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

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Home Health Care
The health plan denied the requested  increase in PCA (personal care assistant hours). 
The health plan's determination is overturned.

The patient is a female with a past medical history significant for cerebral palsy, rheumatoid arthritis, osteoporosis, and an unsteady gait. She is incontinent of bladder. She depends upon a wheelchair for ambulation. This review is for the increase in personal care assistant services from 52 hours a week, to 24 hours per day 7 days a week split shift, for a total of 168 hours a week. Services were denied based upon medical necessity.
At issue is the medical necessity of the requested personal care assistant (PCA) hours.

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

Yes. The requested health service/treatment of increase Personal Care Assistance (PCA) services from 52 to 24 hours a day 7 days a week split shift services, for a total of 168 hours per week is medically necessary for this patient.
The patient is a female with a past medical history significant for cerebral palsy with resulting disability, inability to manage her affairs, activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She is requesting an increase in personal care services from 52 hours a week to 168 hours a week.
The patient needs extensive assistance with medications and bed mobility. She needs maximal assistance with meal preparation, shopping, bathing, dressing upper and lower body, walking, locomotion, toilet use and transfer. The patient is totally dependent for housework.
The Uniform Assessment System (UAS) State of New York noted a total of 52 hours a week. There are notes that the patient uses incontinent supplies/chuck pads at night. No informal helper is noted.
A review of her physical therapy notes, which were the most recent evaluations of her functional status shows that the patient has extensive and maximal assistance needs for most ADLs. This also includes ADLs which are unscheduled such as incontinence and also toileting activities.
The patient has significant medical needs for personal care services which are both scheduled and unscheduled.
A physician note notes that the patient is totally dependent on staff for all of her care needs.
The patient has significant medical needs for personal care services which are both scheduled and unscheduled.  However, these scheduled needs cannot be provided in the allotted time.  The patient's unscheduled needs mainly include transfers and toileting, and incontinence care and cannot be provided in the allotted time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Floaters, Diabetes Mellitus
Treatment: Treatment of eye lesion with laser; bilateral.
The insurer denied Treatment of eye lesion with laser; bilateral.
The determination is upheld.


The patient has a history of floaters and diabetes, diagnosed as background diabetic retinopathy in notes. In the assessment and plan, diabetic macular edema is discussed and the focal laser for treatment is discussed with the patient. The focal laser therapy was denied by the health plan due to the enclosed documentation not demonstrating macular edema.
At issue is the medical necessity of treatment of eye lesion with laser; bilateral.
The requested treatment of eye lesion with laser; bilateral is not medically necessary.
The enclosed documentation shows visual acuity of 20/25 and 20/50 in the right eye (OD) and left eye (OS) respectively. The patient is noted to have diabetic macular edema (DME) on the retinal portion of the exam. DME is diagnosed as retinal thickening or hard exudates within one disc diameter of the center of the macula. Also submitted are spectralis optical coherence tomography (OCT) results showing normal macular thickness with no cysts in either eye. Additionally, fluorescein angiography (FA) of both eyes is submitted on that date, as well, which shows no leakage of fluid consistent with DME. The pictures submitted do not clearly demonstrate hard exudates near the macula. Treatment is recommended only when DME is center involving (Heidelberg's OCT is 305 microns or worse in women and 315 or worse in men) and the visual acuity is worse than 20/25. The submitted documentation shows normal retinal thickness on Heidelberg OCT. The addition of no leakage on FA corroborates this. There is no evidence of DME in the submitted documentation. OCT is a sensitive method for objective evaluation of macular thickness. OCT can also be used to calculate the standardized change in macular thickness. OCT is more sensitive at detecting retinal thickening than is biomicroscopy. There is no thickening of the macula on the submitted OCT documentation. On FA, focal clinically significant macular edema (CSME) is characterized by focal leakage from microaneurysms or capillaries is present whereas diffuse DME is diagnosed when poorly demarcated areas of capillary leakage are present on the FA. Neither is present in the submitted documentation. Therefore, the treatment is not necessary. There is no demonstrated macular edema requiring treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dental problems
Treatment: Dental Implant Placement: Tooth Numbers 10, 11, 14, 15, 2, 3, 4, 5, 6, 7, 8, and 9. 
The insurer denied Dental Implant Placement: Tooth Numbers 10, 11, 14, 15, 2, 3, 4, 5, 6, 7, 8, and 9. The health plan's determination is upheld.

The patient is a female who presents for evaluation and treatment of teeth # (number) 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, and 15. Provided for review are previous letters of appeal and denial, a narrative from the treating provider, a full mouth panoramic radiograph from an unknown date, one page of American Dental Association (ADA) claim forms, a health history, and single clinical note.

Dental Implant Placement: Tooth Numbers 10, 11, 14, 15, 2, 3, 4, 5, 6, 7, 8, and 9 is not medically necessary for this patient.
There is nothing in the documentation that indicates that the patient has had a partial denture provided and then that the partial denture did not function correctly. There is nothing in the provided documentation that shows that the patient even uses a partial denture currently. Further, based on the provided documentation, the teeth do not appear to have been prepped for a partial denture in the past. There has been no evaluation of any current prosthesis. The notes have failed to evaluate the remaining dentition, document any of the decay, nor indicate anything specific to the patient. The letter provided by the treating provider is also in direct conflict with the radiographic documentation provided which shows that the patient currently has a fixed partial denture with evidence of underlying decay, not any type of removable partial denture. The need for implants has not been established. Hence, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin/Psoriasis
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested medication, Otezla, as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with psoriasis to the scalp and extremities, treated with topicals. The provider is requesting Otezla.
At issue is the medical necessity of the requested medication, Otezla.

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

Yes. Otezla (apremilast) is a phosphodiesterase inhibitor, and therefore its mechanism of action is different from injectable biologics. Apremilast works intracellularly to modulate pro- and anti-inflammatory mediators.
The ESTEEM trial (randomized, double-blind) documented favorable response to apremilast over placebo at week 16. Side effects were generally mild and did not result in discontinuation. Psoriasis Area and Severity Index (PASI75) was seen in 33 (percent) % of patients. Efficacy has been demonstrated in psoriatic arthritis as well, and it was first Food and Drug Administration (FDA) approved for spondyloarthropathies.
However, there are no studies to date comparing the efficacy of Otezla to other systemic medications for psoriasis. It is an oral therapy and requires less medication monitoring (current data do not indicate a need for laboratory monitoring) and is not immunosuppressive. Otezla is now among the growing number of systemic therapies for psoriasis. Currently there are no evidence based medical guidelines indicating which therapy is best or delineating a step-wise approach to psoriasis. The guidelines of care for the management of psoriasis state that each patient requires individual tailoring, and a stepwise approach is not recommended. No evidence-based literature could be found to support the use of other therapies before Otezla.

According to the multidisciplinary review (Gresham et al, 2021), vaccine efficacy may be reduced in patients receiving systemic immune-targeting therapies because of the impaired immune response in these patients. There is a trend toward a decreased immune response and vaccine immunogenicity in patients on systemic immunotherapies, particularly patients receiving Azathioprine, Cyclosporine, Methotrexate, Mycophenolate Mofetil, or JAK  (inhibitor drugs). Therefore, it would not be advisable to use a systemic therapy in this patient that can decrease vaccine efficacy and place this patient at higher risk of (coronavirus) COVID-19 complications when a safer alternative is available.

Otezla is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute migraine
Treatment: Nurtec ODT
The insurer denied Nurtec ODT.
The determination is overturned.


The patient has a diagnosis of acute migraine. Case notes indicate that the patient has tried and failed numerous triptans including frovatriptan, zolmitriptan, eletriptan, and almotriptan. The provider appealed the determination because triptans were ineffective for the patient. The medical necessity of treatment with Nurtec orally disintegrating tablets (ODT) is under review.

The requested Nurtec ODT is medically necessary. Nurtec ODT is safe and effective for the treatment of acute migraine. The efficacy of the drug has been demonstrated in multiple randomized controlled trials. Nurtec ODT is an appropriate drug for treatment of acute migraine when a patient has tried and failed first-line therapy, or triptans. In this clinical scenario, the patient has tried and failed four triptans: frovatriptan, eletriptan, zolmitriptan, and almotriptan. The patient did not respond to multiple triptans. As such, the standard of care is trial of a "gepant" agent, such as Nurtec ODT (rimegepant). The patient does not have a contraindication to the use of this drug and other remaining triptans are likely to be less effective than this drug.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The health plan's determination is overturned. 

The patient is a male who presented to the emergency department (ED) with difficulty breathing. Additional symptoms included shortness of breath, rhinorrhea, and cough. There was no fever, vomiting, or diarrhea. He was reportedly unable to complete sentences at home due to his increased work of breathing. Past medical history includes preterm birth at 36 weeks gestation.
Emergency department (ED) vitals were temperature (T) 36.6 Celsius (C), heart rate (HR) 109, respiratory rate (RR) 35, blood pressure (BP) 118/67, oxygen (O2) saturation 99% on room air.
Physical exam was notable for tachypnea and belly breathing with subcostal retractions. Auscultation revealed coarse breath sounds bilaterally. He was given a DuoNeb with little improvement; placement on high flow nasal canula produced decreased work of breathing. Chest x-ray revealed peribronchial cuffing consistent with bronchiolitis or reactive airway disease. Respiratory swabs were obtained, and the patient was admitted to the hospital. He was also given Solumedrol and continued on albuterol and high flow nasal canula. Symptoms improved overnight and the patient was discharged home the following day. At issue is whether the inpatient hospitalization was considered medically necessary.

The health plan's determination is overturned.

The inpatient stay is considered medically necessary for this patient.
This patient presented to the ED with acute respiratory distress. His symptoms improved with respiratory support in the form of high flow nasal canula, which can only be performed in a hospital setting. Thus, this patient's overnight inpatient hospitalization was considered medically necessary due to the treatment and close monitoring required.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Braces and dental visits (codes D8080 and D8670)

The insurer denied coverage for braces and dental visits (codes D8080 and D8670).

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth (mandibular left canine) when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. 

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, a Handicapping Labio-Lingual Deviation (HLD) index 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.

ln this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met, as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer's score on the HLD index is 14 points (4 overjet, 4 overbite, 3 ectopic eruption, 3 labiolingual spread), which is below the required 26 points.

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. This is confirmed by several studies referenced below.

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.

Braces and dental visits (codes 08080 and 08670) are not considered medically
necessary for this patient.

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

The insurer's denial of coverage for braces and dental visits (codes D8080 and D8670) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Appendicitis
Treatment: Inpatient stay

The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient was admitted with a one-day history of abdominal pain. He was found to have appendicitis. He was taken to the operating room for an uneventful laparoscopic appendectomy. Post-operatively he did well and was discharged home. 

The inpatient stay is not medically necessary.

Current protocols and care pathways for simple appendicitis include single dose antibiotics, surgery and then discharge when meeting criteria of afebrile, pain control, tolerating liquids; this is standard of care in simple appendicitis. Most protocols have a 4-6-hour window of fluids, advancing diet, pain control with non-steroidal medications, and discharge. The overnight stay prior to surgery appeared to be due to logistics of availability and timing- not care related - and could be at a lower level of care.
Simple appendicitis can be treated at a lower level of care. Administration of intravenous (IV) antibiotics as well as performing an appendectomy are standard of care. Reference one below indicates that this patient received care within the guidelines of the standards of practice.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Inpatient stay

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

The patient is a  male with a past medical history significant for human immunodeficiency virus (HIV) and polysubstance abuse who came to the psychiatric emergency department for detox, however, he was found to have hypokalemia and pneumonia, therefore transferred to the telemetry unit for further management.
Reportedly, at the time of the initial evaluation, the patient was found to have a fever as well as a serum potassium level of 3.4. The chest x-ray demonstrated right lower lobe pneumonia that was confirmed by a computed tomography (CT) scan. COVID rapid test came back negative. The patient was admitted to the hospital with urinary tract infection, pneumonia, hyperkalemia, HIV infection, polysubstance abuse.

The inpatient level of care was medically necessary in this clinical case, since the patient was most likely immunocompromised due to inadequately treated HIV infection in the setting of pneumonia, possible urinary tract infection, and higher risk of withdrawal for multiple substances.
This patient presented to the hospital with a high fever and was suspected to have community-acquired pneumonia as well as a urinary tract infection. This patient was immunocompromised. His CD4 count was relatively low. There was no information that his HIV infection was adequately treated or was under control.
Therefore, he required treatment with intravenous antibiotics while waiting for the culture results, and monitoring his respiratory status, response to antibiotics, and possible side effects of the antibiotics. Furthermore, there was a high probability that the patient could develop withdrawal from alcohol and other substances. Therefore, he required very close monitoring for that.
In addition, based on the patient's history, there was a high probability that he would not be compliant with the treatment of his pneumonia as an outpatient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Irritable Bowel Syndrome (IBS). 
Treatment: Current procedural terminology (CPT) code 83993, calprotectin, fecal testing. 

The insurer denied coverage for current procedural terminology (CPT) code 83993, calprotectin, fecal testing. 

The denial is overturned. 

The patient has a history of inflammatory bowel disease/syndrome (IBD/S). It is reported that she has been having persistent bloating, gas pains, and diarrhea. A stool for fecal calprotectin was ordered. 

Up To Date has an article titled "Approach to the adult with chronic diarrhea in resource-rich settings." Fecal calprotectin is discussed in the section on general laboratory tests. The article states that fecal calprotectin levels are increased in intestinal inflammation and may be useful for distinguishing inflammatory from non-inflammatory causes of chronic diarrhea. If fecal calprotectin levels are normal a diagnosis of IBD is unlikely. 

An article has been provided for review titled "Calprotectin in Daily Practice: Where do we Stand." (Digestion 2017;95:293-301). The conclusion was that fecal calprotectin is a reliable marker of intestinal inflammation with good clinical sensitivity. It is useful in the differential diagnosis between Inflammatory Bowel Disease and Irritable Bowel Syndrome. 

The scientific literature supports the use of fecal calprotectin as leading to better health outcomes. The FDA [Food and Drug Administration] has cleared calprotectin as a marker intended for differentiating Irritable Bowel Syndrome from IBD. Since the patient has a diagnosis of IBS and is having chronic diarrhea she is a good candidate for the test. It is one of several tests that can help differentiate IBS from IBD. There are no adverse risks from obtaining this test. The use of fecal calprotectin has been shown to be beneficial for patients with Irritable to rule out Inflammatory Bowel Disease. 

The carrier's denial of current procedural terminology (CPT) code 83993, calprotectin, fecal testing performed should be overturned.  It is more beneficial than any other standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Irritable Bowel Syndrome (IBS). 
Treatment: Current procedural terminology (CPT) code 83993, calprotectin, fecal testing. 

The insurer denied coverage for current procedural terminology (CPT) code 83993, calprotectin, fecal testing. 

The denial is overturned. 

The patient has a past medical history of irritable bowel syndrome.  The patient was noted to have a history of digestive issues.  The patient had an urgency to move bowels and had multiple stools per day, which was new.  The physical examination revealed the bowel sounds were normal.  The physician recommended a celiac screen, probiotics, and an endoscopy.  The patient underwent fecal calprotectin testing. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. Calprotectin, fecal testing has final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for current procedural terminology (CPT) code 83993, calprotectin, fecal testing. 

This is the best available treatment for this patient at this time.  The adverse risks are not increased over standard treatment/services. 

Inflammatory bowel disease is a consideration in any chronic diarrhea.  When routine lab testing is negative, further testing is required to evaluate for inflammatory bowel disease.  An appropriate step would be to check for fecal calprotectin which can determine whether further more elaborate testing such as colonoscopy is indicated. 

Fecal calprotectin levels are increased in intestinal inflammation and may be useful for distinguishing inflammatory from noninflammatory causes of chronic diarrhea. Calprotectin is a zinc and calcium binding protein that is derived mostly from neutrophils and monocytes. It can be detected in tissue samples, body fluids, and stools, making it a potentially valuable marker of neutrophil activity . If fecal calprotectin is normal, a diagnosis of IBD (irritable bowel disease) is unlikely. If fecal calprotectin or fecal lactoferrin levels are above the reference range, we proceed with ileocolonoscopy and biopsy to confirm the diagnosis of IBS. 

The carrier's denial of current procedural terminology (CPT) code 83993, calprotectin, fecal testing should be overturned.  It is more beneficial than any other standard treatments.