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

Diagnosis: Gender dysphoria
Treatment: Blepharoplasty and brow ptosis repair (codes 67900, 15823, 15820)
The insurer denied coverage for blepharoplasty and brow ptosis repair (codes 67900, 15823, 15820).
The denial is overturned.

The insurer has denied coverage for blepharoplasty and brow ptosis repair (codes 67900, 15823, 15820) as not medically necessary. In their Final Adverse Determination letter, they write that the patient does not meet the criteria for eye correction for gender reaffirmation. The patient's documentation does not indicate recent documentation from a mental health provider with whom the patient has had an ongoing relationship with and who can speak to her current impact and functional implications of her gender dysphoria. 

In this case, there is evidence of a multidisciplinary approach that includes mental health and medical professionals that have been involved in the decision-making process. The patient's therapists and surgeon recommend facial feminization surgery as a key component of treatment for gender dysphoria. In addition, there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated). The patient has lived as a female for years and has been on hormone therapy for years. This patient has anxiety and dysphoria that her mental health providers attribute to the incongruence of her facial appearance with her assigned sex. A study by Ainsworth et al found improved mental health functioning for transgender women following facial feminization surgery (FFS). Her condition represents a unique clinical situation in which facial feminization is indicated. A systematic literature review on facial feminization by Morrison et al concluded: "based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients." Her condition represents a unique clinical situation in which facial feminization is indicated.  A systematic literature review on facial feminization by Morrison et al concluded: "Based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients."  A recent study by Chou et al concluded: "FFS improves self-perceived and externally perceived facial femininity and reduces limitations in social and professional activities." These procedures are necessary to treat the patient's unique clinical situation of disabling dysphoria related to the incongruence of her facial appearance as documented in the notes and letters from her treating mental health providers. The insurer did not act reasonably. The requested procedures are medically necessary.

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

The insurer's denial of coverage for blepharoplasty and brow ptosis repair (codes 67900, 15823, 15820) is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Rhinitis

Treatment: Current Procedural Terminology (CPT) 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures].

The insurer denied coverage for Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures].

The denial is overturned

According to the medical records, the patient is an adult with a history of chronic rhinitis. The patient had associated nasal obstruction on both sides, right worse than left and rhinorrhea (clear) was noted. The patient had used Flonase for one year and it did not help. The patient was noted to have failed medical management with fluticasone and azelastine sprays. The patient underwent intranasal destruction of intranasal lesion via cryotherapy (ClariFix).  

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. The ClariFix device has been shown in scientific studies to have long-lasting results in the treatment of chronic rhinorrhea.  

"Conclusions: Cryotherapy significantly and clinically improves rhinitis symptoms and quality of life with outcomes that are durable through 24 months after treatment" (Ow, R. A. et al. 2021).

"Conclusion: Cryotherapy is superior to a sham procedure for improving chronic rhinitis symptoms and patient quality of life" (Del Signore, A. G. et al. 2022).
Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures] performed is the best available treatment for this patient at this time. The code used with ClariFix was used for billing purposes. 
  
The adverse risks are increased over standard treatment/services. The most common side effects are epistaxis and nasal swelling. 

The patient has failed medical management, so in-office procedure with the ClariFix device is indicated as next step in treatment. 

The carrier's denial of Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures] performed should be overturned. It is more beneficial than any other standard treatments.

In summary, the denial of procedure code 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures] and coverage for the requested treatment should be overturned This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Rhinitis

Treatment: Current Procedural Terminology (CPT) 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures].

The insurer denied coverage for Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures].

The denial is overturned

According to the medical records, the patient is an adult who presented with chronic rhinitis. The diagnosis was made, and the patient failed Flonase and Azelastine with no relief of symptoms. The patient underwent ClariFix for treatment of the chronic rhinitis and not for swell body reduction.

Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures] performed needs final approval from the appropriate regulatory bodies for this diagnosis. This procedure, though, was not used for destruction of the swell body - it was used for its intended Food and Drug Administration (FDA) purpose of ablation of chronic rhinitis. 

The patient is a good candidate for the listed procedure. The device was not utilized to destroy the septal swell body. Instead, it was used for the treatment of chronic rhinitis by ablation of the posterior septal nerves which contribute to the condition.

Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures] performed is the best available treatment for this patient at this time. It is approved by the FDA for usage of reduction of chronic rhinitis secondary to posterior septal nerve over activity.  The adverse risks are not increased over standard treatment. Flonase and Azelastine were trialed unsuccessfully. This treatment is the next best option with supported evidence.

The ClariFix device was FDA approved for the treatment of chronic rhinitis but not septal swell body reduction. The clinical documentation provided supports that this device was used properly. The patient trialed medications first and the device was used appropriately. There is no other effective option for treatment at this time. The usage is supported by the literature as described above. 

In summary, the denial of procedure code 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures] and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.

The carrier's denial of Current Procedural Terminology 30117 [Excision or destruction (e.g., laser), intranasal lesion; internal approach] with modifier 51 [Multiple Procedures] performed should be overturned. It is more beneficial than any other standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Filamentary Keratitis, Right Eye.
Treatment:  Acthar GEL 80UNIT/ML (milliliter). 

The insurer denied Acthar GEL 80UNIT/ML. The health plan's determination is overturned in whole.

This is a patient with a history of filamentary keratitis. She is currently being treated with Prednisolone Acetate every 2 hours. The patient has persistent inflammation and is developing a cataract due to steroid therapy. The patient is also being treated with Restasis. The patient has a history of a corneal graft for keratoconnus with a history of graft rejection. The treating physician is petitioning the use of Acthar Gel for the treatment of her filamentary keratitis. In the treating physician's experience, Acthar Gel has shown positive outcomes.

Acthar Gel would be considered a medically necessary in treatment of this patient's current eye disease. Acthar Gel is a reasonable choice for the treatment of filamentary keratitis when other therapy such as Prednisolone (Steroid) eye drops and Restasis failed to control the disease. Side effects of steroid treatment is leading to cataract formation as well in this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease, congestive heart failure and left cerebral vascular accident with right side weakness
Treatment: Home care/Personal Care HHC (home health care)- Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift)
The insurer denied coverage for home care/Personal Care HHC- Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift)	
The denial is upheld

This is a patient with chronic medical problems including Parkinson's disease, congestive heart failure and left cerebral vascular accident with right side weakness. The patient is currently approved by the insurer for PCS (Personal Care Service) 24 hours live-in and is requesting home care/Personal Care HHC- Level 2 PCS, per 15 minutes increase to 24 hours per day (split shift); which is currently under review.

According to the Uniform Assessment System (UAS), the patient's cognition is described as "modified independent." She is able to state an emergency plan and dial 911. The patient requires maximal assistance for bathing, personal hygiene and upper body dressing. She is totally dependent for lower body dressing and toilet use. The patient is incontinent of bowel and bladder. She is independent with eating, requires extensive assistance for bed mobility and is non-ambulatory. There has been no significant functional decline compared another UAS report. The patient's functional impairments support the medical necessity of the currently approved 24 hours live-in PCS. Her condition and functional needs are not at a level or unpredictable as to require the requested Level 2 Personal Care Services increase to 24 hours per day (split shift). This physician would agree the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the currently approved PCS 24 hours/day live-in.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).

From a physical medicine and rehabilitation perspective, the requested home care/Personal Care HHC- Level 2 PCS increase to 24 hours per day (split shift) is not medically necessary.

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 home care/Personal Care HHC- Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic neurodermatitis

Treatment: Cibinqo

The insurer denied coverage for Cibinqo.

The denial is upheld.

The is a patient with a diagnosis of "atopic neurodermatitis." The patient is currently on ruxolitinib 1.5% (percent) cream as well as triamcinolone. There is no documentation provided of prior failed medications and no documentation of any possible contraindications or lab abnormalities. The requested medication is Cibinqo tablet.

Based on the provided documentation, Cibinqo is not medically necessary. There is minimal documentation provided regarding the patient symptoms leading to a diagnosis of "atopic neurodermatitis" and no documentation of previously attempted medications to treat the patient. The documentation indicates that the patient is being referred to dermatology for further evaluation. As such, it would appear from the provided documentation that the patient's diagnosis and work-up is in progress. The appeal is denied.  

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

The insurer's denial of coverage for Cibinqo is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Anal Cancer
Treatment: Sucralfate Suspension
The insurer denied Sucralfate Suspension.
The denial is upheld. 

This is a female patient with anal cancer. The patient has chemoradiation planned. The patient is stated to have developed severe oral mucositis; sucralfate suspension has been recommended.

At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The health plan's determination is upheld in whole.

The formulary drug (sucralfate tablet) would be as effective as the non-formulary drug (sucralfate suspension).

There is no evidence that the patient has tried a sucralfate tablet nor that it has been ineffective. The authors of UpToDate note "...Randomized, placebo-controlled trials have failed to confirm a consistent prophylactic benefit for sucralfate." Further, updated guidelines from the Multinational Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO) specifically recommend against the use of sucralfate to treat oral mucositis in patients with a solid cancer receiving cytotoxic chemotherapy, and consider the evidence to be insufficient to prompt a recommendation for any other form of treatment. Similarly, this approach is not recommended by the National Comprehensive Cancer Network (NCCN). As there is no evidence in the documentation, that the patient has tried the formulary alternative, the non-formulary drug would not be more effective.

Therefore, the formulary drug would be as effective as the non-formulary drug.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, stroke, heart failure, diabetes,
hypertension, chronic kidney disease, and incontinence
Treatment: Personal Care Services 24 Hours A Day 7 Days A Week (split shift) For A Total of 168 Hours a Week
The insurer denied the Personal Care Services 24 Hours A Day 7 Days A Week (split shift) For A Total of 168 Hours a Week.  
The denial is overturned.


The requested Personal Care Services 24 Hours A Day 7 Days A Week (split shift) For A Total of 168 Hours a Week is medically necessary.
The patient is a female. Her conditions include dementia, stroke, heart failure, diabetes, hypertension, chronic kidney disease, and incontinence. Denial of personal care services 24 hours a day 7 days a week (split shift), for a total of 168 hours a week, is being appealed. The health plan approved PCS (personal care service) 24 hours a day 7 days a week (live in) for a total of 91 hours a week.
A letter from the patient's provider notes that the patient has chronic medical conditions and needs assistance with ADLs (activities of daily living) both day and night. This includes assistance with toileting, turning/repositioning and hydration/nutrition. Progress note shows the patient is homebound. She is always in bed. She requires frequent diaper change, resulting in aide not getting 5 hours of uninterrupted sleep.
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. Denial of personal care services (PCS) 24 hours a day 7 days a week (split shift) for a total of 168 hours a week is being appealed. The health plan approved PCS (personal care service) 24 hours a day 7 days a week (live in) for a total of 91 hours a week. 
This patient has multiple chronic conditions. The appeal statement and medical records show that the patient is mostly bedbound. She has urinary and fecal incontinence. In addition to needing assistance with ADLs (activities of daily living), the patient needs frequent assistance with toileting and repositioning/turning. Records show that the patient's needs do not allow the aide to get 5 hours of uninterrupted sleep. Due to the patient's continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift, the requested PCS (personal care service) 24 hours a day 7 days a week (split shift) for a total of 168 hours a week is medically necessary.
The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nystagmus
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female who was admitted for worsening nystagmus who presented to emergency room for dizziness, fatigue and tinnitus. On neurological examination, she was found to have nystagmus as well as upper motor neuron signs in both upper and lower extremities and ataxic gait. The patient was admitted for neurological workup. The inpatient stay was denied as it was deemed not medically necessary.

The proposed inpatient hospital admission was medically necessary.
The patient had what was considered severe neurological symptoms that were corroborated by deficits in the neurological examination. According to the Milliman Care Guidelines (MCG), 25th edition guidelines for neurology, inpatient admission is justified with moderate to severe neurological deficits as was in this patient. In addition, given the ataxia, the patient is at high risk for fall and injury.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain, Nausea and Vomiting.
Treatment: Inpatient Hospital Admission.
The insurer denied Inpatient Hospital Admission.  
The denial is overturned.

The patient is an adult female. She presented to the emergency room with abdominal pain x 1 day, severe, associated with nausea / vomiting. The patient had been admitted two weeks previously and was treated with Rocephin and Flagyl.

The patient's CT (computed tomography) abdomen / pelvis showed a left-sided hemorrhagic ovarian cyst, mild to moderate colonic wall thickening throughout the large bowel suspicious for colitis. US (ultrasound) duplex abdomen/pelvis showed a hemorrhagic left ovarian cyst measuring 7.4 x 6.7 x 6.2 cm (centimeters).

The patient was treated with IV (intravenous) NS (normal saline) bolus and continuous IV (intravenous) fluids at 100 cc (cubic centimeters) per hour, and Toradol IV (intravenous), Reglan lV (intravenous), Flagyl IV (intravenous), Rocephin IV (intravenous), MS (morphine sulfate) IV (intravenous), and IM (intramuscular) Haldol.

The patient was to have an MRI (magnetic resonance imaging) pelvis completed, but this was not completed, as the patient left against medical advice.

The Inpatient Hospital Admission was medically necessary.

Inpatient level of care was medically necessary for management of nausea/vomiting, administration of IV (intravenous) fluids and IV (intravenous) anti-emetics, management of colitis with IV (intravenous) antibiotics, and for work up / management of the patient's acute medical issues, which included the hemorrhagic cyst and colitis. The standard of care would indicate that the patient could not have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Level 2 Personal Care Services (PCS), per 15 minutes, increase to 84 hours per week
The insurer denied coverage for Level 2 Personal Care Services (PCS), per 15 minutes, increase to 84 hours per week
The denial is overturned

This patient who has chronic medical problems including diabetes, corticobasal degeneration and hydrocephalus with a ventriculoperitoneal shunt.  She is currently approved by the insurer for PCS 63 hours/week and requesting Level 2 PCS, per 15 minutes, increase to 84 hours/week.

The Uniform Assessment System (UAS) report was reviewed.  This patients' cognitive skills are "minimally impaired."  However, according to Neuropsychological Evaluation report, the patient, "meets criteria for a dementia of moderate severity."  She requires extensive assistance for bathing, dressing, bed mobility, locomotion and toilet transfer/use.  She is occasionally incontinent of bowel and bladder.  Limited assistance is needed for personal hygiene.  Of particular concern is her poor balance and unsteady gait resulting in multiple falling episodes while performing Activities of Daily Living (ADLs) due to underlying and progressive corticobasal degeneration.  The combination of this patients' cognitive and functional decline supports an increase in PCS.  Her condition and functional needs are at a level and unpredictable as to require the requested 84 hours/week.  Additional care is also being provided by her family.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based.  

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

The insurer's denial of coverage for Level 2 Personal Care Services (PCS), per 15 minutes, increase to 84 hours per week is overturned. Medical Necessity is substantiated.