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

Diagnosis: Family History of Breast Cancer
Treatment: BRCA 1 and BRCA2 testing
The insurer denied BRCA) 1 and BRCA testing.
The determination is upheld.

The patient has a personal history of cancer and a family history of breast cancer in her mother and her maternal grandmother. The patient has been recommended to undergo genetic testing for breast cancer antigen (BRCA) 1 and BRCA2 and the testing is under review for medical necessity.
The requested health service/treatment of BRCA1 (breast cancer 1), BRCA 2 (breast cancer 2) gene analysis, lab test is not medically necessary for this patient.
There are no data to show that BRCA1 and BRCA2 testing in this setting improves outcomes in patients such as this patient, without a personal history of breast or ovarian cancer, and with a family history of breast cancer in a first and second degree relative, both diagnosed after age 50. The use of this test in this setting is not supported by peer reviewed literature, it is not standard of care, and it is not supported by professional organizations given that there is no evidence of familial adenomatous polyposis, hereditary breast and ovarian cancer syndrome, or Lynch syndrome.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia.
Treatment: Consumer Directed Personal Assistance Service (CDPAS).
The insurer denied Consumer Directed Personal Assistance Service (CDPAS), Increase to 80 Hours per Week.

The health plan's determination is overturned. 

The patient is a male with past medical history of Alzheimer's dementia, hypertension, benign prostatic hypertrophy, chronic kidney disease, osteoarthritis, urinary incontinence, anxiety, and depression who had been assigned Consumer Directed Personal Assistance Service (CDPAS).

Consumer Directed Personal Assistance Service (CDPAS), Increase to 80 Hours per Week is medically necessary for this patient.
The patient has documented progressive chronic medical conditions of Alzheimer's dementia and osteoarthritis. The patient requires at least limited assistance with all activities of daily living (ADL) except toilet use and bed mobility. The patient has no informal helper outside of the hours that he has care from his grandson. The patient has urinary incontinence with unpredictable and unscheduled care needs that span a continuum of time. The insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's current CDPAS hours and/or adaptive equipment and/or medical supplies are not sufficient to meet the patient's Instrumental activities of daily living (IADL) and ADL care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's telephonic assessment also under estimated his assistance needs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS 80 hours per week are 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 his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids and dysfunctional uterine bleeding
Treatment: Procedure to shrink fibroids.
The insurer denied procedure to shrink fibroids.
The determination is upheld.

The patient has uterine fibroids and dysfunctional uterine bleeding. She has received intravenous iron infusion for her anemia. An ultrasound  showed an 11.8 centimeter (cm) uterus with three fibroids, the largest 6.5 cm. The physical exam was normal. She was counseled and opted for the Sonata system for transcervical fibroid ablation and a laparoscopic hysterectomy as an alternative. At issue is the medical necessity of the  procedure to shrink fibroids.

The requested health service/treatment of outpatient surgery services - procedure to shrink fibroids is not medically necessary for this patient.
The safety and effectiveness of the transcervical radiofrequency ablation with ultrasound guidance (e.g., the Sonata System) as a treatment for uterine fibroids have not been established.
In a prospective, single-arm, multi-center, interventional trial, Chudnoff and colleagues evaluate the 12-month safety and effectiveness of trans-cervical radiofrequency ablation (RFA) for the treatment of symptomatic uterine leiomyomas. Trans-cervical ablation was performed on 1 to 10 leiomyomas per patient with leiomyoma diameters ranging from 1 to 5 cm. Treated leiomyomas included all non-pedunculated types. A total of 147 patients were enrolled and treated. There was a decrease in blood loss over the 12 months and a reduction in menstrual bleeding at 12 months. There were significant mean improvements in symptom severity and health-related quality of life (QOL) as well as leiomyoma volume. The authors concluded that trans-cervical ablation was associated with a significant reduction in leiomyoma symptoms with no device-related adverse events (AEs) and a low surgical re-intervention rate through 12 months, demonstrating its potential to safely and effectively treat all non-pedunculated leiomyoma types through a uterus-conserving, incisionless approach. However the procedure does not have long term studies on its effects and does not present superiority to traditional methods of treatment. The standard of care is to obtain endometrial sampling prior to the ablation because hyperplasia/malignancy is contraindicated with the ablation.  Therefore, it is below standard of care to obtain sampling at the time of the ablation which was the case in this situation. The requested procedure was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 
The insurer denied increase in personal care assistance  hours to 7 days a week 12 hours a day. 
The denial is upheld. 

The patient is a female with a past medical history significant for dementia, hypertension, hypertensive heart disease, coronary artery disease, congestive heart failure, hyperlipidemia, hypertensive nephropathy, osteoarthritis and osteoporosis. The patient is receiving Personal Care Assistance (PCA) hours 7 days a week 9 hours a day.
The subject under review is the medical necessity for the request for increase in hours to 7 days per week 12 hours per day. An increase in services was denied by the health plan based on lack of medical necessity.

The requested health service is not medically necessary for this patient.
The services currently being provided are adequate to meet the patient's need in the allotted time. Additional hours are not medically necessary.
The patient is currently approved for 63 hours per week. The patient is requesting 84 hours a week. This was denied based upon lack of medical necessity.
An increase in personal care services was denied by the health plan stating patient does not meet criteria. No changes were noted in activities of daily living with exception of bathing and personal hygiene. Dressing lower body showed improvement. The patient is able to ambulate with a walker. There is no reported significant changes noted in the patient's medical condition. The appeal noted that the patient needs increased hours for medication reminders.
Uniform Assessment System (UAS) State of New York were reviewed from both dates of assessment. The physician statement was reviewed. An appeal request was reviewed.
There has not been a significant change in the patient's physical status between the two assessments which were listed. It was noted on the appeal that the patient needed reminders taking medications and needs help with all locomotion.
However, according to the assessment, the patient is able to ambulate with a walker. There is no reported significant changes noted in the patient's medical condition. The patient ambulates indoors with a cane or walker. She is self-directed with care. No recent hospitalizations or falls were noted. She had a fall 2-1/2 months ago at home. There was noted frequent incontinence of urine. No pressure ulcers were noted. She requires extensive assistance with most activities of daily living (ADLs). The patient was observed transferring from sitting to standing holding her walker and ambulating. The statements appear similar between the two reports. 
The service hours currently provided are adequate to meet the patient's medical needs in the time noted. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not covered. In order for services to be considered medically necessary, the aide must be performing a service such as medically necessary activities of daily living (ADLs) or Instrumental activities of daily living (IADLs).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis.
Treatment: Personal Care Assistance Services: Total of 30 Hours per Week.

The insurer denied Personal Care Assistance Services: Total of 30 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, congestive heart failure, aortic valve disease, urinary incontinence, fatigue, osteoarthritis, decreased appetite, spine deformity, and gait instability who had been assigned Personal Care Assistance Services (PCAS) 19 hours/week. There was a request to increase PCAS and the patient underwent telephonic assessment tool assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with managing finances, stairs, transportation, equipment management, bathing, and dressing lower body while limited assistance with tasks of managing medication, phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use. With tasks of bed mobility and eating the patient was assessed as independent. Notes from the assessment stated the patient lived with her daughter, who was her PCAS aide. The patient had an office visit with her provider noting the daughter was requesting more hours for Home Health Aid (HHA), as she needed more assistance at home for basic needs, and the patient was not eating well. The patient was referred to Physical Therapy and gastroenterology.

Personal Care Assistance Services: Total of 30 Hours per Week are medically necessary for this patient.

The patient has documented chronic medical conditions of gait instability, spinal deformity, osteoarthritis, and urinary incontinence. According to the recent assessment, the patient requires at least limited assistance with all of her activities of daily living (ADL) except for bed mobility and eating. However, the patient's daughter and medical provider have stated the patient has not been eating well and requires meal preparation and prompting. The assessment under estimated the patient's assistance needs for eating and meal preparation. The current hours are not sufficient to meet her ADL care needs. The requested increase in PCA (personal care assistant) hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the Personal Care Assistance Services: Total of 30 Hours per Week are 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: Experimental/Investigational
Decision: Overturned

Diagnosis: Non-sustained polymorphic ventricular tachycardia. 
Treatment: Automatic external defibrillator with integrated electrocardiogram analysis garment type (wearable vest that automatically delivers treatment shock when a life-threatening heart rhythm is detected). 
The insurer denied coverage for the automatic external defibrillator with integrated electrocardiogram analysis garment type (wearable vest that automatically delivers treatment shock when a life-threatening heart rhythm is detected). 
The denial is overturned. 

This is a male patient with a past medical history of ST segment elevated myocardial infarction (STEMI), and ventricular tachycardia (VT).  The records indicated the patient had a myocardial infarction with an ejection fraction of less than or equal to 35.  The Zoll LifeVest was requested for 3 months.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. 

This automatic external defibrillator with integrated electrocardiogram analysis garment type has final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for an automatic external defibrillator with integrated electrocardiogram analysis garment type (wearable vest that automatically delivers treatment shock when a life-threatening heart rhythm is detected). 

An automatic external defibrillator with integrated electrocardiogram analysis garment type (wearable vest that automatically delivers treatment shock when a life-threatening heart rhythm is detected) is the best available treatment for this patient at this time. 

The requested service is likely to be more beneficial than any of the standard treatment/procedures. 

The adverse risks are not increased over standard treatment/services.

The carrier's denial of coverage for an automatic external defibrillator with integrated electrocardiogram analysis garment type (wearable vest that automatically delivers treatment shock when a life-threatening heart rhythm is detected) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Non-sustained polymorphic ventricular tachycardia. 
Treatment: Automatic external defibrillator with integrated electrocardiogram analysis garment type (wearable vest that automatically delivers treatment shock when a life-threatening heart rhythm is detected). 
The insurer denied coverage for the automatic external defibrillator with integrated electrocardiogram analysis garment type (wearable vest that automatically delivers treatment shock when a life-threatening heart rhythm is detected). 
The denial is overturned. 

This is a male patient who had a history of tobacco use and developed persistent chest discomfort, for which he presented to the Emergency Department and was diagnosed with an acute inferior wall myocardial infarction, with peak troponin 35.9.  Coronary angiography revealed 99% mid right and 95% mid left anterior descending coronary artery disease and he was treated with drug eluting stents in both vessels.  Echocardiography revealed left ventricular systolic function (LVEF) 35% with moderate inferior wall hypokinesis and mild anterior wall hypokinesis.  Telemetry revealed polymorphic non-sustained ventricular tachycardia.  He was discharged on aspirin, atorvastatin, citalopram, clopidogrel, and metoprolol, but not on an ACEI [Angiotensin-converting enzyme inhibitors] or ARB [Angiotensin receptor blocker] due to hypotension.  A medical order for a wearable implantable cardioverter defibrillator (ICD)  was written for the device to be fitted and provided.  Cardiology office notes indicate that the patient was compliant with wearing his wearable ICD, with taking his medications and that echocardiography revealed LVEF 35-40%.  The wearable ICD was discontinued, with plans for follow-up by cardiology in 9 months.

The multi-society guidelines include a Level IIB recommendation for use of a wearable ICD for up to 3 months in patients with a myocardial infarction within 40 days who are motivated, on optimal medical treatment, have a LVEF<35%, and would be a candidate for a future implanted ICD.  This patient was a good candidate for this device because he met all of these criteria, thus this device was the best available treatment for primary prevention of sudden cardiac death following his acute ST segment elevation myocardial infarction.  The adverse risks were not greater than that provided by standard medical treatment and this device has final approval by regulatory bodies for its use in this diagnosis.  An automatic external defibrillator with integrated electrocardiogram analysis garment type was more likely to be beneficial than any of the standard treatments for this patient. The adverse risks are not increased over standard therapy. 

The carrier's denial of coverage for an automatic external defibrillator with integrated electrocardiogram analysis garment type (wearable vest that automatically delivers treatment shock when a life-threatening heart rhythm is detected) should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/metabolic/Nutritional-Diabetes Mellitus
Treatment: Pharmacy/Prescription Drugs-Victoza
The health plan denied Victoza as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This is a patient diagnosed with type 2 diabetes mellitus (T2DM) for 18 years. The patient also has recurrent rectal cancer. This request is for Victoza 1.8 milligrams (mg). As reported on the doctor's appeal she has a history of retinopathy (per provider she cannot use Ozempic and Trulicity). She is interested in keeping her weight stable per her oncologist's instruction. She is on Victoza; she is also receiving chemotherapy. Her A1C (percentage of red blood cells that have sugar- coated hemoglobin) was 7 %. 
Victoza is medically necessary for this patient.
Victoza is a long acting glucagon-like peptide-1 (GLP1) agonist that improves glycemic control and has been shown to be beneficial in the treatment of type 2 diabetes (4-8).
The Food and Drug Administration (FDA) label (9) for Victoza is as follows: Victoza is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (1).
Important Limitations of Use (1.1):
-Not recommended as first-line therapy for patients inadequately controlled on diet and exercise (5.1).
-Has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis (5.2).
-Not for treatment of type 1 diabetes mellitus or diabetic ketoacidosis.
-Has not been studied in combination with prandial insulin.
Victoza is indicated in patients who have type 2 diabetes as an adjunct to diet and exercise. All of the formulary alternatives have been associated with increased or worsening diabetic retinopathy. The patient has baseline diabetic retinopathy, the doctor's appeal reports retinopathy, which is a risk factor for worsening of the diabetic retinopathy with treatment with the formulary alternatives. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic idiopathic constipation. 

Treatment: Motegrity.

The insurer denied coverage for Motegrity.

The denial is overturned. 

This is a female patient whose past medical history includes severe malnutrition, gastroparesis, mast cell activation syndrome (MCAS), and chronic idiopathic constipation. Her constipation did not respond to Reglan, fiber, Linzess, or Amitiza. It is also reported that she had failed numerous over-the-counter medications.

UpToDate has an article titled "Management of chronic constipation in adults." Prucalopride is listed as a treatment for severe constipation. Multiple trials were analyzed and showed an improvement in quality of life scores. This improvement was maintained up to 18 months.

This patient has severe constipation and has failed multiple other regimens including Linzess and Amitiza. It is also reported that she failed the over-the-counter medications. Prucalopride is appropriate for patients who have chronic idiopathic constipation and have failed other treatments. 

The healthcare plan did not act in the best interest of the patient or with sound medical judgment. Motegrity (prucalopride) is a medically necessary treatment.  

The insurer's denial of coverage for Motegrity is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 

Treatment: D2751 white glass with metal crown, tooth #30 and D2751 white glass with metal crown, tooth #31. 

The insurer denied coverage for D2751 white glass with metal crown, tooth #30 and D2751 white glass with metal crown, tooth #31. 

The denial is upheld. 

This is a male patient who presented to the dentist for comprehensive care.  The treating dentist recommended full coverage crowns for tooth #30 and tooth #31.  The insurer has denied these services stating there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service. 

The objective documentation provided for review include copies of periodontal records, clinical intraoral images, and radiographs.  It appears that there is no evidence of fracture or other pathology specifically affecting #30 or #31 based on the images provided for review.  There does not appear to be any radiographic evidence of caries. The clinical photographs and radiographs do not substantiate the requested dental services as enumerated above and therefore the crowns are deemed not medically necessary. 

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

The insurer's denial of coverage for D2751 white glass with metal crown, tooth #30 and D2751 white glass with metal crown, tooth #31 is upheld.  Medical Necessity is not substantiated.