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

Diagnosis: Depression
Treatment: Transcranial magnetic stimulation (TMS) treatments
The insurer denied the Transcranial magnetic stimulation (TMS) treatments.
The determination is overturned.

The patient has a history of opioid use on methadone maintenance, post-traumatic stress disorder (PTSD), Panic Disorder, obsessive-compulsive disorder (OCD), anxiety and depression. A request has been made for approval of transcranial magnetic stimulation (TMS) treatments. The request was previously denied due to inadequate medication trials; plan criteria state failure of 6-8 week trial of maximum tolerated pharmacological dosage to include one of the following: at least three antidepressants from at least two different antidepressant medication classes or at least two different antidepressants from at least two different antidepressant medication classes plus an augmenting agent, during the most recent episode of depression. At issue is the medical necessity of TMS.

The requested health service/treatment of TMS is medically necessary for the patient.
The patient's episode of depression have lasted for approximately 10 years. Additional documentation provided indicates that patient has trialed three different antidepressants from two different classes of medication, in addition to an augmenting agent. In particular, she has had trials of Lexapro 20 milligrams (mg), Celexa 40 milligrams (mg) and Effexor 225 milligrams (mg) which would qualify as three different medications trialed at adequate doses from two different classes. The Patient Health Questionnaire (PHQ) 9 score was 20 and the General Anxiety Disorder (GAD) 7 score was 21. The requested TMS is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, cardiomyopathy, hypertension, congestive heart failure, osteoarthritis, and osteopenia
Treatment: 7 days per week, 24 hours per day (Split Shift) Personal Care Assistance
The insurer denied 7 days per week, 24 hours per day (Split Shift) Personal Care Assistance.
The denial is overturned.

The patient is an elderly female. She reportedly has dementia, cardiomyopathy, hypertension, congestive heart failure, osteoarthritis, osteopenia, anemia and constipation. She lives alone.
The request is for increase in personal care assistance services 7 days/week 24 hours/day split shift. The provider is appealing the health plan's denial of coverage determination, noting the request is medically necessary and appropriate.

The requested increase in personal care assistance service to 7 days/week, 24 hours/day, split shift, is medically necessary.
The patient has multiple comorbidities and has progressive dementia. The patient requires assistance with all of her ADLs (activities of daily living), including bathing, dressing, grooming, shopping, meal preparation and transfers. The patient uses a Rollator for her mobility and is at risk of falls. The patient lives alone and has severe osteoarthritis. The patient has a progressive neurologic condition, which is not expected to improve. The patient needs reminders for her medications. The patient needs increased home care services to ensure safety and avoid falls. Requested increase in personal care services is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Depression, osteoarthritis and thoracic radiculopathy.
Treatment:  Personal Care Aide (PCA) services: 8 hours per day, 7 day(s) per week - for a total of 56 hours per week.

The insurer denied coverage for personal care aide (PCA) services: 8 hours per day, 7 day(s) per week - for a total of 56 hours per week.  The denial is upheld.

This is an adult patient with chronic medical problems including depression, osteoarthritis and thoracic radiculopathy. She lives alone in a studio apartment.  The insurer has authorized PCA services of 6.5 hours per day, 7 days per week (totaling 45 hours per week). Under review is the requested increase in personal care aide (PCA) services: 8 hours per day, 7 day(s) per week - for a total of 56 hours per week.  

The Uniform Assessment System (UAS) report was reviewed. The patient does not have any specific cognitive issues; described as "modified independent."  She requires maximal assistance for bathing, lower body dressing and toilet transfer. She is continent of bowel and bladder. Extensive assistance is needed for personal hygiene, upper body dressing, bed mobility and toilet use. She uses a cane for ambulation. Her gait is described as slow and unsteady by her PCA.   Her functional ability is much the same when compared to previous UAS report.  Her condition and functional needs are not at a level or unpredictable as to require the requested PCA increase. This physician would agree the patient may require additional 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 her currently approved PCA services of 6.5 hours/day, 7 days/week (totaling 45 hours/week).  

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

From a physical medicine and rehabilitation perspective, the requested increase in PCA services: 8 hours/day, 7 days/week - for a total of 56 hours/week 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 increase in personal care aide (PCA) services: 8 hours per day, 7 day(s) per week - for a total of 56 hours per week services is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus
Treatment: Formulary exception for Onglyza
The insurer denied: Formulary exception for Onglyza
The denial is upheld

The patient is an adult female with type 2 diabetes. The request for Onglyza is under review. The prior was denied coverage by the health plan, as approval on criteria requires trial and failure, intolerance, or contraindication to Tradjenta. The provider is appealing this determination, because the patient has been on Onglyza for eight years and interruption or change in the medication could cause serious adverse effects.

The health plan should not cover the formulary exception for Onglyza.
This request is for Onglyza for the treatment of type 2 diabetes. This patient has been on Onglyza for eight years. The formulary alternative is Tradjenta. Onglyza and Tradjenta are in the same drug class. They are expected to be equally safe and effective. The American Diabetes Association clinical guidelines do not recommend the use of Onglyza over the use of Tradjenta. Therefore, no, the health plan should not cover the proposed Onglyza.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion 

Treatment: D8070 braces, D8670 monthly visit, and D8680 retainer

The insurer denied coverage for D8070 braces, D8670 monthly visit, and D8680 retainer

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including Class I malocclusion, overjet, overbite, open bite, ectopic eruption and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 33 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 10 points. The patient's mother is appealing the decision.

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 33 points to justify orthodontic
care. This reviewer concurs with the HLD index of the insurer attaining 10 total points (3 overjet, 2 overbite, 3 ectopic eruption and 2 labiolingual spread).	

Regarding the validity of the Handicapping Labiolingual 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 clinical circumstance as presented do not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

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

The insurer's denial of coverage for D8070 braces, D8670 monthly visit, and D8680 retainer is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations, weakness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of chronic myelogenous leukemia (CML), schizophrenia, and polysubstance abuse who was admitted with complaints of (c/o) palpitations and generalized weakness. Vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). Lab work was notable for a white blood cell count (WBC) of 97.4. A chest x-ray (CXR) showed no acute findings. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with palpitations and possible acute phase chronic myelogenous leukemia (CML) and treated with intravenous fluids (IVF), histamine (H2) blockers, and anti-emetics. Oncology evaluated the patient and determined that the patient was not in an acute phase of CML and did not require inpatient treatment. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of palpitations and generalized weakness. An EKG did not demonstrate any acute ischemic changes and the palpitations resolved while in the ED. Oncology evaluated the patient and it is clearly documented that the patient was not in an acute CML phase and that outpatient treatment was appropriate. Given that the patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG and negative cardiac biomarkers, no new left bundle branch block (LBBB) or newly inverted T-waves believed to be ischemic in origin, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies, this patient could have been safely and appropriately treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Active periodontal disease and attachment loss
Treatment: Deep Gum and Root Cleaning for Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant and Upper Right Quadrant
The insurer denied Deep Gum and Root Cleaning for Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant and Upper Right Quadrant. 
The determination is overturned.

The patient presented for the treatment of scaling and root planing (4341) for upper left (UL), upper right (UR), lower left (LL), and lower right (LR). Provided for review are full mouth radiographic images, a single page of American Dental Association (ADA) claim forms, letters of appeal and denial, explanation of benefits with health plan language, and a narrative from the patient. At issue is the medical necessity of deep gum and root cleaning

Based on the provided documentation, the patient has the presence of radiographic calculus on the roots through the entire dentition, as well as changes to the bone in the form of a loss of lamina dura, as well as bone loss throughout the mouth. As such, the patient has evidence of active periodontal disease and thus attachment loss. The treatment of choice is that of scaling and root planning to remove the deposits from the roots. Therefore, the treatment is medically necessary in the upper right (UR), upper left (UL), lower left (LL), and lower right (LR) quadrants.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. Pelvic and perineal pain.
Treatment: Physical Therapy.
The insurer denied Physical Therapy.
The denial is upheld. 

This is a female patient. The patient was diagnosed with pelvic and perineal pain. Records indicate the patient began physical therapy treatment with a nonparticipating physician. It is noted that the patient underwent ongoing care over the course of a year and documentation did not demonstrate progress. It was noted that continuation of care that is not resulting in a measurable change in the functional status of a patient or where a patient has reached maximum therapeutic benefit is not considered to be medically necessary and therefore this treatment was denied. This determination is under appeal.
Multiple physical therapy notes were provided which included the initial physical therapy evaluation indicating the patient has a history of fusion and multiple other medical conditions. It was noted that the patient had a sling put in for urethrocele for leaking but had to get it done twice because the first time did not work. The patient also had a history of kidney stones. Pelvic floor treatment was initiated. The most recent physical therapy (PT) note indicated this to be visit number (#) 51. The patient had ongoing complaints of pelvic pain rated at 8/10. Patient was noted to have a lot of sensitivity. The patient had not met any short-term or long-term goals.
At issue is the medical necessity of Physical Therapy.

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

No, the requested health service/treatment of Physical Therapy is not medically necessary for this patient.
Records provided indicate the patient has a history of pelvic and perineal pain and participated in pelvic floor therapy for an extended timeframe. As of visit number (#) 45, the patient had ongoing complaints of pelvic pain, left flank pain, low back pain and constipation with aggravating factors of sitting, intercourse, and constipation. The patient had not met any short-term or long-term goals. The patient continued with ongoing therapy and as of visit #51, the patient continued to complain of pain rated at 8/10 and complained of significant sensitivity. The patient still had not met any short-term or long-term goals. The patient had an extended amount of therapy without any evidence of significant improvement in pain or function. Continuation of care that is not resulting in a measurable change in the functional status of a patient or where a patient has reached maximum therapeutic benefit is not considered to be medically necessary.
Therefore, the requested health service/treatment of Physical Therapy is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Maxillary and mandibular crowding.
Treatment: Braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is upheld. 

The patient is a female with maxillary and mandibular crowding and several unerupted permanent teeth. The orthodontist mentioned in the diagnosis that teeth #6 and #11 are impacted. The patient was treatment planned for 36-42 months of Braces and Monthly Visits. 

Braces and Monthly Visits are not medically necessary for the patient at this time. She is in the process of losing her remaining primary teeth as they are replaced with permanent teeth. 
The patient is young and in the mixed dentition phase of development. Neither teeth #6 nor #11 appear to be erupting at a poor angle on the radiograph, and it is too early to determine if it will require an exposure as maxillary canines usually erupt at patient's age. There is still much time to see if the tooth will erupt successfully on its own without orthodontic intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Behcet's disease
Treatment: Otezla
The insurer denied Otezla.
The health plan's determination is overturned.

The patient is a man with Behcet's disease, reflux, hiatal hernia, and gastric polyp. The patient drinks alcohol regularly. The issue in this case is Otezla is being denied by the health plan. The reason for the denial is formulary alternatives (Imuran and cyclosporine) were not tried. Prior treatment has included colchicine with no improvement and the patient was unable to tolerate a 'prednisone dose pack'. The patient has also tried nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and lidocaine.

Otezla is medically necessary for this patient. The formulary alternatives would not be appropriate. There is ample data speaking to the efficacy of Otezla in Behcet's and it is Food and Drug Administration (FDA) approved for the treatment of Behcet's. The formulary options would not appropriate. Cyclosporine is typically used for patients who have eye involvement from Behcet's. While Imuran can be given for patients with oral ulcers from Behcet's, it's typically considered to be a 3rd line drug. The standard of care is steroids, colchicine and then Otezla.

Otezla is medically necessary for the patient as this time, given that he has failed colchicine and is unable to tolerate steroids. According to UpToDate, "escalation of treatment with other medications for the management of oral and genital ulcers should be determined on a case-by-case basis. We generally reserve these options for patients in whom the combination of daily oral colchicine or apremilast and a daily prednisone dose of more than 10 milligrams is required to control oral aphthae and genital lesions or if the adverse effects of prednisone and/or colchicine are intolerable even at lower doses." The other medications listed include Imuran, tumor necrosis factor (TNF) antagonists, cyclosporine, interferon alpha and thalidomide.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chemotherapy induced Neutropenia
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld. 

The patient has inflammatory breast cancer and presented to the emergency room with nausea, vomiting, anorexia, and heartburn. She was neutropenic but afebrile and hemodynamically stable. The patient was admitted "for neutropenia". The patient received antibiotics, antiemetics, and intravenous fluids. At issue is the medical necessity of an inpatient hospital stay.

An inpatient hospital stay was not medically necessary for this patient. The patient was neutropenic but afebrile. The patient received growth factor and supportive care. Antibiotics were administered, but this was done without evidence of an infection. The patient received antiemetics and intravenous (IV) fluids. At no point was the patient hemodynamically unstable and she responded well to interventions for her nausea in the emergency room. Support for hospitalization in this clinical scenario is not supported in the peer-reviewed literature nor by the authors of UpToDate.

For these reasons, the medical necessity for inpatient care is not established.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Prostate cancer
Treatment: Laboratory Testing (81542 - oncology [prostate], mRNA [messenger ribonucleic acid], microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastatic risk score)
The insurer denied: Laboratory Testing (81542 - oncology [prostate], mRNA [messenger ribonucleic acid], microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastatic risk score)
The denial is overturned

The patient is an adult male with localized prostate cancer. The issue is Decipher test.

The health plan should cover the Laboratory Testing (81542 - oncology [prostate], mRNA [messenger ribonucleic acid], microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastatic risk score).

Decipher's genomic test, performed on tumor tissue, matches selection and intensity of treatment with the metastatic potential of the tumor by providing quantitative estimate of risk of metastatic disease and dividing the cancers into high-risk, intermediate and low risk. Decipher has been validated in 40 studies across 29,876 patients for metastasis, prostate cancer-specific mortality, and overall survival. The National Comprehensive Cancer Network (NCCN) 2020 Clinical Practice Guidelines on Prostate Cancer state the following regarding molecular assays: "Men with low or favorable intermediate risk disease may consider the use of the following tumor-based molecular assays: Decipher, Oncotype DX Prostate, Prolaris, Promark. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN [National Comprehensive Cancer Network] risk groups."
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Prostate cancer
Treatment: Laboratory Testing (81542 - oncology [prostate], mRNA [messenger ribonucleic acid], microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastatic risk score)
The insurer denied: Laboratory Testing (81542 - oncology [prostate], mRNA [messenger ribonucleic acid], microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastatic risk score)
The denial is upheld

The patient in this case is an adult male diagnosed with early stage prostate cancer. Biopsy revealed Gleason Sum 3+4=7 cancer in three cores. A Decipher assay was performed.

The health plan should not cover the requested Laboratory Testing (81542 - oncology [prostate], mRNA [messenger ribonucleic acid], microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastatic risk score).

There is no evidence based on the results of prospective randomized controlled clinical trials showing that Decipher can improve health outcomes compared to treatment decision making using clinical and pathologic factors only. While this and other similar tests are felt to of potential benefit and can be considered for use based on NCCN (National Comprehensive Cancer Network) guidelines, there is no definitive evidence showing that this assay improves health outcomes. Given that lack of supporting evidence, it cannot be concluded that this health service is more beneficial than any standard treatment.