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

Diagnosis: Age Related Cognitive Decline, Constipation, Gastroesophageal Reflux Disease, Insomnia, Other Abnormalities of Gain and Mobility.
Treatment: Consumer Directed Personal Assistance Services.

The insurer denied coverage for consumer directed personal assistance services. The denial is upheld.  

This patient is an adult male, who lives alone in a two-bedroom apartment. The needs assessment noted age-related cognitive decline, constipation, gastroesophageal reflux disease, insomnia, other abnormalities of gain and mobility, pain, unspecified fracture of the skull, unspecified fracture of thoracic vertebrae, and vitamin D deficiency. His medications include Acetaminophen, Gabapentin, Omeprazole, Oxycodone, and Vitamin D. 

The assessment notes the patient denies any hospitalizations or facility admissions in the last five years. He notes that two years previous, while riding in an ambulance as a patient, the paramedics dropped him, which resulted in a skull fracture and vertebrae injuries. He did have an emergency room visit one year later due to shoulder and neck pain. He reports he has had several outpatient surgeries within the last four months for neck reconstruction, right shoulder, and two surgeries on his lumbar region. He needs help getting out of bed and going to the bathroom due to having lots of pain. He attends physical therapy three times per week. He is cognitively intact. According to the assessment, he needs maximal assistance with housework and shopping, extensive assistance with meal preparation, and supervision with bathing as his neighbor comes by as a standby for him. He is independent with personal hygiene, dressing, bed mobility, toileting, and toilet transfers. He utilizes a cane for ambulation. During the assessment, it was observed that he walked with a cane with a slightly unsteady gait while his neighbor was on standby. He was wearing a neck brace. He does shop when he is not in a lot of pain and has a delivery service bring the grocery bags into his apartment. He is continent for bladder and bowel. He has not fallen in the last 90 days preceding the assessment. 

The review of the assessment did not find the need for this patient to receive any personal assistance service hours. Consumer Directed Personal Assistance services are not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. The medical necessity for Consumer Directed Personal Assistance services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity

Treatment: Wegovy 0.25 milligram (mg) / 0.5 milliliter (ml) injection

The insurer denied coverage for Wegovy 0.25 milligram (mg) / 0.5 milliliter (ml) injection

The denial is overturned
 

The patient has obesity and a Body Mass Index (BMI) of 37. The patient's physician has documented that the patient has tried diet and exercise and has not been able to lose weight. The patient also has elevated cholesterol. Treatment with Wegovy has been advised.

Up To Date has an article titled "Obesity in Adults: Drug Therapy." The article states that a number of medications are approved by the Food and Drug Administration (FDA) for the treatment of obesity in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those with a BMI of 30 or over or a BMI over 27 with related comorbidities. Semaglutide is a glucagon like peptide 1 (GLP-1) agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction, as well as improvement in glycemia and lipids. It has also demonstrated cardiovascular benefits.

An article in the Journal of the American Medical Association (JAMA) 2021 ;325(14):1414-1425 is titled "Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity." 803 participants in this study were randomized to either continue Semaglutide or to take a placebo after 20 weeks of semaglutide treatment. Those who continued the treatment with semaglutide had ongoing weight loss, a better lipid profile, improved glucose metabolism, better blood pressure control, and physical functioning scores. The group who took the placebo regained their weight. The article states that the result of this study emphasizes the chronicity of obesity and the need for treatments that can maintain and maximize weight loss.

This patient has obesity and has not been able to lose weight with diet and exercise. Wegovy has been shown to be beneficial for treating obesity. A BMI of 37 meets the FDA criteria for giving Wegovy. 

Based on the above, the insurer's denial must be reversed. 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 Wegovy 0.25 milligram (mg) / 0.5 milliliter (ml) injection is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Comprehensive Dental Care.
Treatment: The Tooth-Colored Cap with No Metal (Crown) for Tooth Number (#) 14.

The insurer denied coverage for the tooth-colored cap with no metal (crown) for tooth # 14. The denial is overturned. 

Based on the submitted documentation, which includes copies of progress notes, dental charting, medical history, panoramic, bitewing, and periapical radiographs identifying completed endodontic therapy #14, narrative letter of support from the dentist, email correspondence, and insurer correspondence, it appears that this patient presented to the dentist for comprehensive dental care. Endodontic therapy was recommended and completed on tooth # 14 with the additional recommendation of a full coverage crown on this tooth. The insurer has denied the full coverage crown, stating that the service is not medically necessary as the documentation did not demonstrate medical need and what was provided did not meet their medical necessity criteria. The patient's father is appealing the decision.

Upon review of the clinical and radiographic documentation, these support the recommended treatment. A review of radiographs indicates successful endodontic therapy on #14. This tooth has ample coronal structure after the endodontic therapy for crown support and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be the placement of crowns on endodontically treated teeth, which would have an excellent long-term prognosis with the recommended treatment. As the clinical and radiographic findings support the recommended treatment, the full coverage crown on tooth #14 is considered medically necessary. 

Reverse denial and approve coverage for a tooth-colored cap with no metal (crown) for tooth #14 as medically necessary, as the clinical and radiographic documentation supports this service. The service would be a standard of care in general dental practice.

The tooth-colored cap with no metal (crown) for tooth #14 is considered medically necessary for this patient. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, and in the patient's best interest. 

The medical necessity for the tooth-colored cap with no metal (crown) for tooth # 14 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces, Retainer and Monthly Visit
The insurer denied: Braces, Retainer and Monthly Visit
The denial is overturned.

The patient is a teenage male. The request is for orthodontic benefits with monthly visits and a retainer. The patient has Class II canine malocclusion with moderate upper and lower crowding, as well as a deep bite. The health plan denied coverage of the request due to the patient having a handicapping index scale score of 13 points. The denial is being appealed.

The requested Braces, Retainer and Monthly Visit are medically necessary.

The patient has a crossbite of an anterior tooth with gingival attachment loss and recession of the gingival margin on tooth #27 (lower right canine). This is an automatic qualifier according to the handicapping index scale. The monthly visits are needed to make sure the treatment is progressing properly, and the retainer is needed to prevent relapse at the end of treatment. This case has medical necessity, and orthodontic treatment is needed to correct the problem.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: peripheral arterial disease
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female with a past medical history of hypertension, hyperlipidemia, non-insulin-dependent diabetes mellitus, rheumatoid arthritis, coronary artery disease post-multiple percutaneous coronary interventions, gastroesophageal reflux disease, emphysema/chronic obstructive pulmonary disease, hypothyroidism, gastrointestinal bleed, anemia, right breast cancer post-lumpectomy, chemotherapy, and radiation therapy, cerebrovascular accident with no residual deficits, chronic diastolic heart failure, former smoker, and history of arteriovenous malformations, who presented with bilateral lower extremity claudication, more pronounced on the left side.

The inpatient hospital stay was not medically necessary for this patient. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
This patient presented for an elective procedure due to suspicion for peripheral arterial disease. There were no indications that the patient had acute ischemia in the limb. There was no evidence of hemodynamic instability following the procedure. The elective procedure was done without major complications, and the patient was discharged from the hospital the next day after a short period of observation.
Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The vascular procedure she underwent during the hospital stay did not require admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary Embolism, Deep Vein Thrombosis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied inpatient hospital stay. The determination is overturned. 

The patient is a male who presented with concerns for worsening severe leg pain and shortness of breath. Pertinent history included prostate cancer, chronic diastolic heart failure, valvular disease, and hypertension. Initial examination documented the patient as alert and oriented, with left lower extremity swelling. An electrocardiogram (EKG) did not reveal acute ischemic changes. A Duplex ultrasound revealed a left popliteal deep vein thrombosis. A computed tomography (CT) angiogram of the chest revealed multiple pulmonary emboli, including a large right pulmonary embolus. The main pulmonary artery was dilated, which can be seen in the setting of pulmonary hypertension and/or right heart strain. Therapeutic Lovenox was initiated. The admitting physician documented an impression of pulmonary embolism and deep vein thrombosis. Therapeutic anticoagulation was continued, and an echocardiogram was pursued. The patient was transferred to another hospital facility. At issue is the medical necessity of an inpatient stay. 

Based on the clinical documentation provided, evidence-based literature, and standards of care, acute inpatient level of care was medically necessary for the entire admission.
This patient had a history of active prostate cancer and presented with left lower leg swelling and shortness of breath. Initial evaluation found the patient to have tachycardia and a left popliteal deep vein thrombosis. A CT angiogram of the chest was pursued, which revealed multiple pulmonary emboli, including a large right pulmonary embolus. The main pulmonary artery was dilated, which can be seen in the setting of pulmonary hypertension and/or right heart strain. Therapeutic enoxaparin was initiated, and an echocardiogram was pursued. The patient was transferred on the day of admission. The clinical indications for admission to inpatient care were met. The patient presented with multiple pulmonary emboli in the setting of active cancer and was found to have a vital sign abnormality (tachycardia) as well as concerns for right ventricular strain seen on the CT angiogram.[2]
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: hyperglycemia
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

This is the case of a male with DM1 (type I diabetes mellitus) who presented to the emergency department (ED) due to fatigue, polyuria, and hyperglycemia due to running out of insulin at home. He has history of multiple admissions for diabetic ketoacidosis (DKA). The most recent HgbA1C (hemoglobin A1C) was 14.2. The review of symptoms (ROS) was positive for fatigue and polyuria.

Based on the medical records provided, the inpatient hospital admission was not medically necessary for this patient. Based on the medical documentation provided, this known T1 (type I) diabetic patient presented to the ED with hyperglycemia. He had glycosuria with only trace ketones, normal blood gas and electrolytes, and normal BOHB (Beta-hydroxybutyrate). He had stable vital signs and normal mentation. Thus, his condition could have safely and appropriately been managed at a lower level of care with transition to home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing tooth
Treatment: D7951 Sinus Augmentation, Upper Right Quadrant
The insurer denied D7951 Sinus Augmentation, Upper Right Quadrant.
The denial is overturned.

This patient is an adult male requesting benefits for sinus augmentation (D7951) in the right upper quadrant in preparation for an implant placement where tooth (number) #3 was. The prior denial was due to being denied implant benefits.

The requested health service is medically necessary.

The patient has cheek biting issues due to a missing tooth (#3, upper right first molar). The lack of a tooth there causes his cheek to collapse into his teeth and get pinched. The patient also cannot wear his oral appliance for sleep apnea due to the missing tooth. An implant placed in the area of the missing tooth #3 is appropriate. However, before the implant can be placed, the upper right sinus augmentation needs to be done to allow enough boney support for the already approved implant. Without the sinus surgery, the implant cannot be placed, and the patient's problems cannot be corrected. The sinus augmentation is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glaucoma. 
Treatment: Zerviate 0.24 percent (%) Eye Drop. 
The insurer denied: Zerviate 0.24% Eye Drop. 
The denial is overturned. 

The patient is an adult female. She has a history of glaucoma, for which she underwent micropulse therapy. The health plan's denial of Zerviate (cetirizine ophthalmic solution) is being appealed. Four months ago, the patient's visual acuities were 20/20 in the right eye and 20/30 in the left eye. Exam showed trace to 1+ inferior papillae in both eyes. The patient was noted to be intolerant to timolol, brimonidine, Zioptan, travoprost, latanoprost, Vyzulta, Zioptan, and Xelpros. Two months ago, the patient presented for post-operative exam after micropulse in the left eye. Visual acuities were 20/20 in the right eye and 20/40 in the left eye. Last month, the patient's visual acuities were 20/20 in the right eye and 20/25 in the left eye. Exam showed conjunctival papillae and trace superficial punctate keratitis in both eyes. There was severe optic cupping and thin neuroretinal rim in both eyes. Diagnoses of allergic conjunctivitis and primary open angle glaucoma were noted. In a letter, the request for Zerviate was denied coverage by the health plan, because the patient has not tried and failed or has intolerance or contraindication to generic olopatadine drops. In another letter, the patient's provider stated that the patient is allergic to all preservative medications, and Zerviate is the one medication that does not contain preservatives. 

The requested Zerviate is medically necessary. 

The patient is allergic to preservative drops and the formulary alternatives contain preservatives. Thus, the Zerviate drop, which is an eyedrop that the patient tolerates, is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Foot Cellulitis. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission.  The denial is overturned. 

The patient has a past medical history significant for diabetes mellitus, Methicillin-resistant staphylococcus aureus (MRSA) infection, status-post right below the knee amputation, and recurrent left foot cellulitis, who presented to the emergency department with complaints of left foot pain. 

Vitals on presentation included: Temperature (T) 101.3 (degrees) Fahrenheit (F), blood pressure (BP) 113/60, pulse (P) 104, respiratory rate (RR) 18, oxygen (O2) saturation 99% (percent) on room air (RA). Laboratory results included the following: white blood cell (WBC) count 10.7, hemoglobin (Hgb) 13.2, hematocrit (Hct) 40.6, creatinine 1.08, glucose 134, C-reactive protein (CRP) 5, and urine toxicology positive for cocaine. 

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and ceftriaxone) for possible foot cellulitis. An X-ray of the foot was negative for fracture or injury, and there were no erosive changes to suggest osteomyelitis. Podiatry and Infectious Diseases were consulted. Antibiotics were adjusted due to multiple allergies. Cultures from the wound grew methicillin-sensitive staphylococcus aureus (MSSA). A computed tomography (CT) scan was negative for osteomyelitis. The patient remained afebrile, hemodynamically, and clinically stable. The patient was discharged to continue oral antibiotics (Linezolid) as an outpatient. 

According to documentation, patient was referred by Podiatry for worsening left foot pain despite oral antibiotics. On presentation, patient was febrile (T - 101.3 F), had tachycardia (heart rate 104) and laboratory results showed an elevated WBC (10.7). Wound cultures grew MSSA. Based on above findings in a high-risk patient with documented failure of outpatient intervention, hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation. 

Based on the above, the insurer's denial must be reversed. 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 a full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment: Personal Care Aide (PCA) Services: 24 Hours per Day, 7 Days per Week - Split Shift 
The insurer denied Personal Care Aide (PCA) Services: 24 Hours per Day, 7 Days per Week - Split Shift.
The health plan's determination is overturned.

This is a case review for a male with a medical history notable for dementia, diabetes, and coronary disease. The patient and his care team requested an increase to 24-hour per day, 7 days per week, split-shift personal care.
The patient's physician provided a letter of support for this appeal. The letter describes the patient's current medical conditions, which include a history of cerebrovascular accident, coronary artery disease status post-intervention, dementia, type 2 diabetes on insulin, atrial fibrillation on anticoagulation, heart failure with reduced ejection fraction, and a history of decubitus ulcer. The patient's wife to this point has provided the patient's overnight care. Unfortunately, the patient's wife has medical issues of her own and is no longer physically able to provide the assistance that the patient requires at night. The patient requires assistance with toileting at unscheduled times, including management of incontinence care. He requires assistance with turning and repositioning in bed throughout both the day and night. Given his complex care needs, the physician states that split-shift personal care is necessary for the patient.

The requested health service of Personal Care Aide (PCA) Services: 24 Hours per Day, 7 Days per Week - Split Shift is medically necessary for this patient.

The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, the question at hand is whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.
The documentation provided demonstrates that the patient has personal care needs which are of a frequent and unscheduled nature and would preclude adequate rest from a live-in personal care aide. He requires assistance with frequent toileting and after episodes of incontinence care. His condition appears worse, as outlined by the physician notes and in the assessment. He is only poorly able to direct his own care and will require frequent overnight assistance with these personal care needs to prevent the recurrence of decubitus ulcers or other adverse outcomes. Therefore, the requested increase in personal care hours is medically necessary for the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Alopecia areata and atopic dermatitis

Treatment: Opzelura 1.5 percent (%) Cream

The insurer denied coverage for Opzelura 1.5% Cream

The denial is overturned

The patient has a diagnosis of alopecia areata of the scalp and atopic dermatitis.  The patient has failed therapy with clobetasol, hydrocortisone, triamcinolone, and ketoconazole.  The request is for a formulary exception to continue the use of Opzelura topical cream. 

Based on the submitted documentation, the use of Opzelura is medically necessary.  The patient has failed topical steroids, and requires topical therapy to avoid the need for systemic treatments.  Systemic JAK (Janus kinase)/signal transducer and activator of transcription (STAT) inhibitors are Food and Drug Administration (FDA) approved for the use of alopecia areata and the use of a topical JAK/STAT inhibitor such as Opzelura is reasonable for the treatment of the patient's scalp alopecia areata.  The patient has failed numerous topical steroids of varying strengths.  Opzelura is FDA approved for topical treatment of atopic dermatitis and may have benefit in treating alopecia areata.  The request is reversed based on the standard of care and the submitted documentation.  

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Opzelura 1.5% Cream is reversed.