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

Diagnosis: impacted permanent anterior
Treatment is braces
The insurer denied coverage for braces
The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to an impacted permanent anterior tooth. The orthodontist has completed the HLD (Handicapping Labia-Lingual Deviation) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 10 points on review by internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), 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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation 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. 

ln this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anterior where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care using this criterion. This reviewer concurs with the findings of the insurer of attaining 10 points on the HLD index (3 points overjet, 4 points overbites, 3 points labiolingual spread). 

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. 

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

The insurer's denial of coverage for the braces is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung cancer
Treatment: SBRT (Stereotactic Body Radiotherapy)/Proton Beam Therapy
The insured denied SBRT/Proton Beam Therapy.
The health plan's determination is upheld. 

This is the case of a patient who presented with lung cancer and underwent surgery. The patient had recurrence and was treated with immunotherapy. He had recurrence and was treated with radiation. He recently had liver metastasis and is being evaluated for Proton beam therapy.

SBRT (Stereotactic Body Radiotherapy)/Proton Beam Therapy is not medically necessary for this patient.

Medically necessary treatments are defined as those which are commonly practiced in the US (United States). In this case, the patient has metastatic disease to the liver which is treated with other modalities. This patient has recurrent disease which can be treated with phase I trial or chemo-immunotherapy. If a patient has single metastatic disease in liver, it can be treated with radiofrequency ablation (RFA) or photon based SBRT. National Comprehensive Cancer Network (NCCN) guidelines do not recommend Proton beam for metastatic lung cancer to liver. There are no published data to support this treatment for this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung cancer
Treatment: Increase in Personal Care Worker (PCW) services to 7 days/week, 8 hours/day: 56 hours/week
The insurer denied coverage for an increase in PCW services to 7 days/week, 8 hours/day: 56 hours/week
 The denial is upheld

This is a patient who has lung cancer that is metastatic to the brain. He lives with his daughter and ex-wife in a private home. He is currently approved for Personal Care Worker (PCW) services 5 hours/day, 7 days/week for a total of 35 hours/week. He is requesting via his treating physician an increase in PCW services to 7 days/week, 8 hours/day; 56 hours/week, which is currently under review.  

The Uniform Assessment System (UAS) report was reviewed. The patient requires extensive assistance for bathing and dressing. Limited assistance is needed for personal hygiene, ambulation, toilet transfer/use and bed mobility. Limited assistance is also needed for eating and drinking. The patient is infrequently incontinent of bladder and continent of bowel. He remains capable of using his personal emergency response system (PERS). His cognition has modestly declined from "modified independent" to "minimally impaired." Otherwise there has not been a significant functional decline compared to the prior assessment.  Based on the clinical records reviewed, this physician agrees with the insurer.  The patient's health and safety can be appropriately provided and maintained by the currently approved Personal Care Worker (PCW) services 5 hours/day, 7 days/week for a total of 35 hours/week.

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested increase personal care worker (PCW) services 7 days per week, 8 hours per day; 56 hours per week is not medically necessary.  

The insurer's denial of coverage for personal care worker (PCW) services 7 days per week, 8 hours per day; 56 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic atrial fibrillation
Treatment: Eliquis (apixaban)
The insurer denied Eliquis (apixaban).
The denial is overturned.

The patient is a male with chronic atrial fibrillation, hypertension, hyperlipidemia, and tobacco use. He has been maintained on Eliquis 5 milligrams (mg) twice daily for stroke prevention. This is currently a non-formulary drug, and a formulary exception was requested. The formulary options include Xarelto and warfarin.

At issue is whether the formulary drugs will be or have been ineffective, or would not be as effective as the non-formulary drug, Eliquis (apixaban).

The health plan's determination is overturned in whole.

The formulary drugs (warfarin, Xarelto) would not be as effective as the non-formulary drug (Eliquis, (apixaban)) or would have adverse effects.

The formulary drug Xarelto (rivaroxaban), has been associated with a significantly increased risk of major ischemic or hemorrhagic events in patients over 65 compared with Eliquis (apixaban), as reported in the study by Ray, et al. [1] This was a retrospective cohort study of over 500,000 patients. The formulary drug, warfarin, has also been associated with increased stroke/systemic embolism and bleeding when compared with apixaban in another large, retrospective cohort study. [2]

Eliquis (apixaban), which the patient has been taking with good efficacy and safety, is the best drug for prevention of major ischemic events and safer with regard to bleeding risk, based on data from current studies.

Therefore, the formulary drugs (warfarin, Xarelto) would not be as effective as the non-formulary drug, Eliquis (apixaban).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung cancer. 
Treatment: Tepmetko 225 mg tablet. 

The insurer denied Tepmetko 225 mg tablet. 
The determination is upheld. 

The patient has stage IIIB adenocarcinoma of the lung. The patient has recurrent disease following curative intent therapy. In the metastatic setting, he has received carboplatin+Alimta followed by docetaxel+Cyramza at progression. The patient has progressed again. Previous next-generation sequencing noted a MET exon 14 skipping mutation. The protein MET (also termed Met, c-Met, c-MET), encoded by the proto-oncogene MET found on chromosome 7q31, is a cell surface receptor tyrosine kinase (RTK) predominantly expressed by epithelial cells. Upon binding of its only known ligand, hepatocyte growth factor (HGF), MET homodimerizes, phosphorylates, and triggers the stimulation of a complex system of intracellular signaling cascades. The patient has received lapatinib with progression. Tepmetko has been recommended and is under review for medical necessity. 

The requested Tepmetko is not medically necessary. The patient has stage IIIB adenocarcinoma of the lung. There is a paucity of data demonstrating the benefit of the sequential use of MET exon 14 skipping-targeted agents following the failure of another agent. It is unclear if failure of one agent confers resistance to similar agents and thus this approach is not recommended in the peer-reviewed literature, by the authors of UpToDate, nor in the National Comprehensive Cancer Network (NCCN) Guidelines. Given the lack of outcomes data, medical necessity cannot be established for this service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer. 
Treatment: Radiation therapy for breast cancer, initial phase: 30 fractions (treatment sessions) of Proton Beam Therapy; Image Guided Radiation Therapy (IGRT). 

The insurer denied coverage for radiation therapy for breast cancer, initial phase: 30 fractions (treatment sessions) of Proton Beam Therapy; Image Guided Radiation Therapy (IGRT). 

The denial is upheld. 

The patient is an adult with the medical diagnosis of cancer (CA). The patient has been seen and treated for T2N0M0 (cancer staging) malignant phyllodes of the left breast cancer (CA). Proton Beam Radiotherapy was recommended. 

"Breast cancer is the most common malignancy diagnosed among females in the United States, with an estimated incidence of 231,840 cases in 2015 (1). Long-term follow up of the National Surgical Adjuvant Breast and Bowel Project (NSABP) trials (2) and [early breast cancer trialists collaborative group] EBCTCG meta-analyses (3,4) demonstrated that the prevention of local recurrence after surgery for breast cancer translates into reduced breast cancer mortality. Today, radiation therapy remains a vital component of the curative multimodality therapy for many women with localized breast cancer. Aside from select older women with small, hormone receptor positive breast cancer, most women who opt for breast conservation therapy are recommended adjuvant radiation as part of breast conserving therapy. In more advanced disease, many women require post-mastectomy radiation and/or regional node irradiation" (Cuaron, et al., 2016). 

While electron beam radiotherapy may be unable to achieve a heart-sensitive dose, 3-D [3-dimentional] conformal radiotherapy should be able to achieve it, and the plan is agreeable to approving it. National Comprehensive Cancer Network (NCCN) supports the use of 3-D CT [computed tomography] based treatment planning as routine to delineate target volumes and adjacent organs at risk. 

Charged-particle beams consisting of protons or helium ions are a type of particulate radiation therapy that contrast with conventional electromagnetic (i.e., photon) radiation therapy due to the unique properties of minimal scatter as the particulate beams pass through the tissue, and deposition of the ionizing energy at a precise depth (i.e., the Bragg Peak). Thus, radiation exposure to surrounding normal tissues is minimized. The theoretical advantages of protons and other charged-particle beams may improve outcomes, but this has not been proven. Therefore, the request is not medically necessary for this patient at this time. 

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 radiation therapy for breast cancer, initial phase: 30 fractions (treatment sessions) of Proton Beam Therapy; Image Guided Radiation Therapy (IGRT) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Shoulder Pain. 
Treatment: Magnetic Resonance Imaging (MRI). 

The insurer denied: Magnetic Resonance Imaging (MRI). 
The denial is upheld. 

The patient is a female with 10 weeks of right shoulder pain. A magnetic resonance imaging (MRI) of the shoulder was requested by the patient's physician. This imaging study was denied by the insurance company. This denial is the subject under review.
The appeal states that the patient has had right shoulder pain and decreased movement of the shoulder for more than 3 months and has failed a trial of pain medication (meloxicam). X-rays of the shoulder were unremarkable, and the exam was "concerning for rotator cuff tear." 
The patient was first seen for this issue. The patient had four weeks of pain at that time with no antecedent trauma. Pain was noted with crossing the arm behind the back or raising overhead. There is no documented physical exam for the encounter. Plan was noted as "rotator cuff pathology versus adhesive capsulitis, order for MRI and then referral to orthopedist to consider if physical therapy (PT) versus surgical management needed." Subsequent telephone encounter notes that MRI was denied, and an x-ray was ordered which was unremarkable. A follow up telehealth visit was performed. The visit notes from the treating physician stat there is "some relief from nonsteroidal anti-inflammatory drugs (NSAIDs)." There is no documented physical exam as it was a telehealth encounter. The plan states that the physician will "try again to get MRI authorized to rule out rotator cuff syndrome versus adhesive capsulitis." 
The health plan declined the request due to the patient not having received physical therapy rendered by a qualified provider. They also did not receive any office visit notes showing a positive test on physical exam indicating a specific injury. 

The subject under review is the medical necessity for the MRI.

The health plan's determination is upheld. 

The requested MRI of shoulder is not supported as medically necessary for this patient.
The provider requested the service to determine if the etiology of the patient's pain was due to adhesive capsulitis or rotator cuff pathology. There was no documented physical exam to help determine which is more likely. Either pathology can be treated with a course of physical therapy with a professional. Incomplete rotator cuff tears should be addressed by a physical therapist before considering surgery. If the patient has a grossly abnormal exam, consultation with an orthopedist could be warranted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Down's syndrome
Treatment: home health care
The insurer denied Personal Care Aide/Consumer Directed Personal Assistance Services: 30 Hours per Week. The health plan's determination is overturned. 

The patient is a male with past medical history of Down syndrome, developmental delay, autism spectrum, and nonverbal status whose primary care physician (or provider) (PCP) completed a M11Q form stating the patient lived with his parents, ambulated well but needed help with behaviors, activities of daily living (ADL), and toilet training. In addition, the form stated that the patient was nonverbal and had lack of forward thinking, needed constant supervision as he was mobile and unaware of dangerous situations, and needed help with toilet training and ADLs. 

Personal Care Aide/Consumer Directed Personal Assistance Services: 30 Hours per Week are medically necessary for this patient.
The patient's regular provider has documented medical necessity of increased services. The insured's denial reported the medical provider did not outline specific tasks that could not be accomplished in the current aide hours, but the patient requires maximum assistance with toilet use which is an unpredictable and unscheduled care needs. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these care needs. The plan assumed the patient had informal help outside of all current CDPAS (consumer directed personal assistant services). The requested increase for CDPAS is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient has documented 24-hour care needs and therefore a tasking tool should not of been utilized to calculate CDPAS hours. 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 30 hours/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: Overturned

Diagnosis: Cerebral Palsy
Treatment: Ongoing Physical Therapy Treatment (Weekly Visits)
The health plan denied weekly physical therapy.
The health plan's determination is overturned in whole.  

This is a male patient with cerebral palsy, epilepsy, intellectual and cognitive deficits who has been receiving weekly physical therapy for functional training, balance, strengthening and range of motion. He requires assistance for all activities but has improved with therapy and is gaining strength and ability with his upper limbs. His progress was slowed by COVID 19 (Coronavirus 2019) infection. For these reasons, the medical necessity for physical therapy has been established.

Ongoing physical therapy treatment (weekly visits) are medically necessary for this patient. The patient has been receiving weekly physical therapy for functional training, balance, strengthening and range of motion. He requires assistance for all activities, but has improved with therapy and is gaining strength and ability with his upper limbs. With improving upper limb function, the patient has evolved with his ability to pull himself to sitting and standing position. He will not be independent but every bit of improving function can make a huge difference in his quality of life. He should continue weekly therapy at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I molar relationship on left and right sides and Class II relationship on left and right sides
Treatment: D8080 Braces
The insurer denied: D8080 Braces
The denial is upheld.

The patient is an adolescent female. The request is for orthodontic benefits. The patient has Class I molar relationship on left and right sides. She has Class II relationship on left and right sides. She has a palatal expander cemented in place. The previous denial was due to having handicapping index score of 11.

The proposed treatment is not medically necessary.

There is no way to determine the pre-treatment condition of the patient's dentition from the little records provided (i.e., there are no pre-treatment photos). In addition, the photos that have been provided are after treatment has already been initiated (maxillary expander). There is no support for medical necessity for this case based on the records submitted.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Other/Spine Disorder.
Treatment: Pain Management/Pain Management Services/Ablation, 02 units.
The health plan denied the requested Pain Management Services/Ablation, 02 units as experimental/investigational.
 The health plan's determination is upheld.

The patient is a female with a history of low back pain. The pain began over one year ago. Prior treatment has included injections, medications, as well as therapy modalities. Pain is rated 8 out of 10. Activities of daily living are restricted secondary to the symptoms. A magnetic resonance imaging (MRI) reported multilevel degenerative changes, Modic type II changes at disc spaces (lumbar) L3-4, L4-L5 and (lumbar-sacral) L5-S1. There is a request for intraosseous ablation of the basivertebral nerve.

I uphold the health plan's determination regarding the proposed health service or treatment, in full.

The proposed health service or treatment of Pain Management Services/Ablation, 02 units is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry Disability Index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as a treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment of Pain Management Services/Ablation, 02 units is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.