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

Diagnosis: Dementia
Treatment: Home health care
The insurer denied Personal Care Aide Level 2 Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week. The health plan's determination is overturned.

The patient is a female with past medical history of depression, atrial fibrillation with chronic anticoagulation, diabetes mellitus type 2 with insulin use, osteoporosis, spinal stenosis, osteoarthritis, dementia, urinary incontinence, bowel incontinence, gout, hyperlipidemia, and gastroesophageal reflux disease (GERD) who had been assigned PCA (personal care aide) services. There was a request to increase PCA services.

Personal Care Aide Level 2 Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week is medically necessary for this patient. 

There is documentation from the patient's neurologist and PCP (primary care provider) of worsening cognitive and physical functioning requiring assistance with all activities of daily living (ADL). Due to the patient's dementia, which is noted to be severe, the patient does not have a typical sleep-wake cycle and is up in the overnight hours, requiring assistance with eating, walking, locomotion, transfer toilet, and toileting except for the 3 to 4 hours she may sleep. The patient has 24-hour care needs and therefore a task based assessment tool should not of been utilized to calculate the patient's PCA services. The patient has unpredictable and unscheduled care needs which span a continuum of time and the insurer failed to document plan to meet these unpredictable and unscheduled care needs. The patient's care needs and disrupted sleep cycle would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient is on diuretic therapy increasing frequency of urination and is on anticoagulant medication increasing the likelihood of injury with falls. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 x 12 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Immunosuppression and eosinophilic GI (gastrointestinal) disease. 
Treatment: Dupixent Syn (syringe) 300 mg (milligrams). 

The insurer denied coverage for Dupixent Syn (syringe) 300 mg (milligrams). 

The denial is overturned. 

The patient has a history of immunosuppression and eosinophilic GI disease of the esophagus, stomach, and duodenum. He also has had surgery and chemoradiation for cancer of the anal canal. He has had dysphagia and had endoscopic biopsies showing eosinophilic infiltration. His symptoms did not respond to PPl (Proton Pump Inhibitors) therapy. Topical steroids also did not produce a histologic response. 

Healio reported in an article on June 1, 2022, that FDA (Food and Drug Administration) approval of dupilumab for eosinophilic esophagitis a "victory for rare diseases." The FDA approval was for using dupilumab for eosinophilic esophagitis in young patients. In a phase 3 trial, 60% (percent) of patients on dupilumab achieved a reduction of their eosinophil count to a normal range.  Patients also showed a 22-point average improvement in their Dysphagia Symptom Questionnaire score. This improvement continued throughout the trial. It was advised that patients who are refractory to the standard treatment with a PPI or topical steroids should consider dupilumab. 

The physician has documented that this patient failed PPI therapy and topical steroids. Since budesonide was not effective, it is appropriate to give Dupixent. The formulary drug did not cause a severe adverse reaction but was not effective. Based on the study that led to the FDA approval, it is reasonable to assume that Dupixent would be more effective in those who failed therapy with a PPI and topical steroid. 

The denial for the formulary exception for Dupixent is overturned. Case summary details
the formulary drugs are not expected to cause adverse effects. The formulary drugs were not tried. Note, formulary options were not provided. The formulary drug is not expected to be effective. 

The formulary drug is not expected to be more effective that the formulary alternatives. 
The carrier's denial of Request for Formulary Exception for Dupixent Syn 300 to treat eosinophilic GI disease is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep Apnea
Treatment: Medical Equipment (E0601x1, E0562x1) Durable Medical Equipment (CPAP)
The insurer denied the Medical Equipment (E0601x1, E0562x1) Durable Medical Equipment (CPAP).
The denial is overturned. 

The proposed treatment is medically necessary.

The patient has clinically relevant sleep apnea with disruption of sleep architecture and demonstrated clinical improvement during CPAP (continuous positive airway pressure) titration.

Her CPAP has been previously effective and is being replaced by the current order.

The patient has clinically relevant sleep apnea and her CPAP is medically necessary to control apnea and facilitate normal sleep architecture.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis. 
Treatment: Stelara SQ 90mg every 8 weeks. 

The insurer denied Stelara SQ 90mg every 8 weeks. 
The health plan's determination is overturned. 

The patient is a female with psoriasis. She has failed ciclopirox shampoo. She has also failed methotrexate, folic acid, acitretin, Otezla, Humira, Tremfya, Taltz, and Cosentyx per the appeal letter. She has also failed triamcinolone and halobetasol. She is currently taking Stelara every 12 weeks. Per the appeal letter, the provider is requesting Stelara subcutaneous (SQ) 90 milligrams (mg) every 8 weeks. 

The requested Stelara SQ 90mg every 8 weeks is medically necessary for this patient. While this dosing is not supported by the Food and Drug Administration (FDA) -recommended dosing frequency for psoriasis, which is 90mg every 12 weeks, the patient has tried and failed all other conventional treatments for psoriasis. The patient is limited with other therapies that can be trialed and therefore it is reasonable to increase the Stelara dosing to every 8 weeks. According to the "National Physician Specialty Society Recommendations" for Psoriasis- the American Academy of Dermatology Psoriasis Guidelines- and dermatology literature, Stelara is an effective treatment for the management of psoriasis. Langley et al. write "Treatment with ustekinumab for up to 5 years were safe and effective". Since the patient is responding to Stelara, and has failed all the standard-of-care treatments, Stelara is medically necessary at the requested dosing of 90mg every 8 weeks.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic medical conditions, bowel/bladder incontinence. 
Treatment: Increase Personal Care Services (per 15 minutes) to 70 Hours per Week. 

The insurer denied: Increase Personal Care Services (per 15 minutes) to 70 Hours per Week. 
The denial is overturned. 

This patient is an elderly female who has multiple chronic medical conditions (constipation, arthritis, tremor, vascular dementia, urinary/bowel incontinence).  She is appealing denial of increase personal care services to 70 hours per week.  The plan approved an increase from 45 to 56 hours per week. 

Uniform Assessment System (UAS) evaluation recently completed shows the patient has moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, bathing, personal hygiene, dressing, locomotion, ant toileting; and maximal assistance with managing medication, phone use, bed mobility and eating.  The patient is bed bound.  She is incontinent of bowel and bladder.  Compared to the prior Uniform Assessment System (UAS) evaluation, it showed a decline in managing medication, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting. 

The proposed treatment is medically necessary. 

Personal assistance services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. 

This patient has multiple chronic conditions and is bedbound.  She is appealing the denial of an increase in personal care services (per 15 minutes) to 70 hours per week.  Uniform Assessment System (UAS) evaluation recently completed shows the patient requires maximal assistance to total dependence with all activities of daily living (ADLs).  She is incontinent of bowel and bladder.  Compared to the prior Uniform Assessment System (UAS) evaluation, it showed a decline in managing medication, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting.  The information provided shows that this patient has significant limitations in functioning that have progressed between Uniform Assessment System (UAS) evaluations.  The approved personal care services 56 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living (ADLs).  The proposed increase home care/personal care personal care services (per 15 minutes) to 70 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, end stage renal disease, diabetes
Treatment: Increase Personal Care Worker (PCW) Services from 42 Hours Per Week to 63 Hours Per Week
The insurer denied the Increase Personal Care Worker (PCW) Services from 42 Hours Per Week to 63 Hours Per Week.
The denial is overturned.

This older adult female patient has medical conditions including dementia, end stage renal disease, diabetes, hypertension, anemia, and atrial fibrillation. She is appealing denial of increase in personal care worker (PCW) services from 42 hours per week to 63 hours per week.  

Uniform Assessment System evaluation performed recently showed the patient can ambulate, transfer, and use toilet with assistance. She can feed herself. She has durable medical equipment (DME) including a walker, wheelchair, grab bars, shower bench, toilet seat, and incontinence supplies. Progress reports recommends increase personal care worker  hours due to impaired functional status. The records report the patient has worsening debility. She is fully dependent. She uses a walker in the house. She lives alone.

The proposed increase in personal care worker services is medically necessary.

Personal assistance services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

This patient has multiple chronic conditions. She is appealing denial of increase in personal care worker (PCW) services from 42 hours per week to 63 hours per week.  Uniform Assessment System evaluation performed recently show the patient can ambulate, transfer, and use toilet with assistance. Physician progress report indicates the patient has worsening debility and is fully dependent. The provider has recommended an increase in personal care worker hours. Based on the progression of this patient's debility and dependence with functioning, the proposed increase in personal care worker services to 63 hours per week is medically necessary and appropriate. The approved personal care worker services at 42 hours per week is insufficient to meet the patient's needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, multiple sclerosis, and osteoporosis
Treatment: Personal care service 12 hours a day, 7 days per week, for a total of 84 hours per week
The insurer denied coverage for personal care service 12 hours a day, 7 days per week, for a total of 84 hours per week.
The denial is overturned.

This patient is an adult female with chronic medical problems including hypertension, multiple sclerosis, and osteoporosis. She lives alone in a 1-bedroom apartment. The insurer approved personal care services (PCS) 9 hours/day, 7 days/weeks totaling 63 hours/week and she is requesting an increase to 12 hours/day, 7 days/weeks totaling 84 hours/week.

According to the recent Uniform Assessment System (UAS) report, the patient is described as "alert and oriented X 3, self-directing." Her cognitive skills are "independent." The patient requires maximal assistance for bathing, lower body dressing, and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. Extensive assistance is needed for personal hygiene, upper body dressing, and bed mobility. She is "non-ambulatory due to paraplegia." 

Her significant functional impairments support the medical necessity of increasing PCS. From a physical medicine and rehabilitation perspective, the requested PCS 12 hours a day, 7 days per week, for a total of 84 hours per week is 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 personal care service 12 hours a day, 7 days per week, for a total of 84 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and monthly visits
The insurer denied coverage for braces and monthly visits.
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified an anterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case the clinical circumstance does meet insurance and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labia lingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

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 braces and monthly visits is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient had been discharged from the hospital after a cholecystectomy and presented with shortness of breath (SOB) and abdominal pain. The patient was afebrile and the vital signs were stable. The oxygen saturation was 98% (percent). The abdominal exam was benign. There was no leukocytosis. There was elevation of the liver enzymes. A computerized axial tomography (CAT) scan showed biliary dilatation. A computed tomography angiography (CTA) was negative for a pulmonary embolism. A hepatobiliary iminodiacetic acid (HIDA) scan was negative for a bile leak. No surgical interventions were required, and it was decided that an endoscopic retrograde cholangiopancreatography (ERCP) was not needed. The liver enzymes trended down. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (MCG [Milliman Care Guidelines]) include having acute cholangitis or obstruction of the bile duct. The patient did not have a bile duct obstruction or a bile leak. In addition, there was no hemodynamic instability, severe vomiting, severe pain, or bacteremia. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, or the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

This patient required a workup for the abdominal pain and elevated liver enzymes after the cholecystectomy. However, the magnetic resonance cholangiopancreatography (MRCP) and monitoring of the liver enzymes could have been done with observation status. The patient did not have a pulmonary embolism or a cardiopulmonary event. No acute interventions were required. The patient did not meet Milliman Care Guidelines (MCG) for admission for either Gallbladder or Bile Duct Inflammation or Stone or Undiagnosed Abdominal Pain; inpatient admission was not medically necessary. 

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

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

Diagnosis: Fibromyalgia
Treatment: Savella
The health plan denied: Savella
The denial is: Upheld.

The patient is a female with fibromyalgia. The issue in this case is Savella is being denied by the health plan, initially it was denied because the patient had to try Lyrica first, however the patient is already on gabapentin 300 milligrams (mg) three times a day (tid). The final denial states that the patient must try and fail gabapentin 1200 mg daily in total. The patient has failed Cymbalta. She is currently on nortriptyline. The subject under review is the medical necessity for Savella.

The health plan's determination is upheld.

The requested health service/treatment of Savella is not medically necessary for this patient. The patient cannot try Lyrica as the patient is already on gabapentin 300 mg tid. Concurrent Lyrica and gabapentin use is contraindicated. However, there is no medical reason the patient cannot increase gabapentin up to 1200 mg daily in total. In terms of gabapentin, per UpToDate, "we begin with a dose of 100 mg at bedtime before titrating the dose upwards as tolerated and as required. The usual dose is 1200 to 2400 mg/day (usually in divided doses taken up to three times daily)."  Gabapentin, and Savella have both been found to be effective in treating fibromyalgia.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented to the emergency department with concerns of elevated liver enzymes. Pertinent history included alcohol abuse with daily vodka use and hypertension. Last drink was one day prior to presentation. Initial vital signs revealed a temperature of 97.7 F(Fahrenheit), heart rate (HR) 96, blood pressure (BP) 159/105, respiratory rate (RR) 18, and SpO2 100% on room air. Initial examination documented the patient as alert and oriented. Initial laboratory testing was felt to be drawn next to the intravenous (IV) line. Repeat laboratory testing revealed a white blood cell count (WBC) 3.2, HGB (hemoglobin) 10.0, platelets (Plt) 89, Na (sodium)139, K (potassium) 2.8, Cl (chloride) 98, carbon dioxide (CO2) 23, blood urea nitrogen (BUN) < 6, Cr (creatinine) 0.7, Glucose 79, Tbil (total bilirubin) 0.7, aspartate aminotransferase (AST) 166, alanine aminotransferase (ALT) 36, and alkaline phosphatase (ALP) 73. An electrocardiogram (EKG) was relatively unremarkable. The patient was placed in the hospital thereafter with an impression of alcohol withdrawal, elevated liver function tests, thrombocytopenia, and electrolyte abnormalities. 

The inpatient hospital admission was not medically necessary. A lower level of care was appropriate.
The patient had a known history of alcohol abuse who was directed to the emergency department following outpatient laboratory abnormalities. Initial evaluation found the patient to be afebrile, hemodynamically stable, with a hypokalemia and elevated aspartate aminotransferase (AST). No tremor, diaphoresis, or mentation changes noted. No significant EKG abnormalities were noted. Treatment essentially included electrolyte replacement and a Librium taper. No other issues or complications requiring an inpatient level of care were documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: blepharoptosis
Treatment: blepharoplasty
The insurer denied blepharoplasty. T
he health plan's determination is overturned.

The patient is a female who presents for evaluation of her droopy eyelids. She feels tired and raises her eyebrows to help raise the upper eyelids. She finds it difficult to drive due to droopy eyelids. Levator function is 15 both eyes (OU), Marginal reflex distance (MRD) one is 2 millimeter (mm) OU. Visual fields demonstrate contracted superior visual field to 10 degrees which is improved to 40 degrees with eyelid tapping. Anterior and sideways facial photos demonstrate ptosis OU due to excessive eyelid skin.

Bilateral upper blepharoplasty is medically necessary for this patient.
The patient has symptomatic ptosis caused by blepharoptosis leading to the need for a blepharoplasty in both eyes. This would be the most appropriate treatment for the patient. The patient has significant visual field loss which is improved if tapping of the eyelid up is used. The photographs demonstrate blepharoptosis which is significant and an MRD 1 of 2 mm or less. The patient has difficulty driving due to loss of superior visual field as well as feeling tired.