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

Diagnosis: Tooth sensitivity and caries

Treatment: (D2740)-all white glass crown, Tooth # 20; and (D3320) - nerve treatment on bicuspid tooth, Tooth 20

The insurer denied coverage for (D2740)-all white glass crown, Tooth # 20; and (D3320) - nerve treatment on bicuspid tooth, Tooth 20. The denial was reversed.

This patient is a male it appears that this patient presented for evaluation and dental treatment for teeth #20.  Upon evaluation, tooth sensitivity and caries was noted on #20. There was a notation about infection/decay and the treatment recommendation was for antibiotics and a root canal of Tooth# 20.  Endodontic therapy was recommended due to pulpal involvement with subsequent crown placement. The insurer has denied these services stating they are not necessary as documentation does not support the treatment. 

The radiographs support the recommended treatment. Tooth #20 exhibits significant caries mesially radiographically approximating the pulp chamber and endodontic therapy is indicated.  This tooth has adequate residual coronal structure for support of a crown and although periodontal bone loss is noted it is minimal and within acceptable limits for crown placement.  This tooth would have a good long term prognosis with the recommended treatment.  A standard of care in dental practice would be endodontic treatment for this clinical circumstance with subsequent crown.  Further, these services are necessary for maintenance of overall dental health.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The radiographic findings support the necessity of these services which are a standard of care in dental practice. The prognosis of this tooth with the recommended treatment is good.

The carrier's denial of coverage for (D2740) -all white glass crown, Tooth # 20; and (D3320) - nerve treatment on bicuspid tooth, Tooth 20 is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sore throat and fever
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a female with no significant past medical history. She presented with complaints of sore throat and fever of two days' duration.  She also reported difficulty swallowing, and inability to eat due to throat infection.   There was no cough, or associated headaches.  

The patient's review of systems was positive for fever, throat pain and dysphagia.  Her vitals included blood pressure 120/83, pulse 132 bpm, respiratory rate 19, temperature 103.1F, and oxygen saturation 98% on room air.  Examination was notable for erythema with exudate around the tonsils; she had cervical adenopathy. She had normal cardiopulmonary examination.  It was noted that the patient is able to swallow water, but not solids.  Assessment was acute pharyngitis and dysphagia.  Medical records noted possible streptococcal pharyngitis.  

The patient was admitted to the hospital; Plan was to obtain CBC (complete blood count), CMP (comprehensive metabolic panel), throat culture/sensitivity.  She was started on Tylenol as needed and penicillin (she received IM penicillin G and dysphagia in the emergency department).  She was placed on clear liquid diet. 

Follow-up hospital last includes WBC (white blood count) 24.5, hemoglobin 12.3, hematocrit 36.4, platelets 247, glucose 184, potassium 3.8, sodium 133, BUN (blood urea nitrogen) 7, creatinine 0.7. 

The patient was hemodynamically stable on admission. She had fever, throat pain, and dysphagia; however, there was no evidence of sepsis, change in mental status, or acute respiratory failure. There was no evidence of severe heart failure, acute renal failure, and severe electrolyte abnormalities. There was no evidence of acute upper respiratory airway obstruction that will require urgent airway management and/or hospitalization for additional care.

Signs of upper airway obstruction include:
1) Muffled or "hot potato" voice
2) Hoarseness
3) Drooling or pooling of saliva
4) Stridor
5) Respiratory distress (tachypnea, dyspnea, retractions)
6) "Sniffing" or "tripod" positions, which help maintain airway patency

There was no evidence of deep neck space infections and/or lower respiratory tract infection.  There was no evidence of peritonsillar abscess that required surgical intervention, nor infection of the brain.

The patient reported that she was admitted due to her inability to eat; however, medical records indicate that she was placed on liquid diet on admission and was treated with IM penicillin. 

The proposed treatment is not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.
Appeal type: Medical necessity
Decision: Overturned

The patient in question is a male with a chief complaint of overjet. He has 8 millimeter (mm) overjet and a Class II Division 1 malocclusion with 5mm crowding in the maxilla and 3mm crowding in the mandible. He is treatment planned for orthodontics involving a cervical pull headgear and 4 upper braces to start followed by full braces to correct his bite. The subject under review is the medical necessity of the proposed orthodontic treatment.

The health plan's determination is overturned.

This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. First, Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Second, Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment: Dupixent 300 mg (milligrams)/2 ml (millimeter) Pen
The insurer denied coverage for Dupixent 300 mg (milligrams)/2 ml (millimeter) Pen.
The denial is overturned.

The patient is an elderly female with a diagnosis of generalized atopic dermatitis.  The patient has failed topical steroid therapy with clobetasol, mometasone, betamethasone, and hydrocortisone 2.5% cream as well as oral hydroxyzine.  The patient has greater than 15% total body surface area (TBSA) involvement.  The requested medication is Dupixent.  

The patient has generalized atopic dermatitis that involve a larger surface area.  The patient requires systemic therapy given the extent of involvement; the use of Dupixent would appear to be reasonable given that it is Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis.  The request for Dupixent is supported by the medical literature and specialty society guidelines.  Dupixent is the first systemic therapy approved by the FDA for the management of atopic dermatitis (AD).  In early 2017, the FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments (1-3).  According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD .... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment ... with moderate-to-severe AD who are uncontrolled with topical therapies" (1).  As such, the decision is reversed and Dupixent is approved at the medical discretion of the physician based on the standard of care and the provided medical documentation.

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 Dupixent 300 mg/2 ml Pen is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic brain injury
Treatment: Increase PCW services from seven days per week, 12 hours per day to seven days per week, 24 hours continuous care by more than one person

The proposed treatment of an increase in PCW services to seven days per week, 24 hours continuous care by more than one person is deemed medically necessary. 

The patient is a male with a history of traumatic brain injury (TBI). He is chronically wheelchair/bedbound and dependent on maximum assistance for all of his activities of daily living (ADLs). 

Appeal review requested for potential approval of an Increase in personal care worker (PCW) services from seven days per week, 12 hours per day to seven days per week, 24 hours continuous care by more than one person for improved assistance with completion of the patient's ADLs.

This is a male with a history of traumatic brain injury (TBI). He is chronically wheelchair/bedbound and dependent on maximum assistance for all of his activities of daily living (ADLs). Per recent documentation from the patient's attending physician, the patient needs to be repositioned frequently throughout the nighttime to prevent the development of bedsores/pressure ulcers. Furthermore, the patient's spouse, his main caregiver at nighttime has been recently diagnosed with breast cancer and will require chemotherapy and radiation therapy which will render her with generalized weakness, fatigue and unable to provide care for her husband at nighttime. For these reasons, the currently approved plan of PCW services seven days per week, 12 hours per day is insufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in PCW services to seven days per week, 24 hours continuous care by more than one person is deemed medically necessary for improved assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a left parotid adenoid cystic carcinoma post resection and with known bone metastases. She is staged tumor (T) 3 nodes (N) 1 metastasis (M) 1. She is at risk of local and regional recurrence where radiation therapy is recommended to decrease this risk of recurrence and the proton beam approach is requested. At issue is the medical necessity of proton beam therapy.
The health plan's determination is upheld. The patient has left parotid adenoid cystic carcinoma post resection and with known bone metastases. The proposed proton beam radiation therapy is not considered a standard treatment option recognized in the oncologic medical community. There is a lack of any significant data published in peer reviewed medical literature supporting the efficacy and safety of proton beam radiation for head and neck malignancies including salivary gland adenoid cystic carcinomas. There are multiple studies published that are single institution non-randomized trials stating the need for additional trials to determine the efficacy and safety of proton beam radiation therapy as compared to photon beam radiation intensity modulated radiation therapy (IMRT). Therefore, the proton beam radiation therapy is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Other 
Mental Health Inpatient


This case involves a  patient who attempted suicide with an overdose and required intensive care medical treatment followed by inpatient rehabilitation treatment to address the medical complications of the overdose. During the rehabilitation stay, the patient was started on low dose mirtazapine and quetiapine. The patient  remained severely depressed with anxiety and urges to self-harm prompting a referral for acute inpatient psychiatric treatment to address the  co-occurring disorders. The patient  is diagnosed with bipolar mood disorder, most recent episode depressed without psychotic features and co-occurring opioid and sedative-hypnotic-anxiolytic use disorders.  Overturn in whole the health plans determination of medical necessity.
Yes, the requested health service/treatment of Inpatient mental health treatment is medically necessary for this patient.
The patient's presentation and clinical features included severe symptoms of mood disorder, suicidal risk, and deterioration in functioning in the context of severe substance use disorders. The patient remained at risk for relapse or suicidal behavior during the time interval under review in view of her history of prior suicide attempt and severe symptoms of mood disorder. Additionally, inpatient level treatment and the development of a safe and clinically appropriate discharge plan and disposition is critical in this case to prevent re-hospitalization or immediate relapse together, or another suicide attempt. The patient is at imminent risk for harm to self and has severe symptoms of the mood disturbance complicated with substance use disorders that could not be expected to be treated at a lower level of care in this case scenario.
Additionally, the inpatient stay is medically necessary in order to monitor the response to medications, to insure that the patient will have a sustained response to treatment, and to continue to address the acute risk of suicidal behavior in the context of severe symptoms of bipolar mood disorder with depression and the co-occurring substance use disorders that pose a risk to the patient. The necessity for the admission and the requested inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published practice guidelines and criteria, referenced below, and the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) LOCADTR 3.0 Criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Metastatic disease in the liver

Treatment:  Transarterial embolization

The insurer denied coverage for transarterial embolization.  The denial upheld.

This patient is a female with a history of metastatic breast cancer to her liver refractory to multiple lines of systemic therapy.  Her intrahepatic disease is progressing while her extra hepatic disease remains controlled.  She does not appear to be symptomatic from her liver disease.  This request is for approval of Y-90 radioembolization to her liver.

Per Breast Cancer.org (2019), "The most common treatments for metastatic breast cancer in any location (bone, brain, lung, or liver) are systemic medications, which treat cancer throughout the entire body.  Systemic medications include chemotherapy, hormonal therapy, targeted therapies, and bone-strengthening medication.  Per Bale, R., Putzer, D., Schullian, P., (2019), "Breast cancer represents a leading cause of death worldwide.  Despite the advances in systemic therapies, the prognosis for patients with breast cancer liver metastasis (BCLM) remains poor.  Especially in case of failure or cessation of systemic treatments, surgical resection for BCLMs has been considered as the treatment standard despite a lack of robust evidence of benefit.  However, due to the extent and location of disease and physical condition, the number of patients with BCLM who are eligible for surgery is limited.  Palliative locoregional treatments of liver metastases (LM) include transarterial embolization (TAE), transarterial chemoembolization (TACE), and selective internal radiotherapy (SIRT)...".

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

Per Breast Cancer Now.org, (2019), "Drugs are the main treatment for secondary breast cancer in the liver.  However, sometimes other treatments are used.  These can treat the cancer in the liver and help relieve symptoms, but will not treat cancer in other areas of the body, so may be useful for people whose secondary breast cancer only affects their liver."                                                         

There are currently insufficient clinical outcomes reported in the peer reviewed medical literature to allow one to make conclusions about the safety/efficacy of radioembolization for management of metastatic breast cancer to the liver.  Traditionally, radioembolization has been used for neuroendocrine carcinoma and colorectal adenocarcinoma, where it has been shown to help increase chances of survival.  Radioembolization is also useful for palliation, it did help minimize tumor-related bulk or impending death related to hepatic failure, but neither of these appears to be present in the patient's clinical scenario.      

The requested transarterial embolization is not considered medically necessary for this patient.  The standard of care management option would be to consider a change in systemic therapy.

The carrier's denial of coverage for the requested transarterial embolization is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for hypertension (HTN), diabetes mellitus (DM), polycystic kidney disease, polycystic liver disease status/post (s/p) 2nd simultaneous liver kidney transplantation 7/31/19 with postoperative course complicated by peri hepatic hematoma and middle colic artery hemorrhage requiring interventional radiology (IR) embolization. She was readmitted to the hospital with acute kidney injury and hydronephrosis status/post (s/p) percutaneous nephrostomy with internalized stent complicated by multidrug resistant urinary tract infection (MDR UTI), bacteremia and respiratory syncytial virus (RSV). The plan was for a retrograde pyelogram and stent removal/exchange. At issue is the medical necessity of acute inpatient rehabilitation.
The health plan's determination is upheld.
This is a patient who is s/p simultaneous liver kidney transplantation  who had post-operative complications of peri hepatic hematoma and middle colic artery hemorrhage requiring IR embolization. She was readmitted to the hospital with acute kidney injury and hydronephrosis s/p percutaneous nephrostomy with internalized stent complicated by MDR UTI, bacteremia and RSV. While the patient does require rehabilitation, the requested acute inpatient rehabilitation is not medically necessary and the patient's rehabilitation needs, at this time, could be better met at a lower level of care.
The documentation fails to support that the patient will be able to make functional progress in a reasonable amount of time. For example,  the patient completed sit to stand transfers with maximal assistance (MAXA) and these transfers had only improved to moderate assistance (MODA). Similarly, the patient ambulated 5 feet, then 12 feet with rolling walker (RW) and MODA/MAXA and yet a month later the patient only ambulated 2 trials of 8 feet with RW and MODA. In addition, the records do not support that the patient can tolerate 3 hours of therapy/day as  occupational therapy documented that transfers were not tested because "patient politely deferred 2/2 fatigue from prior PT session" and occupational therapy session on this date was only 20 minutes. Then  physical therapy noted that the patient required seated rest breaks between the ambulation trials of 8 feet each secondary to fatigue and total session time on this date was only 23 minutes. Therefore, this patient is more appropriate for rehabilitation at a lower level of care at this time.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who is under management for Barrett's esophagus and abdominal pain. She has a history of chronic pancreatitis and a neuroendocrine tumor of the pancreas.  The patient has an allergy to 15 separate pain medications, the majority of which are oral opioids. She has been using oral brand Demerol 100 milligrams (mg) twice a day (BID) for pain. An abdominal exam was described as normal. 
The patient's provider prescribed a renewal of Demerol tablets (brand). This request was denied by the health plan; specifically, the patient has not tried covered formulary alternatives which include buprenorphine transdermal patch and tramadol. At issue is the medical necessity of Demerol Brand Tablets. 
The health plan's determination of medical necessity is upheld. The management of pain secondary to chronic pancreatitis usually involves the use of chronic oral opioids. Other measures to reduce pain include uncovered oral pancreatic enzymes, pregabalin, endoscopic treatment of pancreatic duct stones, injections of steroids into the celiac plexus, and surgery. One large prospective study demonstrated that surgery is superior to a purely medical approach with respect to reduction of pain and improved quality of life. With chronic opioid use, patients develop tolerance and addiction. No single opioid has ever been found to be superior for the pain of chronic pancreatitis. Since oral opioids share a similar basic structure, it is not obvious why the patient has so many allergies in this class but not to Demerol. There is no reason that the patient cannot first try formulary analgesics. The provider notes list Ultram (tramadol) under allergies.  However, it is reasonable to try the preferred agent buprenorphine transdermal patch before approval of Demerol.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with Type 1 diabetes mellitus, currently treated with a Medtronic insulin pump which is out of warranty and continuous glucose monitoring, checking blood sugars 3- 4 times a day, HbA1c improved to 8.2% and blood sugar range is wide 60 to 401 milligrams per deciliter (mg/dL), no recent episodes of diabetic ketoacidosis (DKA) or severe hypoglycemia. By report, the patient has episodes of hypoglycemia that are frequent mild to moderate, but no other information was provided. At issue is the medical necessity of a Tandem T-slim x2 insulin pump.
The health plan's determination is upheld.
Hypoglycemia continues to be a major cause of morbidity and mortality in patients with type 1 diabetes and presents a significant barrier to improved glycemic control, young patients and older patients with a long duration of type 1 diabetes are at high risk for severe hypoglycemia due to impaired hypoglycemia awareness. Automated integration of real-time continuous glucose monitoring (CGM) data with continuous subcutaneous insulin infusion (CSII) pump delivery, such as the Tandem pump requested has shown promise in reducing the burden of hypoglycemia. Threshold suspend technology allows for automated suspension of insulin delivery when the sensor glucose falls below a predefined lower limit. The ASPIRE (Automation to Simulate Pancreatic Insulin REsponse) trial documented 31.8% fewer nocturnal hypoglycemia events using a threshold suspend system compared with sensor-augmented pump (SAP) therapy, similarly, a similarly study showed that Tandem Diabetes Care Basal-IQ PLGS [predictive low-glucose suspend] system significantly reduced hypoglycemia without rebound hyperglycemia. Based on the current supporting medical information provided by the physician as well as the letter of necessity, there is not a clear indication that this patient suffers severe frequent hypoglycemia; no documentation of hypoglycemia unawareness or dawn phenomenon has been provided. Thus, it is not clear that the patient would benefit from this type of technology.