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

Diagnosis: Ulcer
Treatment: Personal Care Services
The insurer denied Increase in Personal Care Services, Level Two (2): 24 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 hypertension, hyperlipidemia, coronary artery disease, chronic kidney disease, aortic aneurysm, kidney stones, anemia, osteoporosis, gait disturbance, homebound status, urinary incontinence, fecal incontinence, and stage 2 decubitus ulcer who had been assigned PCA (personal care assistant) services 11 hours/day, 7 days/week, to total 77 hours/week based on the assessment tool. At this assessment, the patient was assessed at total assistance with task of meal preparation, and maximum assistance with stairs and shopping. The patient was assessed at limited support with tasks of managing finances, personal hygiene, walking, locomotion, transfer toilet, and toilet use. There was a request to increase PCA hours and the patient underwent another assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and shopping, while maximum assistance with tasks of stairs, transportation, bathing, dressing lower body. The patient was assessed at extensive assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility while limited assistance with task of managing medication. 

The Increase in Personal Care Services, Level Two (2): 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week is medically necessary for this patient. 

The patient has documented progressive medical conditions that are worsening. The patient has unscheduled care needs that span 24 hours. The patient requires assistance with all activities of daily living (ADL) /Instrumental activities of daily living (IADL). Furthermore, the patient has had a change in assistance needs since her assessment. The patient requires turning and repositioning every 2-4 hours. The patient has unscheduled needs that span a continuum of time. The patient's overnight care needs which include turning/repositioning, toilet use, incontinence care, and offering drinks would not allow a live-in aide 5 hours of uninterrupted sleep. An increase in PCA hours is not solely for safety and supervision but to assist the patient was safe completion of ADLs and IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services, 24 hours per day, split shift, 7 days per week is 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: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Ubrelvy. 
The denial was upheld.

This is a male with a history of headaches. The patient was seen by his neurologist. It was noted that he had tried new medications provided as samples. Ubrelvy 100 milligrams (mg) was helpful, though he occasionally required a second dose. He continued to take Excedrin regularly. He was going to pain management and was waiting occipital nerve blocks. His examination revealed a normal mental status, cranial nerve, motor, reflex, sensory, coordination and gait examinations. Diagnoses were occipital neuralgia, and vascular, headache, not elsewhere classified. Ubrelvy 100 mg 10 tablets was prescribed.
At issue is whether the formulary drugs will be or have been ineffective and would not be as effective as Ubrelvy. Formulary alternatives include eletriptan, naratriptan, rizatriptan, sumatriptan injection, sumatriptan, nasal spray, sumatriptan tablet, zolmitriptan, NURTEC, it is Zembrace Symtouch and Zomig nasal spray.
The health plan's determination is upheld in whole.

There is no documentation that the patient has had trials and failures of any acute migraine medication other than rizatriptan. No formulary alternatives were documented other than rizatriptan.  There is no documentation the patient has tried and failed any other acute migraine abortive. There is no evidence in the peer-reviewed medical literature that Ubrelvy is superior in efficacy to any other acute migraine abortive. There is no rationale why the patient cannot utilize medications such as eletriptan, naratriptan, rizatriptan, sumatriptan oral, sumatriptan nasal, sumatriptan injectable, zolmitriptan oral, zolmitriptan nasal spray, Zembrace Symtouch or Nurtec ODT (in the same class as Ubrelvy). There is no evidence any of these medications are superior to Ubrelvy with regard to safety or effectiveness. The patient may utilize a formulary medication with the expectation of similar safety, similar efficacy and side effect profile compared with Ubrelvy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left lateral epicondylitis.

Treatment: 6 visits of physical therapy outpatient services.

The insurer denied coverage for 6 visits of physical therapy outpatient services.

The denial is upheld. 

This is a male patient with left elbow pain.  He was seen by an orthopedic surgeon who diagnosed him with left lateral epicondylitis and provided a cortisone injection to the site.  The patient subsequently started physical therapy for further treatment of his left elbow.  Currently under review is the medical necessity for the requested (additional) 6 visits of physical therapy outpatient services.  

Physical therapy for the diagnosis of epicondylitis is a reasonable treatment option particularly when combined with other treatment modalities.  However, the submitted physical treatment notes failed to demonstrate significant quantitative improvement to support additional therapy sessions.  There was only modest elbow range of motion improvement and strength was unchanged.  In addition, the patient no longer had significant pain.  

According to the discharge summery note, the patient rated his pain at 1/10.  Additional physical therapy was no longer medically necessary.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  The requested 6 visits of physical therapy outpatient services are not medically necessary.

The carrier's denial of coverage for the requested 6 visits of physical therapy outpatient services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Diabetes Mellitus. 
Treatment: Continuous glucose monitor. 

The insurer denied the continuous glucose monitor.  The denial is overturned in whole.

The patient is a male with history of diabetes mellitus.  The coverage request is for continuous glucose monitor (CGM).  The coverage was previously denied; this is an appeal initiated by the provider.  The medication was previously denied because the patient did not meet medical necessity criteria under health plan.

Per office note the patient is using an insulin pump.  His A1c (estimated average glucose) was 7.5%, 7.9%, and 8.3%.  He is using a sensor with 44% of glucoses above goal, but no hypoglycemia.  Per medical records the patient has low C peptide due to destruction of pancreas by bleomycin (chemotherapy drug) years ago.

The health plan's determination is overturned in whole.

The continuous glucose monitor is medically necessary for this patient.

The national guidelines generally recommend continuous glucose monitor (CGM) use in type 1 diabetes and consider its use as clinically effective and safe.  American Association of Clinical Endocrinologists (AACE) in its comprehensive diabetes care guideline (Handelsman et al.) states that CGM may be considered for patients with type 1 diabetes and type 2 diabetes on basal-bolus therapy to improve A1c levels and reduce hypoglycemia.

The Endocrine society in their statement paper (Peters et al.) stated that CGM has in multiple trials shown to result in improved glycemic control and decreased hypoglycemia in type 1 diabetic patients; however, they do note that the greatest benefits are seen in those who wear the devices more frequently to maximize benefit.  Similarly, the American Diabetes Association (ADA) standards of care notes that when used properly, CGM with intensive insulin regimens is a useful tool to lower A1C in adults with type 1 diabetes who are not meeting glycemic targets, those diabetes patients with hypoglycemia unawareness and/or frequent hypoglycemic episode; however, it notes that due to variable adherence, optimal CGM use requires individual readiness/compliance, as well as sufficient education and support.

This patient has been on the sensor in the past years and has had improving glycemic control and demonstrates compliance with CGM sensor use and follow-up in clinic.  Additionally, the provider states the patient behaves as a type 1 diabetic due to chemotherapy related destruction of pancreas.  In taking all this into consideration, CGM is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental problem (deep bite class two malocclusion).

Treatment: Braces. 

The insurer denied coverage for braces. 

The denial is overturned. 

This patient is a male child, who was treatment planned at his Orthodontist's office for full arch braces in the maxilla and mandible. The patient has a very deep bite class two malocclusion. The Handicapping Labio-Lingual Deviation (HLD) score was 20 while the treating provider noted a deep impinging bite with trauma to the anterior hard palate from the lower incisors. From the records provided, there is no evidence of trauma from the lower incisors in the anterior hard palate. The bite is very deep and this reviewer's HLD is 23, not 20, due to 9 millimeters (mm) overbite. 

"Our results suggest that state-modified HLD indices fail to identify a considerable percentage of handicapping malocclusions...hese findings may exacerbate access to orthodontic care disparities among Medicaid-eligible populations" (Cousin 2020).

"Subjects with moderate to severe malocclusion with no history of orthodontic treatment had more negative oral health-related quality of life than adolescents who had completed orthodontic treatment." (Jamilian et al 2016).

"Malocclusion can be regarded as a condition affecting oral health, leading towards increment in dental caries, periodontal diseases, possible Temporomandibular disorder (TMD), and psychosocial problems or other serious risks to oral health and hygiene. According to the World Health Organization (WHO), malocclusion is the third-highest oral health concern around the globe. It is essential to note that malocclusion, dental, and periodontal disease has been designated as the most prevalent categories of oral pathologies. The etiology of a malocclusion involves both genetic and environmental factors...ngle classified the normal occlusion and malocclusion according to molar relationship into; normal occlusion, Class I malocclusion, Class II malocclusion with two divisions according to incisors angulation (division I and II), and Class III malocclusion. As recommended by the American Academy of Orthodontics (AAO), the conduction of orthodontic examination must be ensured for 7 year old children, because by analyzing the physical aspects of teeth, an expert can determine whether or not the child is at risk of malocclusion. The early examination might also assist in the investigation and initiation of treatment during childhood, thus reducing the negative consequences on the health and well-being of patients as well as minimizing the severities related to dental and skeletal malformations" (Alogaibi et al 2020).

Due to the severity of the class two malocclusion with deep overbite, normal function including hygiene would be quite difficult. This case is medically necessary to correct the malocclusion for proper function. This will prevent loss of function as well as any trauma which may occur in the future due to the current occlusal scheme.

The medical necessity for braces is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Orthodontic treatment
The insurer denied the orthodontic treatment.
The health plan's determination is overturned. 

The patient in question is a female with a Class III malocclusion, moderate spacing of the upper and lower arches and anterior crossbite of teeth #7-#10. She is missing teeth 5, 12, 21 and 28. She is treatment planned for 30-36 months of orthodontics to correct her malocclusion. Under review is the medical necessity of Braces: Comprehensive Orthodontic Treatment of the Adolescent Dentition and Periodic Orthodontic Treatment Visit(s).

Braces: Comprehensive Orthodontic Treatment of the Adolescent Dentition and Periodic Orthodontic Treatment Visit(s) is medically necessary for this patient.
The patient has significant maxillary anterior spacing with teeth #7-#10 in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. They are already exhibiting significant wear. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Surgical Services  (All)

Diagnosis: low back pain
Treatment: Minimally Invasive Sacroiliac Joint (SIJ) Fusion 
The insurer denied Minimally Invasive Sacroiliac Joint (SIJ) Fusion. The health plan's determination is overturned. 

The patient is a female with chronic low back pain. Pre-operative records provided are limited but include clinic notes and magnetic resonance imaging (MRI) report. Additional history is also provided by the patient and hospital's appeal letters. The patient's past medical history (PMH) is significant for depression and seizures. Physical exam was notable for tenderness to the R (right) sacroiliac (SI) joint. There is mention of a physical exam which documents a + (positive) compression test, Gaenslen's maneuver, and distraction test but these notes are not provided for review. A magnetic resonance imaging (MRI) demonstrated L4/5 severe facet arthropathy, grade 1 anterolisthesis, and moderate stenosis. Prior treatments included physical therapy (PT), home exercise program, chiropractic care, activity modification, NSAIDS (nonsteroidal anti-inflammatory drugs), SI joint injections with "significant relief" provided as a description in the provider's appeal letter but post-injection documentation has not been provided). The patient felt her pain limited her activities of daily living and was recommended a R SI fusion. She underwent a R SI joint fusion using SI Bone.

Minimally Invasive Sacroiliac Joint (SIJ) Fusion is medically necessary for this patient.
According to Schmidt et al, "After failure of conservative treatment, percutaneous SI arthrodesis can be considered."
According to Polly et al, "This Level 1 study showed that minimally invasive SIJ fusion using triangular titanium implants was more effective than nonsurgical management at 1 year in relieving pain, improving function, and improving quality of life in patients with SIJ dysfunction caused by degenerative sacroiliitis or SIJ disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment."
These and many other studies continue to support the treatment of SI joint pain in the properly selected patient with SI fusion. This patient met the appropriate conservative work-up and treatment and continued to have symptoms that affected her ADLs. Therefore, she meets reasonable medically necessity for SI joint fusion.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Primary osteoarthritis of the left hip secondary to developmental dysplasia of the hip.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with a medical history of primary osteoarthritis of the left hip secondary to developmental dysplasia of the hip, who had undergone prior hip surgeries and underwent left hip conversion of previous surgery to total hip arthroplasty.  The patient received perioperative intravenous (IV) Cefazolin.  The findings were advanced degenerative changes, femoral head and acetabulum.  There were no complications and the patient tolerated the procedure well.  The patient was pain managed with Hydromorphone injection and Toradol injection.  The patient was admitted post-operatively for post-op management.  The patient continued to receive pain management with oral Oxycodone. Physical therapy evaluation was done with weight bearing ambulation and recommendation for anticipated home services.  The patient was medically cleared for discharge home on day 2 of admission with instructions to follow up with outpatient orthopedic surgery.  

The medical records demonstrate a non-complicated post-surgical course.  Vital signs were stable.  Pain medication provided satisfactory relief.  The patient was able to tolerate oral analgesia.  There were no wound problems, and the hemovac had been removed.  Satisfactory progress was made with Physical Therapy/Occupational Therapy and independence was noted.  There were no medical conditions to warrant ongoing management (i.e. no fever, pain, infection nor bleeding).  These services could have been provided at a lower level of care.

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

The inpatient hospital admission is not considered medically necessary for this patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type II Diabetes Mellitus
Treatment: Formulary exception for Humalog Kwikpen
(insulin lispro [human])
The insurer denied the Formulary exception for Humalog Kwikpen (insulin lispro [human]).
The denial is overturned. 

The patient is a male with type 2 diabetes, hypertension, and chronic kidney disease. He has tried and failed Novolog Flexpen due to hyperglycemia. His A1C (glycated hemoglobin) was 8.4%. The request for Humalog Kwikpen is under review.

Yes, the health plan should cover the proposed Humalog Kwikpen.

The prior request for Humalog Kwikpen was denied as prior authorization criteria requires a trial of Novolog and Fiasp. This patient has tried and failed Novolog. Novolog is a form of aspart insulin. Fiasp is also a form of aspart insulin, with very similar impact on lowering A1C (glycated hemoglobin) as Novolog insulin in people living with type II diabetes [1]. Therefore, as this patient has tried and failed Novolog, he can reasonably be expected to try and fail Fiasp. Without Humalog Kwikpen, this patient will be at increased risk of hyperglycemia, which can cause retinopathy. Therefore, yes, the health plan should cover the formulary exception for Humalog Kwikpen.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection; Gastritis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld. 

This female patient has with a history of marijuana use, multiple sclerosis (MS), and urinary incontinence who presented to Emergency Department (ED) with complaints of abdominal pain, diarrhea for one day. In the ED, the patient's white blood count and heart rate were increased, urinalysis revealed leukocyte and bacteria. The patient was given Keflex and Toradol injection in ED, and admitted with diagnosis of urinary tract infection (UTI) and gastroenteritis. The patient was given intravenous (IV) fluids, IV Rocephin, and was tested for clostridium difficile. Psychiatry consult recommended Lexapro. The patient had no suicidal ideations. She was transitioned to oral antibiotics. The patient improved and was discharged in stable condition to a facility. 

The insurer denied coverage for the inpatient hospital admission as not medically necessary and noted that the patient presented to the hospital because there was no one to care for her at home. The insurer noted a lack of fever or unstable blood pressure, or decline in kidney failure. The patient was taking Tecfidera for her multiple sclerosis, but stopped several months prior due to lack of access to medical care. 

Per MCG Health Guidelines for UTI Rapid Review Guidelines (RRG), this patient's clinical presentation fails to meet the clinical indications for admission to inpatient care. As per MCG Health guidelines for Urologic Disease General Recovery Guidelines (GRG), this patient's clinical presentation fails to meet the clinical indications for admission to inpatient care. 

Based on the review of the medical record and literature above, the inpatient hospital admission is not considered medically necessary for this patient.

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

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, emesis, fever and shortness of breath
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male who had presented to the emergency department of the facility filing the appeal. The patient had multiple complaints including nausea, emesis, fever and shortness of breath. The patient had a concurrent history of chronic obstructive pulmonary disease (COPD), hypertension, methicillin resistant staphylococcus aureus (MRSA), hepatitis C, and a prior blood transfusion. The patient had some relief with his home inhaler.  

The patient's blood pressure on presentation was 184/101. The bilirubin was 4.2. The white count was 15.7. The hemoglobin was 18.2.  The patient had stopped all his medications for his blood pressure. The patient reported coffee ground emesis and the emergency room (ER) physician documented acute alcoholic gastritis. The patient was noted to have evidenced anxiety and tremors and was placed on librium. An endoscopy showed linear esophageal ulcerations and Cameron's ulcers.

No, the treatment as provided was medically appropriate, but not medically necessary at the level of service provided.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had reported hematemesis without anemia or signs of active bleeding. The patient did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.