections, physical therapy. A percutaneous laminectomy/laminotomy (MILD - minimally invasive lumbar
decompression) procedure has been recommended. 

The health plan should not cover the requested health service.

The patient is an adult male with a history of severe spinal stenosis at L4-5 (lumbar four to five), and to a lesser degree, L3-4 (lumbar three to four). There is severe lateral recess narrowing as well as neuro-foraminal stenosis. The patient was complaining of sacroiliac joint pain and underwent a sacroiliac joint injection. A minimally invasive lumbar decompression/percutaneous laminectomy was recommended. MILD (minimally invasive lumbar decompression) is a fluoroscopically guided minimally invasive laminectomy which targets debulking of the ligamentum flavum in order to relieve symptoms of neurogenic claudication caused by spinal stenosis. However, this patient has severe spinal stenosis secondary to degenerative changes, facet arthropathy. The patient has severe lateral recess narrowing, and
severe neuroforaminal stenosis. With the exception of the debulking of the ligamentum flavum, the remainder of the factors contributing to the spinal stenosis will be unchanged, specifically the neuroforaminal synopsis. As such the requested percutaneous laminectomy/laminotomy is not medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: periodontal disease
Treatment: implant on tooth 3, 5, 19, 20, 29, and 31
The insurer denied coverage for implant on tooth 3, 5, 19, 20, 29, and 31.
The denial is overturned.
 
Upon review of the submitted documentation it appears that this patient with a diagnosis of spastic cerebral palsy since childhood presented for dental evaluation and rehabilitation of multiquadrant edentulous spaces in the maxilla and mandible. The dentist recommended the implants and related services after extraction of non maintainable teeth, due to the sequelae of the cerebral palsy including cognitive issues and motor skill impairment that would preclude the patient from successful use of removable or other oral appliances. The insurer has denied these services as not medically necessary stating that the services are not a covered benefit according to New York State guidelines. The Doctor is appealing the decision on behalf of the patient noting that her underlying medical condition precludes proper function. 

The documentation provided for review documents the underlying medical issues and the patient's psychomotor impairment due to this condition. The patients' clinicians uniformly note that the underlying cerebral palsy and correlated manifestations of this condition make it impossible for her to perform the necessary motor skills that would be necessary to wear a removable denture or use other oral appliances, skills that would be unnecessary with fixed implant retained prostheses. Further, it would appear that these implants and related services might be covered after meeting certain criteria. As such the implants are deemed medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for implant on tooth 3, 5, 19, 20, 29, and 31 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other- Heart Failure
Treatment: Full Hospital Admission 
The health plan denied: Full Hospital Admission
The determination is: Overturned

The patient is a female with a past medical history significant for chronic systolic heath failure and severe right ventricle (RV) cardiomyopathy due to arrhythmogenic right ventricular cardiomyopathy (ARVC), pacemaker, implantable cardioverter defibrillator (ICD), deep vein thrombosis (DVT), antiphospholipid (APA) syndrome, and subdural hematoma. She was admitted under the inpatient level of care for urgent orthotopic heart transplant (OHT) evaluation and listing after outpatient right heart catheterization (RHC) demonstrated RV failure, a cardiac index (CI) of 1.8, and a pulmonary artery pulsatility index (PAPi) of 0.7. An echocardiogram demonstrated a mildly reduced left ventricular ejection fraction (LVEF) of 40 percent (%), severe tricuspid regurgitation (TR), severe RV enlargement, and reduced function. Once the patient was hospitalized, the patient was listed for heart transplantation as a status 3. During her hospitalization, she required intermittent intravenous (IV) diuresis for RV failure, and her hemodynamics were tenuous with the patient being frequently hypotensive, with the systolic blood pressure (SBP) in the 80s millimeters of mercury (mmHg). The liver function tests (LFT) were elevated, requiring a liver ultrasound (US) to rule out liver cirrhosis prior to the OHT. The patient remained admitted under the inpatient level of care and waited for heart transplantation due to concerns regarding patient's hemodynamic instability and high risk of death. She was successfully transplanted. Her post-operative course was notable for RV failure but was successfully weaned off inotropes. She was also treated for acute cellular rejection (grade 2R). The patient was discharged home in stable condition. The patient's health plan has denied coverage for inpatient level of care due to lack of medical necessity. 
At issue is the medical necessity of inpatient level of care.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of full hospital admission is medically necessary for this patient. The patient was admitted under inpatient level of care for urgent listing for OHT due to end-stage RV failure from ARVC. She was hypotensive due to end stage heart failure and needed IV diuresis for medical optimization prior to OHT. Given the patient's tenuous hemodynamic status and the high risk clinical features discussed above, the patient was at significant risk for morbidity and mortality. The inpatient level of care would be supported by peer reviewed medical literature and expert consensus guidelines on acute heart failure management given the patient's high risk clinical features of severe RV failure, hypotension, and need for IV diuresis for medical optimization prior to OHT [1-5].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, diabetes. 
Treatment: Increase Personal Care Aide 2 12 Hour Split Shift, 7 Days a Week. 

The insurer denied: Increase Personal Care Aide 2 12 Hour Split Shift, 7 Days a Week. 

The denial is upheld. 

This elderly male patient has medical conditions that include osteoarthritis, coronary artery disease, chronic obstructive pulmonary disease (COPD), and diabetes. Denial of an increase in personal care aide (PCA) 12 hours split shift, seven days a week, is being appealed. The health plan approved an increase personal care aide to live in services, seven days a week. 

Uniform Assessment System (UAS) evaluation completed 4 months ago shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, phone use, transportation, bathing, personal hygiene, dressing, and toileting; limited assistance with locomotion and bed mobility; and supervision with eating. He has frequent bladder incontinence. 
A letter from the social worker (SW) references the neurologist's letter. The letter from the Provider notes the patient has cervical spine disease, essential tumor, benign paroxysmal positional vertigo (BPPV)/dizziness, insomnia, hypertension, syncope, and hand numbness. The patient is severely disabled with recent worsening. A letter from the patient notes he lives alone. He has imbalance when walking and falls. He requires and assistive device for ambulation. He sometimes is unable to use one of his arms due to stinging.

The proposed treatment is not medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. The denial of an increase in personal care aide 12 hours split shift, seven days a week, is being appealed. The health plan approved an increase in personal care aide to live in services, seven days a week. Uniform Assessment System (UAS) evaluation completed 4 months ago shows the patient requires assistance with all activities of daily living, except eating. He has bladder incontinence. The appeal statements report the patient is disabled. The patient reports needing assistance with ambulation due to imbalance and falls. The information does not support that the patient has continuous needs that would prevent an aide getting five hours daily of uninterrupted sleep during the aide's shift. The plan's increase in personal care aide to live in services, seven days a week is appropriate and medically necessary to meet this patient's needs. The proposed increase in personal care aide to 12 hours split shift, seven days a week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure 
Treatment: Inpatient hospital admission 
The insurer denied coverage for the inpatient hospital admission. 
The denial is upheld. 
 
The patient is an adult male with a history of heart failure with preserved ejection fraction (HFPEF) secondary to Amyloidosis. He presented to the emergency department (ED) with complaints of shortness of breath (SOB) and bilateral leg edema worse over the previous 2 days. The patient was followed at cardiology clinic and was on Bumex and Metolazone for acute decompensated heart failure (ADHF). He was getting weekly outpatient infusions. 

At presentation to ED, vital signs were within normal limits and his oxygen saturation on room air was 98% (percent). He was in no acute distress but was noted to have some basilar crackles on lung exam and pedal edema up his knees. Lab studies were within normal limits; noteworthy was serum creatinine increased from his baseline to 1.3. His B-type natriuretic peptide was elevated at 4831. Chest x-ray showed cardiomegaly, but otherwise clear. Electrocardiogram (EKG) showed first degree atrial ventricular (AV) block. 

Patient was admitted to Telemetry for heart failure. He was treated with intravenous (IV) Bumex and Metolazone. The dose of Bumex was increased to 4 milligrams (mg) twice a day (BID). He responded to medication with diuresis. He was at baseline dry weight. He was switched to oral Bumex and discharged home the next day. 

This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours. The patient had been stabilized. There was not acute coronary syndrome; cardiac enzymes and EKG did not reveal any myocardial infarction (MI). He was stable to be discharged home after a period under observation with close follow up in outpatient setting. 

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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Tacrolimus 0.1 percent (%) ointment.
The insurer denied tacrolimus 0.1 percent (%) ointment.
The determination is overturned.

This is a male patient with psoriasis. His inguinal folds and scalp are affected. The prescriber is a dermatologist. The medication under review for medical necessity is tacrolimus 0.1 percent (%) ointment. 

The requested health treatment of tacrolimus 0.1% ointment is medically necessary for this patient. While the patient does not have atopic dermatitis, the patient has psoriasis with involvement of sensitive skin sites; therefore, tacrolimus ointment use is warranted.
According to the current evidence-based dermatology literature, tacrolimus ointment is an effective treatment for the management of psoriasis (1-4).

Lebwohl et al writes "Tacrolimus ointment is effective for facial and intertriginous psoriasis" (2). Freemen et al writes "In summary, tacrolimus 0.1% ointment may be a safe and effective treatment option for patients with psoriasis on the face, intertriginous areas, or both" (3). Malecic et al writes "With regard to topical tacrolimus, two double-blind trials concluded that the effect of topical tacrolimus was significantly more potent than placebo and another trial showed that tacrolimus had statistically significant benefit over calcipotriol" (4). The evidence-based literature is consistent. Tacrolimus ointment is an appropriate agent for the treatment of the patient's psoriasis. After review of the clinical documentation, the patient has involvement of the groin which precludes the use of a potent topical steroid.