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

Diagnosis: Acute Kidney Injury

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is upheld.

The patient was admitted from skilled nursing facility (SNF) for dehydration and altered mental status. He was found to have acute kidney injury, which was improving with intravenous (IV) fluid, he was also evaluated by cardiology for elevated troponin but not require any invasive procedure and discharged.

The member was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, no documentation of refractory pain, he was able to tolerate oral diet and did not total parenteral nutrition and his condition responded to intravenous fluid and kidney function stabilized.

A lower level of care is appropriate when Oral replacement therapy is feasible for individuals with mild or moderate dehydration who can drink and have no significant dehydration-related cognitive or physical compromise.

"A randomized study of 13,347 non-critically ill adults requiring IV (4) fluid treatment in the emergency department randomized to treatment with isotonic crystalloid or normal saline found no difference in hospital-free days but found that patients treated with the isotonic crystalloids had a lower composite outcome of death, need for renal-replacement therapy, or persistent renal dysfunction than the saline-treated group."

There is no evidence-based literature to support that inpatient level of care was medical necessary and his condition could have been treated safely at a lower level of care.

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

The insurer's denial of coverage for the hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.
Treatment: Hypoglossal nerve stimulator.
The insurer denied Hypoglossal nerve stimulator.
The denial is overturned.

The patient is a female with history of significant sleep apnea.  The patient has an AHI (apnea-hypopnea index) of 32.9 which qualifies as severe OSAS (obstructive sleep apnea syndrome).  Drug induced Sleep Endoscopy shows only AP (anteroposterior) collapse without lateral wall motion. The patient has failed CPAP (continuous positive airway pressure) and oral appliances and now seeks approval for a hypoglossal nerve stimulation procedure.

Yes, the health plan should cover the requested health service.
Otolaryngology's academy's recommendations, as well as the literature, support that this procedure is the treatment of choice for OSA (obstructive sleep apnea) as seen in this patient. The patient has the appropriate diagnostic findings and has not tolerated CPAP (continuous positive airway pressure).  The procedure is not experimental/investigational. It is accepted standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.
Treatment: Hypoglossal nerve stimulator.
The insurer denied Hypoglossal nerve stimulator.
The denial is overturned.

The patient is a female. She has sleep apnea with daytime somnolence, and AHI (apnea-hypopnea index) of 32 and desaturations to 84% on polysomnogram. The patient is reported to failed CPAP (continuous positive airway pressure) therapy and also an oral appliance.

Patient had drug-induced sleep endoscopy without concentric airway collapse. She has had septoplasty and turbinectomy.

Hypoglossal nerve stimulator has been requested for further therapy.


Yes, the health plan should cover the requested health service.
For this patient, the proposed procedure is required to treat the sleep apnea, which is not controlled by more conservative measures.  It meets the standard of care and is not for the convenience of the patient.

The principal specialty in Otolaryngology  (the American Academy of Otolaryngology-Head and Neck Surgery) has examined the scientific support for hypoglossal nerve stimulator in sleep apnea and concludes the following:

The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP).  Not all adult patients are candidates for UAS (upper airway stimulation) therapy and appropriate polysomnographic, age, BMI (body mass index) and objective upper airway evaluation measures are required for proper patient selection.

This patient has had proper evaluation and meets clinical criteria for this intervention.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.
Treatment: Hypoglossal nerve stimulator.
The insurer denied Hypoglossal nerve stimulator.
The denial is overturned.

The patient is a female with a history of OSA (obstructive sleep apnea). AHI (apnea-hypopnea index) on sleep study was 32.9 with a BMI (body mass index) of 29.2. The patient could not tolerate CPAP (continuous positive airway pressure), and underwent a sleep endoscopy where there was no complete concentric collapse at the velum. There is also a history of a failed oral appliance trial. The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's OSA (obstructive sleep apnea). The request was denied as being experimental/investigational, and the provider is appealing the previous denial.

Yes, the health plan should cover the requested health service. The provider is requesting placement of a hypoglossal nerve stimulator to treat the patient's OSA (obstructive sleep apnea). There is support in the literature for the efficacy of the Inspire hypoglossal nerve stimulator for the treatment of a subset of patients with OSA (obstructive sleep apnea) who have failed, or cannot tolerate, CPAP (continuous positive airway pressure) therapy. A prospective multi-center study documented a reduction of AHI (apnea-hypopnea index) out to 12 months. In addition, there was a randomized, controlled withdrawal arm of the study which reported AHI (apnea-hypopnea index) reduction out to 18 months. Therefore, based on current scientific literature, scientific evidence would support the efficacy of upper airway stimulation therapy with a hypoglossal nerve stimulator for a subset of patients with OSA (obstructive sleep apnea) who meet FDA (United States Food and Drug Administration) criteria for the procedure.

In this particular case, the patient would meet FDA (United States Food and Drug Administration) criteria for the device in terms of BMI (body mass index), age, AHI (apnea-hypopnea index) and sleep endoscopy findings (there was no complete concentric collapse on sleep endoscopy). The patient has had a previous septoplasty and turbinate surgery, as well as an oral appliance trial, which did not eliminate the symptoms. There was also a reported failed CPAP (continuous positive airway pressure) trial. There would be no contraindications to the procedure based on the information provided. Therefore, based on the information provided, the medical appropriateness of the requested service would be confirmed, and the health plan should cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hidradenitis suppurativa
Treatment: Humira 80 milligrams/0.8 milliliters (Pre-Service)
The insurer denied the Humira 80 milligrams/0.8 milliliters (Pre-Service).
The denial is upheld.

The patient is a man with hidradenitis suppurativa, Hurley stage III, for whom Humira injections 80 milligrams per week are requested. He has tried and failed infliximab infusions 10 milligrams per kilogram every four weeks (anaphylaxis), intravenous (IV) ertapenem 1 gram daily for 12 weeks, finasteride 5 milligrams daily, various oral antibiotics and intralesional Kenalog (ILK) injections.

No, the proposed Humira injections 80 milligrams per week are not medically necessary.
The requested treatment schedule (dosage) is not standard and there is no documentation that explains the request for non-standard dosing in this patient. The recommended Food and Drug Administration (FDA) approved dosing schedule for moderate to severe hidradenitis suppurativa is 
1) Initial dose (Day 1): 160 milligrams (given as four 40 milligram injections on Day 1 or as two 40 milligrams injections per day on Days 1 and 2).
2) Second dose two weeks later (Day 15): 80 milligrams (two 40 milligram injections in one day).
3) Third (Day 29) and subsequent doses: 40 milligrams every week or 80 milligrams every other week. 

The request is for 80 milligrams weekly, which is not the standard dosage.

The patient has never used Humira and there is no documentation that he is resistant to the standard dosing schedule.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headaches. 
Treatment: Ajovy. 

The insurer denied coverage for Ajovy. 

The denial is overturned. 

This case involves a teenaged female who has been recommended to utilize the requested Ajovy due to ongoing headaches. The documentation indicated she has had a trial and failure of amitriptyline/nortriptyline, propanolol, topiramate, Zoloft, venlafaxine, and birth control.  The documentation indicated she has utilized the requested medication previously which was very effective within a couple of doses.  The physician indicated the Botox would be the only other choice; however, it is off label.  The physician argues the requested medication is appropriate for the patient given she is five foot six inches tall weighing 155 pounds.  The main complaint was visual disturbances.  The documentation indicated since her prior visit she has had a mild concussion without loss of consciousness approximately 2 weeks prior.  She according to the physician did not have any significant abnormalities.  She was alert and oriented and it is noted she continued to be well controlled on the requested Ajovy.  The recommendation was made to continue use of medications. 

Up to Date has a section dealing with treatment of migraine in children/adolescents. They state that "For children of any age, many pediatric headache specialists will offer amitriptyline, topiramate, or propranolol. However, there are few high-quality pediatric data to guide us as to the most efficacious or safest choice of pharmacologic therapy in children." Note that this patient has failed the noted choices. They go on to state that "Botulinum toxin therapy, injectable calcitonin gene-related peptide (CGRP) antagonists, and portable neurostimulation devices are alternatives for the acute and preventive treatment of migraine when oral medications fail or result in significant adverse effects." 

Finally, a very recent study by Greene et al, albeit retrospective, found that anti CGRP medications were effective in patients with migraine resistant to a host of various treatment regimens in upwards of 30% (percent) of the patients. They concluded in their study of 112 adolescents that "Side effects with calcitonin gene-related peptide monoclonal antibody treatment in adolescents were similar to those reported in adult trials. Calcitonin gene-related peptide monoclonal antibody treatment appears to benefit a proportion of adolescents with chronic refractory headache disorders." 

This patient as the notes indicate is well developed with a long history of migraine resistant to essentially all conventional approaches to treatment. The records also show that with Ajovy she has had a consistent and ongoing improvement in her symptoms with no recorded complications. 

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 Ajovy is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus, Essential Tremor, Acute Embolism and Deep Vein Thrombosis (DVT), Immunosuppressed Status.

Treatment personal care aide (PCA) services, 49 hours per week.

The insurer denied coverage for personal care aide (PCA) services, 49 hours per week.

The denial is upheld.

The patient has a history of osteoarthritis, diabetes mellitus, essential tremor, acute embolism and deep vein thrombosis (DVT), immunosuppressed status, hypertension, gastro-esophageal reflux disease and cancer, currently receiving radiation therapy. Per Uniform Assessment System (UAS) - New York Comprehensive Community Health Assessment Report, the patient was re-assessed due to a significant change in status. The patient lives alone on the 6th floor of a building with elevator access. She reported being more forgetful since a recent hospitalization for DVT. Her overall self-sufficiency had deteriorated since the last assessment; assistance is needed with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She needs limited assistance with ADLS except dressing and personal hygiene (extensive-maximal assistance). Impairments are similar. She is continent. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; note:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

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

Tasking tools do not demonstrate significant deterioration in the last year. The assessments take the patient's impairments into account. Supervision/safety concerns are not covered as stand-alone services. The hours 41 hours offered by the insurer are supported by the documentation.

Based on the above, the medical necessity for the personal care aide (PCA) services, 49 hours per week is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite.
Treatment: D8080 Braces, Pre-service.
The insurer denied the D8080 Braces, Pre-service.
The denial is upheld.

The patient is a female.  The request is for dental benefits for orthodontic treatment (braces).  Orthodontic records have been created - x-rays and photos.  Clinical consultation was performed with a presenting diagnosis of deep impinging over-bite with soft tissue damage.

The Health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index, the score necessary to be approved for braces, and did not meet the criteria of any of the automatic qualifiers.

No, the proposed treatment of orthodontic therapy (braces) is not medically necessary.
The information supplied does not support a deep impinging over bite with soft tissue damage.  There is no evidence on the photos that the upper gums are being damaged by the edges of the lower incisor teeth.

As there is no evidence of tissue damage in the upper gum area, orthodontic therapy (braces) designed to correct the over bite would be not warranted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical Radiculopathy.

Treatment: coverage for physical therapy (PT) eval mod complex (97162), neuromuscular reeducation (97112), therapeutic exercise (97110), and manual therapy (97140) for multiple dates of service.

The insurer denied coverage for coverage for physical therapy (PT) eval mod complex (97162), neuromuscular reeducation (97112), therapeutic exercise (97110), and manual therapy (97140) for multiple dates of service.

The denial is overturned.

This case involves a male who has a history of cervical radiculopathy as well as right shoulder pain and impingement.  The documentation indicated the patient was seen with pain for over 2 months that seemed to be worsening to the right shoulder.  The documentation indicated objectively the right shoulder at 150 degrees of flexion with 85 degrees of abduction with pain.  External rotation was 25 degrees and internal was 30 degrees.  There was a positive Neer and Apley's(Shoulder/scratch test) as well as a positive empty can.  Strength was reduced and there was tenderness to palpation.  The documentation indicated the patient underwent therapy services.  The patient continued with additional therapy services.  The appeal documentation detailed the patient received a total of 7 physical therapy sessions greatly improving his condition.  The patient was currently 80% improved with therapy.  The documentation indicated the request has been received to evaluate services performed on additional dates.

Patient had noted ongoing radicular neck pain and right shoulder pain with Neuro deficit.  It was medically necessary for continued physical therapy/therapeutic exercises with noted modalities to decrease pain level and increase range of motion (ROM). There was noted significant improvements with these treatments allowing increased function without any adverse effects. 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 physical therapy (PT) eval mod complex (97162), neuromuscular reeducation (97112), therapeutic exercise (97110), and manual therapy (97140) for multiple dates of service is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Severe Persistent Asthma

Treatment: Dulera (mometasone furoate-formoterol fumarate).

The insurer is denied coverage for Dulera (mometasone furoate-formoterol fumarate).

The denial is upheld. 

The patient has a history of severe persistent asthma. The patient's Medical Doctor (MD) is requesting that she be approved for inhaled corticosteroids (ICS)/ long-acting beta agonists (LABAs) formulation of Dulera (Mometasone Furoate and Formoterol).

The LABA/ICS combinations approved in the Formulary are Symbicort, Breo and Advair.

As per MD note, the patient has tried Symbicort and discontinued it as she was experiencing back and chest pain on using it. She has tried Breo 200 which made her irritable and anxious. The patient then was tried on the lower dose Breo 100 which also the patient could not tolerate due to sleep issues. The physician notes that she cannot use Advair. There is no reason provided. It is unclear if the patient has tried Advair and what the issues were with it.

Since Advair is a similar drug to Dulera- both ICS/LABA combinations, it should be tried first and if the patient is unable to tolerate it, it should be documented what those reasons are before Dulera can be approved. There is no documentation in the medical records as to why Advair is not an option. Thus, it can not be said that Dulera is likely to be more effective than the formulary options.

The insurer's denial of Formulary Exception for Dulera (mometasone furoate-formoterol fumarate) is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Onychomycosis.
Treatment: Formulary exception for Jublia (efinaconazole).
The insurer denied the Formulary exception for Jublia (efinaconazole).
The denial is upheld.

The patient is a male with a history significant for onychomycosis. According to the patient's provider, the patient prefers a topical medicine as opposed to the oral medication (i.e. itraconazole oral, terbinafine oral), which requires liver monitoring while taking the medication.

No, the health plan should not cover the formulary exception for Jublia.
There is no data to suggest that the formulary drug would be less effective than the one prescribed. There is no evidence that the patient had or would have an adverse reaction to the formulary medication.

Therefore, given the above, the health plan should not cover the formulary exception for Jublia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, incontinence of bowel and bladder, abnormalities of gait and mobility, and hypertension

Treatment: Consumer directed personal assistance services (CDPAS) of 24 hours per day, 7 days per week

The insurer is denied coverage for consumer directed personal assistance services (CDPAS) of 24 hours per day, 7 days per week.

The denial is overturned. 

The patient is a female with a history of Alzheimer's dementia, incontinence of bowel and bladder, abnormalities of gait and mobility, and hypertension. She has been receiving consumer directed personal assistance services (CDPAS) 12 hours per day, 7 days per week. An increase to Consumer Directed Personal Assistance Services (CDPAS) of 24 hours live-in a day to 7 days per week 2-12 hours a day (split-shift) is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; note:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse."

The provision of diapers is not by itself adequate for prevention of pressure sores changing diapers regularly is also necessary. In this case the provision of assistance with transfers, ambulation and toileting is needed throughout the 24 hours, with safety being an additional benefit. Thus 24 hour split shift is medically necessary. The health plan did not act reasonably in the best interest of the patient.

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 24 hours a day, 7 days per week 2-12 hours a day (split-shift) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autoimmune encephalitis (DPPX).
Treatment: Positron Emission Tomography (PET) Scan.
The insurer denied the Positron Emission Tomography (PET) Scan.
The denial is upheld.

The patient is a male with autoimmune encephalitis (DPPX) requesting a positron emission tomography (PET) / computed tomography (CT). The patient complains of diarrhea, headaches, muscle twitching, cognitive decline, anxiety, and depression. DPPX has an increased risk for cancer and a positron emission tomography (PET) scan is requested to evaluate for such.

No, the proposed positron emission tomography (PET) / computed tomography (CT) is not medically necessary.
The proposed positron emission tomography (PET) / computed tomography (CT) is not medically necessary. A search on PubMed.com finds several case reports of using positron emission tomography (PET) / computed tomography (CT) imaging in autoimmune encephalitis (DPPX); however, there are not randomized controlled trials or cohort trials from more than one institution to validate its efficacy. The use of positron emission tomography (PET) / computed tomography (CT) in this circumstance is not standard of care and is does not meet general criteria for medical necessity.