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

Diagnosis: Lewy body dementia
Treatment: Home Care / Personal Care home health care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per day (Live In)
The insurer denied: Home Care / Personal Care home health care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per day (Live In)
The denial is: Overturned.

The patient is a female with medical history notable for Lewy Body dementia. The patient is approved for 56 hours per week of level 2 personal care services. The patient and her care team requested an increase to 24-hour live-in services, which was denied by the health plan.
The patient's physician wrote a letter of medical necessity for this appeal. The letter reviews the patient's functional and medical status. She has Lewy Body dementia; she is not able to direct her own care. She requires assistance with nearly all functional needs. Because she requires assistance with toileting, which is "a 24/7 unscheduled need requiring assistance," the physician states that live-in care is medically necessary. They provide additional detail and background regarding her cognitive and functional deficits.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone in an apartment. Her cognition is severely impaired. She is oriented to name only and is unable to direct her care. She is unable to remember to complete any tasks and has a history of wandering. For her Instrumental activities of daily living (IADLs), she requires total dependence for meals, housework, finances, medications, stairs, and shopping. For her activities of daily living (ADLs), she requires maximal assistance for bathing. She requires extensive assistance for hygiene, dressing, walking, locomotion, toilet transfer, and toilet use. Ambulation is very limited; she uses a walker for short distances with human support. She is frequently incontinent of urine and uses pull-ups. A task tool associated with the assessment recommended 46 hours per week to address her personal care needs.

The requested health service of Home Care / Personal Care home health care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per day (Live In) is medically necessary for this patient.
The patient requires human assistance for all ADL's and IADL's. She has advanced dementia and is not able to direct her own care. She cannot be expected to be left alone as she does not have the ability to call for assistance if needed. She requires hands-on assistance for all ADL's. She cannot toilet independently and has incontinence. These needs will be unscheduled and continuous by nature, and thus she will require continuous live-in support.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Home Care / Personal Care home health care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Live In). 
The insurer denied: Home Care / Personal Care home health care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Live In). 
The denial is: Overturned.

This is a case review for a female with medical history notable for frailty with recent hip fracture, wheelchair bound status, dementia, and incontinence. The patient was approved for 40 hours per week of level 2 personal care services. The patient and her care team requested an increase to 24 hours per day (live-in) personal care services, and this request was partially denied by the health plan; they did approve an increase to 56 hours per week. This denial is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference with her son present. The patient lives alone. Her cognition was minimally impaired; she was alert and oriented to person and place only and is not self-directing in her care. For her Instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, stairs, and shopping. She requires extensive assistance for finances, medication, and phone use. For her activities of daily living (ADLs), she requires total dependence for bathing, dressing lower body, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She is unable to bear weight and is wheelchair-bound. She is frequently incontinent of urine and occasionally incontinent of stool. Compared with a prior UAS, she showed a decline in function across several IADL's and ADL's.

The requested health service of Home Care / Personal Care home health care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Live In) is medically necessary for this patient.
The patient is wheelchair-bound and requires hands-on assistance for all functional needs. She has dementia and is not able to direct her own care. She is frequently incontinent of urine and requires total dependence for toileting. She lives alone. She cannot be expected to manage these needs by herself. By definition, she requires continuous 24-hour care for her unscheduled and periodic personal care needs such as toileting. Live-in care is appropriate for her given that she has no established nightly needs and a live-in aide would be reasonably expected to sleep overnight.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Mounjaro. 
The insurer denied Mounjaro. 
The determination is upheld. 

This is a female patient with a history of obesity. She is requesting a formulary exception for Mounjaro. The plan denied the request because they did not receive documentation that the patient tried and failed at least three out of the four formulary alternatives that include Ozempic, Rybelsus, Trulicity, and Victoza. In an appeal letter, the patient's provider indicated that the patient was treated with metformin for years "without any improvement", and that she took Ozempic "but this medication was also denied coverage. There are no medical records for review in the documentation provided. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects. 

There is no evidence that the formulary drugs will be or has been ineffective or would not be as effective as the non-formulary drug Mounjaro. All medications, including the formulary preferred drugs as well as the non-formulary requested medication have a similar side effect profile and there is no evidence that the non-formulary drug would have less adverse effects. 

There is no evidence that the patient has tried and failed three out of the four preferred formulary drugs which include Ozempic, Rybelsus, Trulicity, and Victoza. There are no clinical trials that support the concept that the requested non-formulary medication, Mounjaro, would be safer or more effective than the formulary options.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Ozempic (1 MG/DOSE) 4MG/3ML SC SOPN (1 milligram per dose 4 milligrams per 3 milliliters subcutaneous Solution Pen-Injector)
The insurer denied coverage for Ozempic (1 MG/DOSE) 4MG/3ML SC SOPN 
The denial is overturned

The patient has obesity with a Body Mass Index (BMI) of 35. The patient had been on a daily exercise program along with diet modifications but continues to gain weight. The patient has pre-diabetes and the physician states that the patient has tried and failed the preferred product of Metformin. The patient developed migraines and vomiting on Metformin. The patient has been able to tolerate a Semaglutide in the past. The patient is now requesting to restart the Semaglutide as the patient has continued to gain weight. 

UpToDate has an article titled "Obesity in adults: Drug therapy." The article states that a number of medications are approved by the Food and Drug Administration (FDA) for the treatment of obesity. These medications should be used in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those individuals with a BMI of 30 or a BMI of 27 in patients with weight-related comorbidities who have not met weight loss goals with lifestyle intervention alone. Semaglutide is a Glucagon-like peptide-1 (GLP-1) receptor agonist that is approved by the FDA for the treatment of obesity. It has demonstrated efficacy in weight reduction as well as improvement in glycemia and lipids. 

This patient has a BMI of 35 in spite of lifestyle changes. Semaglutide is indicated as treatment for obesity under these circumstances. In addition, the physician states that the patient was intolerant to Metformin. The medical literature supports using Ozempic for obesity in patients with a BMI of 35. The health care plan did not act reasonably or with sound medical judgment. Ozempic is medically necessary. The denial is overturned.

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 Ozempic (1 MG/DOSE) 4MG/3ML SC SOPN (1 milligram per dose 4 milligrams per 3 milliliters subcutaneous Solution Pen-Injector) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is upheld.

This is a male patient with a Class I malocclusion, mild maxillary crowding and mild mandibular crowding, mild overjet and mild overbite. The issue for review is whether the requested health service/treatment of braces is medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 13 with no auto qualifiers. Auto qualifiers include cleft palate deformity or craniofacial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment for braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dialysis Port Site Infection
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male was admitted for possible dialysis access infection. He was started on intravenous antibiotics and vascular surgery was consulted. The patient underwent tunneled catheter placement and hemodialysis was resumed by nephrology. The patient's condition also required blood pressure monitoring due hypertensive urgency which responded to adjustment of medication. The patient's admission was prolonged due to refusing dialysis treatment.

The proposed treatment was not medically necessary.

The patient was hemodynamically stable, with normal oxygenation and negative repeated blood cultures. The patient did not have significant electrolytes disturbance or change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. Analysis of a database of 240,198 adult admissions with a principal diagnosis code for sepsis (median age 72 years) found that 25% (percent) of patients were discharged in 3 days or less. [1]
Analysis of a database of 161,606 adults (mean age 78 years) admitted with a principal diagnosis code for sepsis reported 25% of patients were discharged in 3 days or less. [2]
A multiyear analysis of patients hospitalized for sepsis in one of 114 VA (Veterans Administration) hospitals found, in the last year of the analysis (39,271 patients, median age 68 years), that 25% of patients were discharged in 3 days or less. [3]
Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 braces and D8670 x 12, 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 anterior crossbite among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth (maxillary left canine) when clinical attachment loss and recession of the gingival margin are present.

Upon review of the submitted documentation 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, the use of the HLD 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 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 met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual 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 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 D8080 braces and D8670 x 12, monthly visits is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache
Treatment: Trigger point injections
The health plan denied: Trigger point injections
The determination is: Upheld.

The patient is a female. She has a diagnosis of occipital neuralgia. The patient is being treated with multiple medications. There is a request for trigger point injection. At issue is the medical necessity of trigger point injections.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of trigger point injections is not medically necessary for this patient. Trigger point injections are only supported if there is a comprehensive conservative care program in place, including therapy, or other active modalities. The documentation fails to substantiate trigger point injections are being used in conjunction with a functional restoration program. Therefore, this request is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unilateral Primary Osteoarthritis, Left Knee
Treatment: Hyaluronan Injections
The health plan denied the requested Hyaluronan as not medically necessary.
The health plan's determination is overturned.

This is a female with knee pain who was denied Hyaluronan injection for left knee degenerative joint disease (DJD) by her health plan.

At issue is the medical necessity for the requested health service/treatment of Hyaluronan injections.

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

Yes, Hyaluronan is medically necessary for this patient with moderate left knee DJD unresponsive to conservative treatment thus far. It is reasonable to try Hyaluronan injection for left knee osteoarthritis. She has tried physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs) and steroid injections. The patient continues to experience left knee pain with exam and x-rays consistent with knee DJD.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: low back pain
treatment: Anterior Lumbar Interbody Fusion (ALIF) Surgery (Surgery to Join the Bones in Low Back)
The insurer denied Anterior Lumbar Interbody Fusion (ALIF) Surgery (Surgery to Join the Bones in Low Back).
The health plan's determination is upheld.

This is a female with a history of low back pain. She has had physical therapy, injections and medications without relief. She is a former smoker. The neurologic exam shows no motor, sensory or reflex abnormalities. The lumbar magnetic resonance imaging (MRI) shows disc bulging and degeneration at L (lumbar) 5-S (sacral)1. The provider has recommended an anterior lumbar interbody fusion (ALIF) L5-S1. 

The Anterior Lumbar Interbody Fusion (ALIF) Surgery (Surgery to Join the Bones in Low Back) is not medically necessary for this patient.

The patient has a normal neurologic exam with degenerative findings on MRI scan. The neurologic exam shows no motor, sensory or reflex abnormalities. There is no spondylolisthesis and no findings of instability. Therefore, the requested procedure is not medically necessary.

Per the literature:
Saltychev et al cite "there is strong evidence that LF (lumbar fusion) is not more effective than conservative treatment in reducing perceived disability because of CLBP (chronic low back pain) among patients with degenerative spinal diseases. It is unlikely that further research on the subject would considerably affect this conclusion". Eck et al cite "establishing an appropriate treatment strategy for patients presenting with low-back pain, in the absence of stenosis or spondylolisthesis, remains a controversial subject. Inherent to this situation is often an inability to adequately identify the source of low-back pain to justify various treatment recommendations, such as lumbar fusion".
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Subserosal Leiomyoma of Uterus
Treatment: Lupron Depot-3 month 11.25 mg (milligrams)
The insurer denied the request for Lupron Depot-3 month 11.25 mg.
The health plan's determination is upheld.

This patient is a female under consideration of Lupron Depot-3 month 11.25 milligram (mg) injection for treatment of a subserosal leiomyoma of the uterus. In this case, the medication under consideration is a non-formulary drug under the health plan. The patient is noted to have symptomatic fibroids and is not a surgical candidate as she will be needing a heart transplant. The health plan does not cover Lupron Depot 11.25 mg except for uterine leiomyomata that have resulted in bleeding to anemia. In this case, the patient is reported to have normal menses that are regular. She has a prior history of ovarian cystectomy.

The review of systems noted normal periods, absent abdominal pain, absent pelvic pain during periods, and absent abnormal bleeding. The patient is noted to be 221 pounds. Her body mass index (BMI) is 36 kilograms per meters squared (kg/m2). The diagnosis of excessive menstruation with a regular cycle is assigned. Lupron Depot was prescribed. The magnetic resonance imaging (MRI) of the pelvis noted several fibroids with a uterus of 9 by 7 by 11 centimeters (cm). The endometrial stripe is 2 millimeters (mm). The largest myoma is a posterior intramural myoma of 3.2 by 4.6 by 4.4 cm. There is a small intracavity fibroid of 0.9 by1.0 by 0.8 cm. The historical records from an appointment were reviewed. 

In this case, the patient would not be indicated for Lupron Depot 11.25 mg injection for leiomyomas without anemia also being present. A review of the medical records in this case noted that the patient has regular and normal periods with a negative review of systems for abnormal bleeding, pain or anemia. The patient is noted to have leiomyomas by MRI of the pelvis. In this case, the endometrial stripe is actually very thin. There has been no evaluation for anemia present and there is no positive review of symptoms to support anemia. In this case, a complete blood count with mean corpuscular volume (MCV) should be performed and if there is microcytosis, formal iron studies should also be completed. In this case, under the formulary, this drug is approvable for treatment of anemia due to fibroids. If absent, there would be no indication for this medication for therapy and it also carries risk for reduced bone mineral density over time.

In this case, the patient would be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), oral Progesterone, or oral contraceptive pills for abnormal bleeding if present. This would be considered the mainstay of care for leiomyomas if heavy bleeding or abnormal bleeding are present. However, in this case, the review of systems was normal without any complaints and thus, there may not need to be any interventions. At this time and based upon the medical records, the non-formulary use of Lupron Depot 11.25 injection is not clinically appropriate for this presentation at this time.

The health plan's determination is upheld in whole.