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

Diagnosis: Schizophrenia
Treatment: Consumer Directed Personal Assistance Services: 35 Hours per Week
The insurer denied Consumer Directed Personal Assistance Services: 35 Hours per Week.
The determination is upheld.

This is a male patient with a medical history notable for schizophrenia and mild mental retardation. The patient is approved for 26 hours per week of consumer directed personal assistance services. The patient and his care team requested an increase to 35 hours per week, and this request was denied by the health plan. This denial is the subject under review.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via video teleconference. The patient lives in an apartment. The patient is alert and oriented and able to direct his own care. For his instrumental activities of daily living, the patient requires maximal assistance for meal preparation, housework, and shopping. He requires extensive assistance for finances. He requires limited assistance for stairs and transportation. He is independent for all activities of daily living. His continent of urine and stool. He has not had any recent falls. There is no pressure ulcer present. A task tool associated with the assessment recommended 11.51 hours per week to address his personal care needs.
There were no letters of medical necessity or medical records provided for review. The request for increase in personal care hours did not specify which personal care needs, if any, are not currently being met by the allotment of hours. At issue is the medical necessity of Consumer Directed Personal Assistance Services: 35 Hours per Week.

The requested health service of Consumer Directed Personal Assistance Services: 35 Hours per Week has not been demonstrated to be medically necessary for this patient.
The patient receives 26 hours of care per week, which is more than double the amount recommended by the UAS task tool. He receives consumer directed hours and can spread these out as needed. He requires assistance with instrumental activities of daily living and is independent for activities of daily living. It is unclear which personal care needs, if any, are not being addressed by his current allotment of ours. Therefore, it has not been clearly demonstrated that the requested increase in personal care hours is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overweight

Treatment: Ozempic

The insurer denied coverage for Ozempic

The denial is upheld

 
This is an adult female diagnosed with overweight. This request is for Ozempic. As per visit note; she is tolerating Ozempic very well; she has lost 16 lbs and she is down to 164 lbs and her body mass index (BMI) is already below 26. She has hypertension (HTN), obstructive sleep apnea (OSA) (on Continuous Positive Airway Pressure), and hyperlipidemia (HLD). She is unable to obtain Ozempic; provider prescribed Saxenda but it is like Wegovy which is on backorder. She states in her letter she tried working on both a bike and treadmill and she tried diet with plan Optavia 3 times and she cut red meat and alcohol out her diet for the past year. She has asthma. 

The policy criteria require the submission of medical records indicating a diagnosis of type II diabetes which is the approved indication of Ozempic. The patient does not have type II diabetes. The request does not meet the policy criteria. The health plan acted reasonably with sound judgment in their denial. 

Semaglutide is a glucagon like peptide 1 receptor (GLP1R) agonist(1) that is Food and Drug Administration (FDA)-approved in treating type II diabetes and obesity (2-4). Recent studies published in major peer-reviewed medical journals have shown the safety and efficacy of semaglutide for the treatment of obesity(5-7). This medication is now available for treating obesity in the form of Wegovy. There are no studies showing the safety or efficacy of the requested medication for patients who do not have diabetes, such as this patient. There are no extenuating circumstances in this case. The request is, therefore, not medically necessary. The denial remains upheld.

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 Ozempic (semaglutide) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Periodontal Disease.
Treatment:  Cleaning inside roots of premolar tooth #21, post and hard cap material under cap for teeth #14 and #21, and tooth-colored cap with metal underneath for tooth #21.

The insurer denied coverage for cleaning inside roots of premolar tooth #21, post and hard cap material under cap for teeth #14 and #21, and tooth-colored cap with metal underneath for tooth #21.  The denial is upheld.

Upon review of the submitted documentation which includes copies of radiographs and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment. Based on the documentation, endodontic procedure and post and crowns were recommended for tooth #21 as well as #14. The insurer has denied the services, stating that these services are not medically necessary treatment, as the clinical documentation does not support it insofar as the patient does not meet the conditions of the New York State Medicaid program for approval of the requested services, and there is a questionable prognosis of the teeth even with the recommended treatment. 

Based on the submitted objective information for review, which consists solely of the radiographic examinations, the radiographic documentation does not support the extensive dental treatment recommended by the dentist. There are no dental treatment notes, no dental charting, nor periodontal charting provided for review. The radiographic documentation does not indicate the need for the services. As the documentation is inadequate to support the treatment, these services are considered not medically necessary. 

Uphold denial for cleaning inside roots of a premolar tooth #21, post and hard cap material under cap for teeth #14 and #21, and tooth colored cap with metal underneath for tooth #21, as the provided documentation for review is inadequate and did not support the extensive treatment recommended.

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

Cleaning inside roots of a premolar tooth #21, post and hard cap material under cap for teeth #14 and #21, and tooth colored cap with metal underneath for tooth #21 is not considered medically necessary for this patient.

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 cleaning inside roots of premolar tooth #21, post and hard cap material under cap for teeth #14 and #21, and tooth-colored cap with metal underneath for tooth #21 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

This is a male patient with a Class I bite and severe crowding in both the maxillary and mandibular arches. Tooth 31 is impacted. The patient is treatment planned for 24-36 months of orthodontics with extraction of teeth 5 and 29 but the treatment was denied due to lack of medical necessity. At issue is the medical necessity of braces.

Impacted teeth can lead to bone defects of the adjacent erupted teeth. (1) It is a generally accepted practice guideline to address the impacted tooth by attempting to surgically remove it or to gain space to allow the impacted tooth to erupt. 
The patient has an impacted mandibular right second molar. This tooth should have erupted. (2) Side effects of impacted mandibular second molars include a significant increase in periodontal defects distal to the erupted first molars (3) due to the inadequate development of bone in that region as a result of the impacted tooth. No treatment will put the mandibular right first molar (tooth 30) at risk. Therefore, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
Treatment: braces
The insurer denied braces.
The health plan's determination is overturned. 

The patient in question is a male presenting with a skeletal Class I malocclusion. He has minor spacing in the maxilla and minor crowding in the mandible. Tooth 3 is missing. He has a 2 millimeter (mm) anterior open bite. He is treatment planned for 24-30 months of braces to address the crowding and open bite. 

Braces are medically necessary for this patient. Anterior open bite patients are among the most difficult patients to treat. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. Braces are medically necessary as this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest tightness and dyspnea on exertion. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

This is an adult male who presented to the hospital complaining of chest tightness and dyspnea on exertion for several days. Past medical history was significant for ischemic heart disease and Coronary Artery Bypass Graft (CABG), diabetes mellitus and hypertension. On arrival to the hospital vital signs were stable:  BP (Blood Pressure) 153/76 mmHg (millimeters of mercury), Pulse 88 beats per minute. Physical examination revealed no significant abnormalities. 12 lead electrocardiogram demonstrated normal sinus rhythm with 1mm (millimeter) ST (heart rhythm) elevations in the inferior leads and ST depressions in the lateral leads. Serum troponin levels were not elevated. The patient was admitted to the hospital and treated for hypertension and possible acute cardiac syndrome.  hest pain did not resolve with treatment and cardiac catheterization was performed. Findings demonstrated multivessel coronary artery disease with bypass grafts open to the left anterior descending artery, left circumflex and obtuse marginal arteries.  Left ventricular ejection fraction was 51-55 percent. Stents were placed in the Right Coronary Artery (RCA) and the patient was discharged the following day. 

This patient presented with persistent chest pain and an abnormal electrocardiogram showing ST (heart rhythm) elevations suggestive of an acute inferior ischemic event. He was admitted and ultimately underwent cardiac catheterization and percutaneous intervention to the right coronary artery. Acute care hospital inpatient admission was medically necessary. 

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cellulitis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.
 
Patient is an adult female with past medical history significant for obesity, learning disability, lower abdominal abscess and venous stasis ulcers of bilateral extremities who presented to the emergency room with complaints of flank pain and bleeding under right breast.

Vitals on presentation included: Temperature 97.8 degrees F, Blood Pressure 118/79, Pulse 92, Respiratory Rate 16, oxygen (O2) saturation 99% on Room Air. Laboratory results included the following: white blood cell count (WBC) 6.0, Hemoglobin (HGB)-10.6, Hematocrit (HCT)-32.2, creatinine-0.74, glucose-92.

Patient was started empirically on intravenous antibiotics (oral Levaquin and intravenous clindamycin) for bilateral intertrigo under breasts with superimposed cellulitis. She received wound care. Patient remained afebrile, hemodynamically stable. She was discharged to continue oral antibiotics (Augmentin) as an outpatient.    

According to documentation, patient returned to the emergency department with intertrigo and breast cellulitis. Otherwise, patient was afebrile, hemodynamically stable with a normal WBC. Patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on above findings, patient met criteria for observation level of management.  

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Wegovy 0.5 milligram (mg) pen injector. 
The insurer denied coverage for Wegovy 0.5mg pen injector. 
The denial is overturned. 

The patient presented for weight loss counseling. He completed a 3-month course of a weight loss management program. He was started on Wegovy. He has morbid obesity, and his body mass index (BMI) is 62.3. He continues on a program of diet and exercise. He would like to continue treatment with Wegovy. 

In "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 in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those with a body mass index (BMI) over 30 or a body mass index (BMI) over 27 with related comorbidities. Semaglutide is a Glucagon-like Peptide (GLP)-1 agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction, as well as improvement in glycemia and lipids. It has also demonstrated cardiovascular benefits. 

In "Effect of Continued Weekly Subcutaneous Semaglutide vs. Placebo on Weight Loss Maintenance in Adults with Overweight or Obesity." 803 participants studied were randomized to either continue Semaglutide or to take a placebo after 20 weeks of Semaglutide treatment. Those who continued the treatment with Semaglutide had ongoing weight loss, a better lipid profile, improved glucose metabolism, better blood pressure control, and physical functioning scores. The group who took the placebo regained their weight. The article states that the result of this study emphasizes the chronicity of obesity and the need for treatments that can maintain and maximize weight loss. 

Wegovy is a Food and Drug Administration (FDA) approved treatment for obesity in patients with a body mass index (BMI) over 30. The medical literature supports the beneficial effects of Semaglutides in achieving weight loss in obese patients. It is a medically necessary treatment. 

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 Wegovy 0.5 milligram (mg) pen injector is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain and shortness of breath
Treatment: Stress Echocardiogram
The insurer denied the stress echocardiogram.
The denial is overturned.

The patient is an adult female. She has a past medical history of hyperlipidemia. She was seen by her cardiologist for evaluation of chest pain and shortness of breath. For further evaluation of her symptoms, a transthoracic echocardiogram was obtained, which demonstrated normal biventricular function without significant valvular abnormalities. Reportedly, the patient is unable to walk on a treadmill due to arthralgias which have significantly limited her mobility and ability to walk even short distances. The patient did not have a nuclear stress test, since she cares for her four grandchildren under the age of five years old, and she lives with her pregnant daughter. Consequently, for further evaluation of her symptoms, a dobutamine stress echocardiogram was requested. Of note, the patient had a nuclear stress test last year, which did not demonstrate any evidence of ischemia.

The stress echocardiogram is medically necessary.

This patient with ASCVD (atherosclerotic cardiovascular disease) risk factor of hyperlipidemia has been experiencing episodes of chest pain. Based on the provided documentation, it is clear that the patient is unable to exercise on a treadmill due to severe arthralgias. Consequently, stress testing with a pharmacological agent is appropriate. With that said, due to her exposure to a pregnant woman, it is reasonable to forgo obtaining a nuclear stress test to avoid any potential nuclear exposure. Consequently, obtaining a Dobutamine Stress Echocardiogram is considered appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The patient presented with abdominal pain and black stool. There was a history of a gastric ulcer. The patient also reported taking Pepto-Bismol. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The hemoglobin was 12.2. An endoscopy revealed gastritis but no active bleeding. There was also a non-bleeding angioectasia in the duodenum. The patient was advised that they should have a colonoscopy, but wanted to leave the hospital and follow up as an outpatient. 

Clinical indications for admission for Upper Gastrointestinal Bleeding (Milliman Care Guidelines (MCG) M-180) include hemodynamic instability, ongoing active bleeding, peptic ulcer with high-risk endoscopic features, variceal bleeding, severe coagulopathy, severe anemia with signs of cardiac ischemia, bowel obstruction, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, bowel obstruction or perforation, bacteremia, and inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had black stool and reported having melena. The patient was not actively bleeding while in the hospital. The endoscopy could have been performed with observation status as an ambulatory procedure. The patient did not require any acute interventions. The patient did not meet MCG criteria for admission for Upper Gastrointestinal Bleeding or Undiagnosed Abdominal Pain. The health care plan acted reasonably and with sound medical judgment. An 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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hypoglycemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

This is a patient born via repeat cesarean section at 39.1 weeks gestation, birth weight 2400 grams. Apgar scores were 8 and 9 at one and five minutes respectively. Initial care was in the Well Newborn Nursery. Glucose screening was undertaken due to Small for Gestational Age (SGA).  The glucose was 56 milligrams (mg)/deciliters (dL) and subsequently was 57 mg/dL. The 52 mg/dL.  However, the glucose was 45 mg/dL at 21 hours-old, followed by 43 mg/dL, and then, at 46 hours-old, the point of care testing (POCT) Glucose was 34 mg/dL on an exclusive demand breast feeding schedule. There was documentation of associated poor feeding and fatigue. The patient was diagnosed with neonatal hypoglycemia and transferred to the Neonatal Intensive Care Unit (NICU) for further management - ad lib feeds at breast and supplemental formula with continued monitoring and possible need for intravenous (IV) glucose. The following afternoon, the POCT glucose was 79 mg/dL (post-feeds). Subsequently, POCT glucoses were as follows: 70 mg/dL, 85 mg/dL, 64 mg/dL, and 79 mg/dL. Also, a basic metabolic panel had a glucose of 107 mg/dL. The patient was discharged the following day.
 
This infant was at risk for neonatal hypoglycemia by virtue of being SGA. Initial care was in well newborn with normal glucoses until approximately 21 hours-old when the POCT glucose was 43 mg/dL. Inexplicably, another POCT glucose was not done until 25 hours later when it was only 34 mg/dL. There was no confirmation of hypoglycemia by a serum glucose (done in the laboratory). Thereafter, all POCT glucoses were greater than 60 mg/dL which is the nadir for normal neonatal glucose after 48 hours of age. Assuming the POCT glucose of 34 mg/dL was an accurate reflection of the serum glucose, transfer to the NICU for continuous cardiorespiratory monitoring and further management of "hypoglycemia" was a reasonable undertaking at a Neonatal Facility, Level II per Milliman Care Guidelines (MCG): LOC-005. Also, it was in accord with MCG: P-595, Newborn Care, Term, with Severe Illness or Abnormality wherein "higher-level neonatal care (i.e., other than Level 1 nursery) for neonate whose gestational age is 37/07 weeks or greater is indicated by: Hypoglycemia."   

In view of the above, the denial for NICU level of care is upheld for days one, two and four and reversed only for day three.

Based on the above, the insurer's denial must be modified. 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 the full hospital neonatal intensive care unit (NICU) admission is modified. Reverse denial for day three of admission.