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

Diagnosis: Progressive dementia and Parkinson's disease

Treatment: Personal care assistance (PCA) services 24 hours per day, 7 days per week (Monday through Sunday), live in

The insurer denied coverage for personal care assistance (PCA) services 24 hours per day, 7 days per week (Monday through Sunday), live in

The denial is overturned

 
This is an advanced elderly female with progressive dementia and Parkinson's disease. She will be living alone, as her daughter is planning to move out. She requested personal care assistance (PCA) services 24 hours per day, 7 days per week (Monday through Sunday) live-in. The insurer approved PCA services 8 hours/day, 7 days/week for a total of 56 PCA services/week, leading to an external review.

According to the Uniform Assessment System (UAS) report the patient' cognition is described as "moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." She is reportedly totally dependent to maximal assistance for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient also reportedly requires maximal assistance for bathing, personal hygiene, dressing, eating, bed mobility (has a hospital bed) and toilet transfer/use. She is reportedly total dependent for locomotion (requires a Hoyer lift) and is non-ambulatory. The patient is frequently incontinent of bladder and occasionally incontinent of bowel. There has been no reported activities of daily living (ADL) change or falls over the prior 90 days. 

The letter from the patient's treating physician describing her clinical condition and need for additional PCA services were reviewed. The office visit note was also reviewed. The documented impairments including dementia, progressive Parkinson's disease, functional tetraplegia and recent (healed) pressure ulcers support the assertion of the patient' functional incapacity and need for additional PCA services. This physician would agree; the patient' clinical condition, cognitive impairment and functional decline are at a level and unpredictable as to require the requested PCA services 24 hours per day, 7 days per week (Monday through Sunday) live-in. The patient clearly has day and night time needs including repositioning in bed as well as body positioning to avoid respiratory compromise and joint contractures. Based on the clinical records, a live-in PCA is likely capable of consistently obtaining approximately 5 hours of uninterrupted sleep over the course of a 24 hour shift. Based on the documents reviewed the patient's functional needs are more appropriately provided and maintained by the requested PCA services 24 hours per day, 7 days per week (Monday through Sunday) live-in.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care assistance (PCA) services 24 hours per day, 7 days per week (Monday through Sunday), live in services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Vtama 1% EX Cream
The insurer denied: Vtama 1% EX Cream
The denial is overturned.

The patient is an adult female. She has a history of guttate psoriasis. Per the chart notes, she is noted to have had poorly controlled psoriasis in the past, with psoriasis noted on the chest, abdomen, back and lower extremities. This was causing significant psychological distress to the patient and affecting her quality of life. She is currently taking Sotyktu, Vtama, and Zoryve with improvement on this regimen per provider notes. Otherwise, in the past, the patient has tried calcipotriene, mometasone and triamcinolone per the denial letter from the health plan and the attached past pharmacy claims. There is no documentation of tacrolimus or pimecrolimus use. Since the patient is of childbearing potential, methotrexate and cyclosporine were not recommended by her provider. Per provider notes, the patient would like to continue Vtama 1% cream, as this has been efficacious in the past and it was covered by previous insurance. However, the health plan denied this, as the patient has not trialed tacrolimus or pimecrolimus. This denial is being appealed. The request was denied as the patient has not tried tacrolimus or pimecrolimus or has a documented reason why the patient cannot use these.

The requested Vtama is medically necessary.

Tapinarof (Vtama) cream has been studied for the treatment of psoriasis and has been shown to be efficacious, even in classic plaque psoriasis. On the other hand, in clinical practice, tacrolimus and pimecrolimus are mainly used in intertriginous or inverse areas. The records from the provider state that the patient has more classic plaque psoriasis rather than inverse psoriasis. Therefore, while there have not been any head-to-head trials comparing tapinarof to tacrolimus or pimecrolimus, it is reasonable to use tapinarof over tacrolimus or pimecrolimus in this patient given the distribution of the psoriasis and the prior efficacy of tapinarof in this patient per chart notes. This patient has documented efficacy to Vtama per notes and is currently using Vtama; due to this, denying this medication may result in destabilization of disease. Moreover, while the plan guidelines state that tacrolimus or pimecrolimus should be used prior to Vtama, in clinical practice, tacrolimus and pimecrolimus are most useful for inverse psoriasis (or psoriasis in intertriginous areas). This patient has documented plaque psoriasis (not mainly in intertriginous areas). Therefore, due to the distribution of psoriasis and prior efficacy of Vtama, Vtama is preferred for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes
Treatment: Formulary exception for Mounjaro 10mg (milligrams) / 0.5mL (milliliter) Pen
The insurer denied: Formulary exception for Mounjaro 10mg (milligrams) / 0.5mL (milliliter) Pen
The denial is upheld.

The patient is an adult female diagnosed with T2DM (type 2 diabetes mellitus). This request is for Mounjaro. As per the visit note dated last month, the patient is on Mounjaro. She has T2DM (type 2 diabetes mellitus), Fatty liver and HLD (hyperlipidemia). She failed metformin (diarrhea and gas); Glumetza; Actos; Bydureon; Trulicity (due to gastrointestinal 
problems); Ozempic (due to gastrointestinal problems) and Januvia. The patient's A1C (glycated hemoglobin) last month was 5.7 % (percent). Three years ago, it was 8.4 %.

The health plan should not cover the Formulary exception for Mounjaro.

The patient has failed Trulicity and Ozempic due to gastrointestinal symptoms. The patient can try Victoza, which is among the health plan's preferred formulary alternatives, as it is reasonably expected to be as effective as the requested medication. The requested medication Mounjaro (Trizepatide) is FDA (United States Food and Drug Administration) approved for the treatment of adults with type 2 diabetes. It is a GLP-1 
(glucagon-like peptide 1) and GIP (glucose-dependent insulinotropic polypeptide) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c (glycated 
hemoglobin) as well as weight loss (1-3). There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American diabetes Association guidelines recommend using GLP-1 (glucagon-like peptide 1) receptor agonists as a first line agent. There is no preference for the requested medication over GLP-1 (glucagon-like peptide 1) receptor agonists (4). The patient can try one more formulary alternative: Victoza. The request is not consistent with generally accepted standards of medical practice and is therefore not medically appropriate. Therefore, the health plan should not cover the formulary exception for Mounjaro.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: interstitial lung disease (ILD)
Treatment: Durable Medical Equipment: High-Flow Oxygen (6 Units)
The insurer denied Durable Medical Equipment: High-Flow Oxygen (6 Units)
The health plan's determination is overturned. 

The patient is a young girl with a progressive autoimmune interstitial lung disease (ILD), who has been using an Airvo device for the provision of oxygen (O2) by high-flow nasal cannula (HFNC).
Multiple medical records have been submitted in support of the appeal, accompanied by letters of medical necessity and an explanatory note from the patient's mother. 

The requested Durable Medical Equipment: High-Flow Oxygen (6 Units) is medically necessary for the patient.
The patient is suffering from an advanced and progressive ILD and as such is requiring increasingly growing amount of respiratory support, now well in excess of 5 liters/minute of O2 (oxygen). This is completely expected. An important goal of care for such patients is to provide them with optimal respiratory support in order to enable them to be as active and mobile as possible. Being active and mobile not only improves the patients' quality of life but also retards the progression of the disease. Moreover, being active and mobile is sine-qua-non for lung transplant candidacy, and, for many patients with ILD, lung transplantation is the ultimate life-saving procedure.
At this point in her disease progression, she clearly does not need the kind of support a ventilator would provide. Moreover, being supported by a ventilator would render her less mobile. Therefore, the use of a ventilator would be inappropriate.
The provided medical records support the need for and the adequacy of the requested device. It is less invasive than a ventilator and it enables a greater degree of mobility.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: Braces and monthly visits

The insurer denied coverage for braces and monthly visits

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, ectopic eruption and anterior crowding among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 31 total points. 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 attaining 16 points by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. 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 completes the second portion of the index arriving at 31 points to justify orthodontic care. The reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care. 

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

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for braces and monthly visits is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee Osteoarthritis
Treatment: CT scan of right knee
The insurer denied the CT scan of right knee.
The determination is overturned.

This is a female patient with advanced right knee osteoarthritis. She opted to undergo robotic assisted right total knee replacement so her surgeon ordered a computed tomography (CT) scan of her right knee for the pre-operative planning of this operation. The patient's health plan denied coverage of the knee CT scan with a determination that it was not medically necessary. At issue in this case is the medical necessity of the pre-operative CT scan of the knee for Mako robotic assisted right total knee arthroplasty.

The requested health service/treatment of radiology services-CT scan of right knee for robotic assisted total knee replacement is medically necessary for this patient. The provided medical records document that this patient had successful left total knee replacement surgery using Mako robotic assisted technology. She failed conservative management of advanced right knee osteoarthritis and opted to undergo similar Mako robotic assisted total knee replacement on the right knee as well. Thus, the medical necessity of the total knee replacement is established based upon the supplied documentation in the records. The United Healthcare criteria for pre-operative CT scanning of the knee for intraoperative navigation is therefore satisfied. The policy states that a CT scan of the knee is appropriate for surgical planning using intraoperative navigation for joint replacement when the knee replacement is deemed medically necessary. Lastly, recent articles in the peer-reviewed orthopedic literature have documented the advantages of robotic assisted total knee replacement. A recent article published by Zhang and colleagues in 2022 concluded that "Robotic assisted total knee arthroplasty demonstrated improved accuracy of component positioning and patient-reported outcomes." Therefore, the medical necessity of the pre-operative CT scan for robotic assisted total knee replacement in this case is established. This determination is based upon the provided records which demonstrate that she has failed conservative management of advanced right knee osteoarthritis and the current literature that has proven the advantages of robotic assisted total knee replacement surgery using CT scanning as a pre-operative planning tool.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sarcoidosis, osteoarthritis, metastatic bladder cancer
Treatment: consumer-directed personal assistance services (CDPAS) 7 days per week, 24 hours per day, live in; 91 hours per week.
The insurer denied coverage for consumer-directed personal assistance services (CDPAS) 7 days per week, 24 hours per day, live-in: 91 hours per week.
The denial is: Overturned.
 
This is an elderly adult patient with chronic medical problems including sarcoidosis, osteoarthritis, and more recently diagnosed metastatic bladder cancer. The patient lives alone in a private residence. The insurer reduced their consumer-directed personal assistance services (CDPAS) from 7 days/week, 24 hours/day live-in; 91 hours/week to 7 days/week, 10 hours/day (70 hours/week); leading to an external review.

The Uniform Assessment System (UAS), was reviewed. The patient's cognition is described as modified independent. The patient reportedly requires maximal assistance due to total dependence on completing much of their Instrumental Activities of Living (IADLs) tasks including meal preparation, ordinary housework, and shopping. The patient reportedly requires extensive assistance for bathing, personal hygiene, dressing, and toilet transfer/use. Limited assistance is reportedly needed for bed mobility, eating, locomotion, and ambulation. The patient reports being infrequently incontinent of the bladder and continent of the bowel. The patient's activities of daily living (ADL) status has reportedly declined over the prior 90 days. There have been no reported falls over the prior 90 days. The patient's functional ability has also declined when compared to the previous UAS report.

Based on the enclosed clinical documents, the patient does have a medical condition, functional incapacity, and level of care that requires resumption of the previously approved CDPAS 7 days per week, 24 hours per day, live-in; 91 hours per week. The letters from treating physicians respectively, describing the patient's clinical condition were reviewed. Of particular note is the patient's more recent diagnosis of metastatic urothelial/bladder cancer with associated bladder/bowel incontinence, bone pain, and progressive balance deficits. The Nighttime (care) Logs were also reviewed, demonstrating continued care requirements during the evening hours. As noted earlier in this report, the patient's functional ability has declined when compared to the previous UAS. Based on the more recent clinical notes, the patient's functional ability has likely continued to significantly decline. Based on the documents reviewed, the patient's functional and home care needs are more appropriately provided and maintained by resuming CDPAS from 7 days/week, 24 hours/day live-in: 91 hours/week.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for consumer-directed personal assistance services (CDPAS) 7 days per week, 24 hours per day, live-in; 91 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hemorrhagic cyst versus ovarian torsion

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient was an adult female who presented to the Emergency Department (ED) with complaint of abdominal pain of 1 week duration. Evaluation was consistent with a hemorrhagic cyst versus ovarian torsion. Vital signs were stable and she was afebrile. She was admitted overnight for observation to rule out ovarian torsion. 

This patient presented with abdominal pain and stable vital signs. Findings were suggestive of an ovarian cyst and possible torsion. The classic presentation of ovarian torsion is the acute onset of pelvic pain, often with nausea and possibly vomiting, in a woman with an adnexal mass. Pelvic ultrasound is the first line imaging study for patients with suspected ovarian torsion. A definitive diagnosis of ovarian torsion is made by direct visualization of a rotated ovary at the time of surgical evaluation. The decision to proceed with surgery is based upon a clinical diagnosis, which is often based upon the presence of acute pelvic pain and an adnexal mass with a sonographic appearance consistent with torsion, and after exclusion of other conditions. 

This patient's presentation,  as per providers' notes, was suspicious for torsion and she was admitted for observation. Observation does not require admission. The patient could have been observed in the ED. If pain worsened, then a laparoscopy would have been performed. If the pain improved, then she could have been sent home with outpatient follow-up for her ovarian cyst. Inpatient admission was 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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, cough, shortness of breath
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male that was hospitalized for chest pain and chronic obstructive pulmonary disease in acute exacerbation (COPDAE). He presented to the emergency department for evaluation of chest pain, cough, and shortness of breath. The patient's past medical history was remarkable for known chronic obstructive pulmonary disease (COPD), cigarette smoking, chronic kidney disease (CKD), and hypertension. Vitals were stable. Oxygen saturation was 95% (percent) or greater on room air. There were rhonchi on his physical exam. Electrocardiogram (EKG) showed sinus rhythm, left axis deviation, and nonspecific T-wave abnormality. Troponin panel was negative. Blood urea nitrogen (BUN) and creatinine (Cr) were elevated to 47 and 3.56, respectively. Chest computed tomographic angiography (CTA) revealed stable aneurysmal dilatation of the aortic root and no dissection or pulmonary embolism (PE). Nuclear stress test was negative. The patient was treated with antibiotics for community-acquired pneumonia (CAP) consisting of right lung infiltrates and transient hypertension using oral hydralazine and amlodipine. The requested coverage for Inpatient Hospital Admission was denied as based on the policy and the patient is appealing the decision.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, hypoxemia, acute respiratory failure, mental status changes, pulmonary edema, angina with acute coronary syndrome, pulmonary embolism, acute myocardial infarction, complicated pneumonia, hypertension requiring inpatient hospitalization, sepsis, stroke, or any other medical condition, symptom, or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received for uncomplicated chronic obstructive pulmonary disease in acute exacerbation and community-acquired pneumonia like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the requested health service was not medically necessary.