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

Diagnosis: Oligodontia. 
Treatment: D6010, Surgical placement of implant body, endosteal implant (tooth #2, #4, #5, #6, #7, #8 #9, #10, #11, #12, #13, #18, #20, #21). 

The insurer denied coverage for D6010, surgical placement of implant body, endosteal implant (tooth #2, #4, #5, #6, #7, #8 #9, #10, #11, #12, #13, #18, #20, #21). 

The denial is upheld. 

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas as enumerated above. The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. The insurer has denied the services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. In addition, the patient already has numerous integrated endosteal implants in the maxilla and mandible which should be adequate for support of maxillary and mandibular prostheses. Further the documentation provided does not support, justify, or substantiate the requested treatment.  Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary. 

The health care plan acted reasonably and with sound medical judgement and 
the best interest of the patient. 

Uphold denial of coverage for dental implants as not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services 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 D6010, surgical placement of implant body, endosteal implant (tooth #2, #4, #5, #6, #7, #8 #9, #10, #11, #12, #13, #18, #20, #21) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Personal care assistant (PCA) level 2 hours, 4 hours per day 7 days a week for a total of 28 hours a week.
The insurer denied personal care assistant (PCA) level 2 hours, 4 hours per day 7 days a week for a total of 28 hours a week.
The determination is upheld.


The patient has a past medical history significant for dementia, osteoarthritis, and gait instability.
The patient is currently approved for 4 hours a day times () 5 days a week for a total of 20 hours a week. The services were denied based upon medical necessity. Review is for the medical necessity of personal care assistant (PCA) level 2 hours, 4 hours per day 7 days a week for a total of 28 hours a week.
The requested health service is not medically necessary for this patient. PCA hours above 20 hours a week or not medically necessary.
Additional services were requested by the patient's niece, stating that the patient's health started to decline in the last 2-3 months. The patient gets confused in regard to the days of the week. She is unsure if she took her medicine properly. Sometimes the patient will not eat full meals unless someone is preparing the meals and reminds her to eat.
Services were denied by the health plan as: Your abilities to perform physical function including dressing upper and lower body, bed mobility, meal preparation, medication management and ordinary housework status same. Many of your abilities to perform physical function, daily activity stay the same. Therefore, the hours stay the same at 4 hours per day 5 days a week for a total of 20 hours per week. Additional hours are not provided for standalone safety supervision, companionship or when aid is not performing specific task.
The Uniform Assessment System (UAS) State of New York noted a total of 20 hours a week.
Services include maximal/total assistance for food preparation, housework and other instrumental activities of daily living (IADLs). The patient is independent with locomotion, toilet use and bed mobility. The patient is infrequently incontinent
The UAS State of New York was reviewed and the physician letter dated was reviewed.
The patient's medical status according to the nurse's assessment on the UAS showed similar findings. There has not been a specific change or deterioration noted which would necessitate additional medical services. The patient is independent for ambulation and eating when food can be provided. Most of her services include IADLs such as shopping and meal preparation along with housecleaning. These needs did not specifically change and can be performed within the 20 hours a week which have been allotted for her services
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Pharmacy/Prescription Drugs
The insurer denied Ajovy for medical necessity.
The denial was overturned in whole. 

The patient is a female diagnosed with migraine headaches. Ajovy is prescribed for prevention of migraines headaches. The patient has previously tried and failed Trokendi extended release (XR) and amitriptyline. The patient was given samples of Ajovy.

At issue is the medical necessity of Ajovy 225 milligrams (MG)/1.5 milliliter (ML) subcutaneous (SC) solution auto-injector (SOAJ).

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

The requested health service treatment of Ajovy 225 MG/1.5ML SC SOAJ is medically necessary for this patient.

The patient has a diagnosis of chronic migraine. The plan denied Ajovy because the member had not tried and failed a pre-specified number of formulary alternatives. The documentation provided indicates that the patient has tried and failed amitriptyline and Trokendi.

Ajovy was prescribed for prevention of migraine. Ajovy is United States Food and Drug Administration (FDA) approved for prevention of both episodic and chronic migraine. As such, the request for Ajovy is on-label. The patient has demonstrated a trial and failure to two different classes of migraine preventative agents including antidepressants and anticonvulsants. The patient has also tried a muscle relaxant (Flexeril) and non-pharmacologic treatments with massage. It is unlikely that the formulary alternatives will be as effective as the requested medication of Ajovy. The formulary alternatives include topiramate (long acting Trokendi was already tried and failed), divalproex (which is generally contraindicated in people who menstruate), and venlafaxine (which is another antidepressant). The use of Ajovy is appropriate, in the member's best interest, and medically necessary. There are no guidelines that require multiple oral medications to be tried and failed before use of this medication.

Therefore, the requested health service treatment of Ajovy 225 MG/1.5ML SC SOAJ is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Home Health Care
The insurer denied an increase in consumer directed personal assistant services (CDPAS) from 84 hours per week to Live-In 24 hour CDPAS.
The health plan's determination is upheld.

The patient is a female with past medical history significant for Alzheimer's disease with progressive dementia, hypertension, hyperlipidemia, urinary tract infections, seizure disorder, diabetes, and hypothyroidism.

This review is for the medical necessity of an increase in consumer directed personal assistant services (CDPAS) from 84 hours per week to live-in 24-hour CDPAS. Services were denied by the health plan based upon lack of medical necessity.

The increase in CDPAS from 84 hours per week to live-in 24-hour CDPAS is not medically necessary for this patient.

Additional CDPAS service hours are not medically necessary. The 84 hours a week already being provided are sufficient to meet the patient's medical needs. Additional service hours beyond 84 hours a week or not medically necessary.

The patient is a female with multiple medical problems including Alzheimer's disease with progressive dementia including cognitive and physical disabilities. She has had noted decline from one year to the next. This is documented in the Uniform Assessment Systems (UAS) state of New York, which were reviewed. 

An appeal letter stated that the patient's daughter cannot provide care for her mother outside of her authorized CDPAS hours. It is stated that she is exhausted and needs to take care of herself and an extra hour a day of support would be helpful. Currently, CDPAS services are provided by the patient's daughter, doing 55 hours a week and another individual doing 29 hours a week.

Based upon documentation provided, the 84 hours a week of services are sufficient to meet the patient's needs. The documentation provided did not delineate additional needs that could not be met during this allotment time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fatty liver, Morbid obesity.
Treatment: Liver biopsy.
The insurer denied the Liver biopsy.
The determination is upheld.

The patient has a body mass index (BMI) of 45.62 kilograms per square meter (kg/m2),underwent laparoscopic gastric bypass and was noted to have fatty infiltration and underwent a concomitant wedge liver biopsy. Preoperative liver function tests (LFTs) or documentation of non-alcoholic steatohepatitis/nonalcoholic fatty liver disease (NASH/NAFLD) were not provided. Pathology of the subcapsular wedge biopsy revealed minimal steatosis.
At issue is the medical necessity of a liver biopsy.

The liver biopsy is not medically necessary.

There is currently a lack of any national guideline from the American Society for Metabolic and Bariatric Surgery (ASMBS) or large high level prospective trial or randomized controlled trial (RCT) documenting any benefit from routine liver biopsy during bariatric surgery. In general, many individuals who undergo bariatric surgery may have a suggestion of some degree of steatosis of the liver, observed intraoperatively, however, it is also well understood and documented in numerous publications that bariatric surgery and weight loss improves NASH/NAFLD. There is no clear outcomes benefit to perform a liver biopsy in patients with normal synthetic liver function tests (LFTs) or who do not carry a clinical diagnosis of NASH as most patients will not undergo subsequent re-biopsy of the liver to actually document improvement/progression. There is no documentation that this patient had preoperative evidence of clinically concerning LFTs, or prior clinical history of NASH/NAFLD.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-Obesity. 
Treatment: Surgical Services-Liver Biopsy during gastric bypass. 

The health plan denied the Liver Biopsy as not medically necessary. The reviewer has upheld in whole the health plan's determination. 

The patient underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy) performed on. The records support that she had a body mass index (BMI) of 46.9 kilograms per meters squared (kg/m2). The operative dictation states that the surgeon noted a fatty liver with hepatomegaly and nodular changes. He obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging, or clinical data to indicate liver pathology. The pathology report provides the diagnosis of moderate steatosis. 

The provider submitted current procedural terminology (CPT) code 47100 (liver biopsy, wedge). The  denial of coverage for liver biopsy per the letter is that there is no documentation of objective signs or symptoms of liver disease to warrant liver biopsy. Per this letter guidelines on the use of liver biopsy in clinical practice do not mention routine biopsy of the liver with bariatric surgery. The claim form indicates that the provider submitted CPT code 47379 (unlisted lap procedure liver). 

The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of roux en Y gastric bypass performed. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy. 

According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery.[1] Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy. 

In this case the patient is morbidly obese with a body mass index of 46.9 kg/m2. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology. Furthermore, if liver biopsy is deemed necessary by the treating surgeon, this can be accomplished by tru-cut needle biopsy (CPT 47000) and does not require a wedge liver biopsy (CPT 47379 or 47100). [1.2,3] 

Accepted indications for liver biopsy include documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy (47379 liver biopsy, wedge, or CPT 47100). Routine liver biopsy is not an accepted or standard aspect of bariatric surgery.[1]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Areata

Treatment: Xeljanz, 10 milligrams

The insurer denied coverage for Xeljanz, 10 milligrams

The denial is overturned.

The patient has a diagnosis of alopecia areata.  The patient has been successfully treated with oral Xeljanz without complication and with improvement.  The patient has previously failed therapy with oral minoxidil and dexamethasone as well as topical agents.  The requested medication is continuation of Xeljanz.  

The patient would currently be stable with his prescribed regimen had he not decreased his dose to conserve medication.  It would be medically inappropriate to deny coverage for a therapy shown in studies to improve the patient's condition following successful therapy having failed numerous topical and oral alternatives.  The patient was successfully treated without any adverse effects noted with oral Xeljanz.  The use of Xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment. 

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

Based on the above, the medical necessity for the Xeljanz 10 milligrams is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Small for Gestational Age (SGA).
Treatment: Norditropin Flexpro Injectable.

The insurer denied coverage for Norditropin Flexpro Injectable.  The denial is upheld.

This is the case of a child with a history of small for gestational age (SGA) and intrauterine growth restriction. The patient was one of a triplet birth born at less than 5 pounds. The patient was seen by Pediatric Endocrinology, for a follow up consultation regarding growth.
	
Growth hormone (GH) for the treatment of children who are small for gestational age (SGA) and who fail to exhibit catch-up growth is standard of care. This indication has approval from the FDA (Food and Drug Administration) [1] support from consensus guidelines [2-4] and randomized controlled trial evidence to support its use [5-9]. The most recent and most relevant consensus guidelines are those of the combined meeting of the International Societies of Pediatric Endocrinology and the Growth Hormone Research Society [2]. Here it is recommended that if a patient fails to exhibit catch-up growth by either two or four years, that GH therapy be initiated. At age four years this is defined as <2SD [standard deviations]. The diagnosis of SGA is made at birth. The diagnosis of SGA with failure to catch up is made after a growth point at age two. This diagnosis can be made at any time after age two assuming that the patient has not had catch up growth to above -2SD. For example, if a patient is found at age eight and still has still not caught up, then that patient would qualify for the SGA indication. 

The patient caught up to a height taller than -2 SD. The patient therefore does not meet criteria for the SGA indication.

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the Norditropin Flexpro Injectable is not substantiated. The insurer's denial is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Uncontrolled and labile hypertension
Treatment: Formulary exception for EXFORGE HCT 320-25 TAB
The insurer denied the Formulary exception for EXFORGE HCT 320-25 TAB.
The denial is upheld.

The patient is a male. He was referred for EXFORGE HCT (hydrochlorothiazide) 320-25 as a formulary exception for management of his hypertension. His PMH (past medical history) is remarkable for hypertension treated with losartan, losartan HCTZ (hydrochlorothiazide) and amlodipine. The request for coverage has been denied and the decision is being appealed.

Based on the current medical literature, the request should not be approved for this patient.

There is no submitted information that only EXFORGE HCT (Hydrochlorothiazide) 320-25 can treat this patient's hypertension to establish that it is medically necessary for this patient. A number of clinical trials have shown that blood pressure control is the most important determinant of benefit from antihypertensives. At the same level of blood pressure control, most antihypertensives provide the same level of cardiovascular benefit and not the choice of antihypertensive drug. There is insufficient evidence that EXFORGE HCT (Hydrochlorothiazide) 320-25 is more effective than the other formulary antihypertensive choices available to the patient, which have published and time-proven efficacy and safety for his medical condition. Therefore, the request is not medically necessary, based on the submitted information and the current published medical literature evidence-based standards.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other Sleep Apnea

Treatment: Oral device

The insurer denied coverage for oral device.

The denial is overturned.

According to the documentation submitted, this is a female with a history of obstructive sleep apnea (OSA).  She had a sleep study analysis.  The patient's OSA was positional.  Supine apnea-hypopnea index (AHI) was 8.4/hour and non-supine apnea hypopnea AHI was 1.2/hour.  The physician recommended positioning therapy, weight loss, and an oral device for OSA.  There is no record of continuous positive airway pressure (CPAP) trial for this patient.  The physician letter states that CPAP is not indicated in this patient for unclear reasons.

Per standard of care, in general a patient should show a trial of CPAP and CPAP failure prior to consideration of oral appliance.  CPAP remains the first-line or primary therapy for the treatment of adult patients with OSA.  Oral appliance therapy should be overturned for use with mild or moderate OSA patients who did not benefit from CPAP therapy or were intolerant to CPAP.  

However, standard of care and published literature allow for patient preference, thus, even if the patient does not do a trial of CPAP, the patient can proceed with oral appliance.  It is recommended that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of therapy or prefer alternate therapy.

Thus, the insurer did not act reasonably, with sound medical judgment, or in the best interest of the patient.

Based on the above, the medical necessity for an oral device is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Bronchiolitis. 
Treatment: Inpatient hospital admission. 

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

The patient is a male with history of asthma who presented to the Emergency Department (ED) with belly breathing and tachypnea. He was noted to have upper respiratory infection (URI) symptoms for the past few days. He had been taken to an Urgent Care Center where he was discharged on albuterol and steroid inhalers. The patient did not have significant improvement with the above so was taken to the ED. His main complaints were cough and wheezing.  Vitals signs in the ED were temperature 101 Fahrenheit, heart rate (HR) 125, respiratory rate (RR) 50, blood pressure (BP) 125/67, and oxygen (O2) saturation 95% on room air (RA). The patient was in respiratory distress and noted to be tiring. He was tachypneic with intercostal retractions. Lung exam revealed bilateral wheezing. White blood cell (WBC) count was 5.2, electrolytes were within normal limits (WNL) and chest x-ray (CXR) revealed no acute infiltrates. The viral panel was positive for respiratory syncytial virus (RSV). 

The patient was admitted to the Pediatric Intensive Care Unit (PICU) for impending respiratory failure. He was treated with bronchodilators (BD) and intravenous (IV) steroids. The patient was placed on bilevel positive airway pressure (BIPAP) 10/5 with fraction of inspired oxygen (FiO2) 40%. He was found to have otitis media and placed on antibiotics. The patient slowly improved in the PICU over the next 24 hours and was weaned off BIPAP. He was transferred to the medical floor and discharged home the following day on inhalers and oral antibiotics. 

Based on patients' presentation with severe bronchiolitis and impending respiratory failure requiring PICU admission and treatment with non-invasive ventilation (NIV), it was appropriate to admit this patient to the hospital. This patient had failed outpatient management and was not safe to be treated in another less intensive setting. 

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

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