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

Diagnosis: Class I occlusion 
treatment: braces
The insurer denied braces.
The health plan's determination is upheld. 

The patient in question is a young male with a Class I occlusion with 6-millimeter (mm) overbite and 4 mm overjet. He has minor maxillary mandibular crowing. He is in the late-mixed dentition phase of development. His treating provider states tooth number (#) 6 is impacted. He is treatment planned for 24-30 months of orthodontics (braces) to correct his malocclusion. 

Braces are not medically necessary for this patient. The patient's overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient.
While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but his overjet would not affect oral health related quality of life unless it was greater than 6 mm. If his teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Skeletal Class I malocclusion. 
treatment:  Braces.

The insurer denied braces.  The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 7.  She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 24-30 months of orthodontics (braces) to address the crowding and crossbite. 

Braces are medically necessary for this patient. This patient presents with an anterior crossbite on tooth 7. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.

If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Full braces and monthly brace adjustment visits.
The insurer denied Full braces and monthly brace adjustment visits.
The determination is overturned.

The patient is a female with a Class I malocclusion and a bilateral posterior crossbite. She has moderate crowding, and appropriate overbite and overjet. She is missing tooth number 7. She is treatment planned for 24-30 months of braces with rapid palatal expansion to correct her crossbite, but this was denied by the health plan. At issue is the medical necessity of full braces and monthly brace adjustment visits.

This patient presents with a bilateral posterior crossbite and mandibular crowding. She is treatment planned for rapid maxillary expansion to assist with orthodontic correction. Such a procedure can only be performed before the patient reaches skeletal maturity, otherwise, the ability to achieve orthopedic expansion is greatly reduced. (1) In that case, the only option to achieve orthopedic expansion will be to perform it in conjunction with a surgical procedure (2), which would greatly increase the morbidity of the patient. It is necessary to start treatment to hopefully alleviate the need for future surgical procedures about the dentition. Orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Ureteropelvic junction obstruction (UPJO).
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a female with a ureteropelvic junction obstruction (UPJO) and renal calculi, who was treated with a robot-assisted laparoscopic pyeloplasty with stent placement, removal of kidney stone and ureterolysis. The surgery was uncomplicated. She received intravenous (IV) antibiotics, intravenous fluids (IVF) and IV pain meds after surgery. She tolerated a liquid diet and was discharged home after an uneventful hospital stay.

The inpatient hospital stay was not medically necessary.

Observation after a robot-assisted laparoscopic pyeloplasty is indicated because of the level of complexity of the surgery and its attendant risks such as bleeding, urine leak, pain control, ileus and urine leak. However, an acute inpatient level of care is not medically necessary. Next day discharge is the goal in the absence of complications and was achieved in this patient's case. In the absence of complications, a lower level of care is appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polyarthritis

Treatment: Pregabalin Cap 75 milligrams (mg)

The insurer denied coverage for Pregabalin Cap 75 milligrams (mg)

The denial is upheld 

This case involves an adult female with a request for pregabalin capsules 75 milligrams (mg). A progress note indicated the patient had a diagnosis of polyarthritis, rheumatoid arthritis, diffuse pain, and fibromyalgia. Past treatments were documented as adalimumab, duloxetine, hydroxychloroquine, methotrexate, and prednisone. The treatment plan included magnetic resonance imaging (MRI) of the right ankle, lab work, switching to abatacept from adalimumab, and starting the patient on a trial of Lyrica (pregabalin) for fibromyalgia/diffuse neuropathic pain. 

A determination letter indicated the denial of a request for coverage of pregabalin cap 75mg, as the patient did not meet the requirements of the plan. 

A letter of medical necessity indicated that it was necessary for the patient to continue the use of Lyrica due to diffuse neuropathic pain and rheumatoid arthritis. The treating physician stated that the patient has failed other medications, including Cymbalta. 

A final determination letter indicated the denial of an appeal request for pregabalin cap 75mg, as documentation was not submitted to support that the patient meets plan approved criteria, such as failure, contraindication or suspicion of an adverse reaction to the preferred drug gabapentin. 

Evidence based literature indicates pregabalin appears to be effective in reducing absolute pain scores in patients with arthritis. Additional literature indicates pharmaceutical therapies for patients with rheumatoid arthritis and fibromyalgia include gabapentin and pregabalin. Records indicate that the patient has a diagnosis of polyarthritis, rheumatoid arthritis, diffuse pain, and fibromyalgia. Additionally, the physician stated that the patient has failed Cymbalta for pain relief. However, the progress note submitted was incomplete, containing only the treatment plan and past medications. While the patient may benefit from treatment with the requested medication, there is no documentation of the patient's specific pain symptoms, a physical exam, or response to other treatments. As such, the request for Pregabalin Cap 75mg is not medically necessary for this patient.

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 Pregabalin Cap 75mg is not substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: foot pain.
Treatment: custom shoe inserts.
The insurer denied custom shoe inserts.
The health plan's determination is overturned. 

The patient is a young male who presented with bilateral arch pain of several months in duration. Examination revealed hyperpronation in the propulsive phase of gait with calcaneal eversion and compensated equinus. Diagnosed pronation deformity of the foot, propulsion deformity, calcaneovalgus, and plantar fasciitis were rendered.

Custom Shoe Inserts are medically necessary for this patient.
Given the patient's continued foot pain due to progressive deformities, and despite the use of prefabricated inserts, custom shoe inserts are medically necessary to improve function, alleviate symptoms, and prevent worsening deformity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Patella chondromalacia and tendinitis.
Treatment:  Gel on hyaluronan injections (procedure code J7326).

The insurer denied coverage for gel on hyaluronan injections (procedure code J7326).  The denial is upheld.

The patient is an adult male who presents for a follow-up appointment for his left knee. The telemedicine note reported that the patient has a diagnosed with left knee patella chondromalacia and Patella tendinitis. The patient was recommended for physical therapy and oral anti-inflammatories. The Magnetic resonance imaging (MRI) showed patella cartilage damage. The encounter diagnoses was noted as patellofemoral pain syndrome of the left knee, chronic pain of the left knee and patella chondromalacia, left. The treatment recommendations were for hyaluronic acid injection to treat his knee. The x-rays of the bilateral knee revealed no acute fracture or dislocation. The joint spaces are preserved with no osteophytes or erosion; normal bone alignment and mineralization; there is no right or left knee joint effusion.

The letter of medical assessment noted that the patient has left knee osteoarthritis with symptoms affecting activities of daily living. The patient has been managed with exercise program, activity modifications, and non-steroidal anti-inflammatory drugs (NSAIDs).

Per the cited references, the American Academy of Orthopedic Surgeons (AAOS) Clinical Practice Guidelines (CPGs) organize and summarize the available data regarding numerous nonoperative and operative treatments for musculoskeletal problems, including the management of knee osteoarthritis (OA). The AAOS CPG cited moderate evidence against the routine use of hyaluronic acid (HA) injections for the management of symptomatic knee osteoarthritis (OA).  In this case, the clinical records do not support a diagnosis of osteoarthritis for this patient. Per the Plan's criteria, there is no coverage for the requested treatment for the patient's condition. As such, the denial of coverage for gel on hyaluronan injections (procedure code J7326) is upheld as 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 hyaluronan injections (procedure code J7326) is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Drug induced constipation.
Treatment:  Formulary Exception for Movantik.

The insurer denied: Formulary Exception for Movantik.  The denial is upheld.

The patient is an adult female with stage 4 lung cancer, on Fentanyl, with opioid induced constipation. She has failed Senna, Colace, Miralax and Milk of Magnesia (MOM). The physician (MD) is requesting treatment with Movnatik. Movantik was denied, as the patient has not failed lubiprostone and Symproic.

The health plan should not cover Movantik.

The patient has not failed lubiprostone and Symproic. There is no medical literature to support that Movantik is more effective than lubiprostone and Symproic for the treatment of opioid induced constipation. Lubiprostone and Symproic are likely to be as effective as Movantik. There is no literature to support that lubiprostone and Symproic are likely to cause more side effects than Movantik. Therefore, the health plan should not cover Movantik.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Infection
Treatment: Full hospital admission:
The insurer denied: Full hospital admission:
The denial is upheld.

This patient is an adolescent male with a rash on his face that was getting worse three days prior to admission. The patient had gone fishing and the way back he was walking through bushes that slapped him on his right cheek where he developed an itchy burning maculopapular rash with vesicular changes and some honey-colored crusting at the center. The patient was initially seen by his primary care physician who started clindamycin and prednisone for suspected poison ivy with bacterial superinfection. He received three doses of clindamycin without improvement of
symptoms. The rash spread to his arms, chest, and groins. Hence, he presented to the emergency department for further evaluation. The patient was seen in the emergency department and given intravenous clindamycin and discharged home. He came back for worsening symptoms and was admitted for intravenous vancomycin and intravenous steroids, Bactroban, and Benadryl. Vancomycin was switched to linezolid on day #2 due to vancomycin reaction. The patient was discharged home on day #3. The patient had no fever, and his vital signs were stable, complete blood count differential and C-reactive protein were normal. 

The requested health service was not medically necessary.

Based on the Milliman Care Guidelines (MCG) criteria, patients admitted with cellulitis not responsive to adequate outpatient therapy are eligible for inpatient hospitalization. This patient
only received three doses of clindamycin, which would not be sufficient to bring about a change in the infection. The spread of lesions was most likely related to contact dermatitis rather than
infection, as the patient remained afebrile, had a normal C-reactive protein, and a normal complete blood count differential.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malignant Neoplasm of Upper Lobe
Treatment: Keytruda Injection 100 Milligram per 4 Milliliters
The insurer denied: Keytruda Injection 100 Milligram per 4 Milliliters
The denial is upheld.

The patient in this case is an adult male who has non-small cell lung cancer. He underwent wedge resection with completion lobectomy last year. This revealed a 1.6 centimeter (cm) 
adenocarcinoma with 6 positive lymph nodes. Programmed death-ligand 1 (PD-L1) testing was negative. Currently, treatment with single agent pembrolizumab has been prescribed.

The requested service is not medically necessary.

The patient in this case was diagnosed with lymph node positive non-small cell lung cancer last year. No information is provided regarding treatment rendered following that surgery and no information is provided regarding the status of this cancer currently. Also, no information is provided showing that this patient has Programmed death-ligand 1 (PD-L1) positive non-small cell lung cancer at the present time. Notably, this cancer was Programmed death-ligand 1 (PD-L1) negative last year. Based on the available information, use of pembrolizumab as a single agent at the present time is not medically necessary. This use of pembrolizumab does not meet standard criteria for use of this agent based on the National Comprehensive Cancer Network (NCCN) guidelines. Therefore, it cannot be concluded that pembrolizumab is being used in accordance with generally accepted standards of medical practice.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
home health care

Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 24 Hours per Day (Split Shift)
The health plan's determination is overturned. 

This is a male patient with a history of syncope, recent left hip fracture, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, hypertension, seizure disorder, benign prostatic hyperplasia, Alzheimer's dementia, atrial fibrillation, heart failure, depression, anxiety, muscle weakness, and bladder and bowel incontinence. 

Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 24 Hours per Day (Split Shift) is medically necessary for this patient. 
There is documentation in the recent Uniform Assessment System (UAS) of the patient being totally dependent for tasks of locomotion, transfer toilet, toilet use, and bed mobility. This represents a significant decline in function as compared to the previous UAS. The patient's care needs cannot be met solely with adaptive equipment and medical supplies.
The patient's nursing home attending physician documented the need for the patient to be turned and positioned every 2 hours to prevent skin breakdown and bedsores, which is consistent with generally accepted practice guidelines. As noted in "Pressure Injuries: Prevention, Evaluation, and Management", prevention measures in patients at increased risk of pressure injuries including keeping skin clean (particularly following incontinence events) and encouraging patients to change positions often, with assistance if necessary. Increased moisture from urine, stool, and sweat can cause skin maceration and escalate the risk of pressure injuries. Per NY Codes, Rules, and Regulations section 505.14, a live-in personal care aide must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. A live-in aide would not be able to receive 5 hours of uninterrupted sleep and also meet the requirement to be turned and positioned every 2 hours. Therefore, split-shift care is required to meet the patient's frequent care needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Services, 12 Hours a day, 7 days a week for a total of 84 hours. 
The insurer denied Personal Care Services, 12 Hours a day, 7 days a week for a total of 84 hours. 
The health plan's determination is overturned. 

This is a case review for a male with medical history notable for dementia, mobility issues, and incontinence. 

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via video teleconference. The patient lives with his wife in a one-bedroom home. His cognition was moderately impaired. He was alert and oriented person and place only. His short-term, procedural, and situational memory was disrupted. He is not able to direct his own care and is not safe to be left alone. 

The requested Personal Care Services: 12 Hours per Day, 7 Days per Week (Total of 84 Hours) is medically necessary for this patient. 

The patient suffers from advanced dementia, incontinence of both stool and urine, and severe mobility issues which leave him bed bound and wheelchair bound. He is not able to direct any of his personal care tasks due to advanced dementia. He is also unable to participate in the majority of these tasks, and they must be completed by a caregiver. His only informal assistance comes from his wife who is elderly and is unable to complete many of these tasks. His personal care needs can be expected to be continuous and unscheduled throughout the day. Therefore, the requested increase in personal care hours is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CVA (cerebrovascular accident), type 2 diabetes mellitus, hypertension, and pure hyperlipidemia
Treatment: Increase Personal Care Assistance (PCA) Services From 84 to 168 Hours Per Week (split shift)
The insurer denied: Increase Personal Care Assistance (PCA) Services From 84 to 168 Hours Per Week (split shift)
The denial is overturned.

The patient is an elderly male for which there is a request for personal care assistant services increase from 84 hours to 168 hours. A final adverse determination denial notice explained the rationale as to why the increase was previously non-certified by the health plan. The patient had previously received 12 hours per day/7 days per week for a total of 84 hours. It was noted that the patient was bedridden and did not have any family members to assist at night to support her activities of daily living and care maintenance. It was noted that the patient had a previous history of CVA (cerebrovascular accident), type 2 diabetes mellitus, hypertension, and pure hyperlipidemia. It was noted that the patient was hospitalized related to an acute CVA cerebrovascular accident) and was bed ridden as a result. It was noted that the patient required maximum assistance for bathing, personal hygiene, upper body dressing, and toilet use. The patient was totally dependent with lower body dressing, locomotion.

The requested Increase in Personal Care Assistance (PCA) Services From 84 to 168 Hours Per Week (split shift) is medically necessary. 

In this instance, the patient was previously approved for 12 hours per day of personal care assistant services. However, the patient was noted to have an acute hospital stay for acute CVA (cerebrovascular accident), leaving him bedridden. The patient is at an increased risk for adverse clinical outcomes if there are no caregivers who can render adequate bed care to prevent skin breakdown and subsequent infections. It was noted that there were no family members that were able to accommodate this care, given the advanced age and frailty. Because of being bedridden, and because of inability to provide care during the night from family members, the patient is at an increased risk for skin breakdown, subsequent infections, and worsening of his overall clinical state. As such, the additional hours that are being requested are reasonable and medically necessary.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: Dementia.
Treatment: Personal Care Services: 24 Hours per Day, 7 Days per Week (Live-In/Split-Shift).
The insurer denied Personal Care Services: 24 Hours per Day, 7 Days per Week (Live-In/Split-Shift).
The health plan's determination is upheld. 

The patient is a female with a medical history notable for dementia, incontinence, and mobility issues.

Personal Care Services: 24 Hours per Day, 7 Days per Week (Live-In/Split-Shift) is not medically necessary for this patient.

The patient has functional impairment secondary to dementia. According to the records provided, she maintains some executive functions and requires supervision and oversight to complete some activities. 24-hour personal care assistance can only be granted if there is a need for personal care assistance for providing personal care support for activities that occur continuously and unscheduled throughout any given 24-hour period. Personal care cannot be granted for safety monitoring and supervision alone. Because the patient can complete many of her activities of daily living using supervision only, by definition, her needs are more supervisory. She may require 24-hour supervision, but supervision may not be provided by a personal care assistant in the absence of performing other personal care tasks. There is insufficient documentation that the patient requires assistance for a continuous 24-hour period beyond supervision and safety monitoring. Therefore, the requested increase has not been demonstrated to be medically necessary for the patient.