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

Diagnosis: osteoarthritis

Treatment: personal care services of 8 hours per day, 7 days per week for a total of 56 hours per week

The insurer is denied coverage for personal care services of 8 hours per day, 7 days per week for a total of 56 hours per week

The denial is overturned. 

This female patient has a history of essential tremors, paroxysmal atrial fibrillation, occlusion of the right posterior inferior cerebellar artery with infarction (history of stroke), essential hypertension, cervical spondylosis, osteoarthritis and uterine prolapse

The information provided for review indicates the patient needs assistance for various activities throughout the day. Therefore, it is medically necessary to have a caregiver present for at least most daytime to early evening hours. Even with 8 hours of services, this may not fully meet her needs for toileting related care, mobility, and both morning and evening activities of daily living (ADL). There does not appear to be reasonable justification for reducing services. Maintaining services at 56 hours per week is medically necessary to ensure the patient's care remains at least at the level of care she had been receiving. 

The UAS identified an informal caregiver, but the goddaughter reported that the patient does not have a caregiver after service hours. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. Considering the request for PCW services is for 8 hours per day, 7 days per week, it is reasonable to conclude that there are no informal caregivers who are able to provide care during these hours on a regular basis. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance for daily activities.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for personal care services of 8 hours per day, 7 days per week for a total of 56 hours per week is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Transfemoral Amputation

Treatment electric knee prosthesis (L5828 x 1, L5845 x 1, L5848 x 1, L5856)

The insurer denied coverage for electric knee prosthesis (L5828 x 1, L5845 x 1, L5848 x 1, L5856)

The denial is overturned

The patient has a history of a right transfemoral amputation.  His current prosthetic knee is in need of replacement.  Under review is the medical necessity of requested electric knee prosthesis (L5828 x 1, L5845 x1, L5848 x 1, L5856).

The requested prosthesis has a microprocessor (computerized) controlled hydraulic stance and swing phase prosthetic knee system.  The electrical mechanical precision of this prosthesis provides improved feedback to the patient with resultant greater stability, balance and functional mobility.  The requested prosthesis is able to monitor the complete gait cycle and can make virtually simultaneous corrections while ambulating.  Additional advantages of the requested microprocessor prosthesis include increased swing/stance phase responsiveness and decreased cardio-vascular effort required with routine use.  

In this particular case, the patient's prosthetic knee is more than five years old.  As noted, the cost of repair exceeds the cost of replacement, is not the most updated version of the prosthesis and would not have the manufacturer's warranty.  A replacement microprocessor prosthesis is the more fiscally prudent and technologically sound option to meet this patient's clinical needs.  

The health plan did not act reasonably, with sound medical judgment or   in the best interest of the patient.  The requested electric knee prosthesis (L5828 x 1, L5845 x1, L5848 x 1, L5856) is medically necessary for this patient.

Based on the above, the medical necessity for an electric knee prosthesis (L5828 x 1, L5845 x 1, L5848 x 1, L5856 is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: malocclusion

Treatment: D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is upheld. 

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, a Handicapping Labiolingual Deviation Index is utilized. 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 does not claim an automatic qualifying condition and states they are aware that this patient would not meet the threshold for approval of
orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 6 points on the HLD index (2 overjet, 2 overbite, 2 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

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

The carrier's denial of coverage for D8080 braces and D8670 monthly visit is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented with hematuria. He was afebrile and the vital signs were stable. The abdominal exam was benign. He was using nonsteroidal anti-inflammatory drugs (NSAIDs) frequently. The hemoglobin was 7.3. It was felt that he may have been having an upper gastrointestinal (GI) bleed, although no GI bleeding was reported. He refused a rectal exam. A computed tomography (CT) scan was negative for acute disease although retroperitoneal adenopathy was found. He was transfused one unit of packed red blood cells (PRBC) and then left the hospital against medical advice (AMA).

Milliman Care Guidelines (MCG) clinical indications for admission for Anemia, Iron Deficiency or Unspecified (MCG: M-35) include hemodynamic instability, active bleeding, or hemolysis, altered mental status, recurrent syncope, severe cardiac arrhythmias, severe thrombocytopenia, and acute renal failure. The patient did not have these conditions.

This patient required a workup for the cause of the anemia. He was transfused a unit of PRBC. However, the transfusion could have been given with observation care. He was then stable to have been referred for an outpatient workup. There was no evidence of active gastrointestinal bleeding. He did not meet MCG criteria for admission for anemia. 
The health care plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

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

Diagnosis: Moderate to Severe Psoriasis
Treatment: Skyrizi 75mg (milligram)/0.8 (milliliter) ml, Pre-service
The insurer denied the Skyrizi 75mg/0.8ml, Pre-service
The denial is upheld.

The patient is a male with history of psoriasis. He has failed topical steroids and Cosentyx. His provider is requesting approval for Skyrizi.

No, the treatment with Skyrizi is not medically necessary.
The patient has not failed methotrexate, which is among the health plan's preferred alternatives. Therefore, Skyrizi is not considered medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
It is appropriate to require the use of methotrexate prior to Skyrizi. The provider states that the patient wants to attend parties and drink socially, but this is not a contraindication to methotrexate. It is a long-standing treatment for psoriasis, and can be safe and effective when properly managed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a diabetic male that presented with chest pain with risks factors for coronary artery disease (CAD). He was admitted to telemetry and myocardial infarction (MI) ruled out. He received intravenous fluids (IVF), aspirin (ASA), and nitroglycerin (NTG) sublingual (sl).  The patient had a computed tomography (CT) scan. He underwent an uncomplicated cardiac catheterization that showed diffuse disease and a decision was made to treat him medically. He was discharged on optimal medical therapy.

Inpatient level of care was denied as not medically necessary.

No, the proposed inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care.

In this case, the patient presented with angina and work up led to a cardiac catheterization.  Orders did not include medical therapy for unstable acute coronary syndrome (ACS) such as intravenous (IV) heparin, dual anti-platelet inhibitors, high dose beta blockers or intravenous nitroglycerin (NTG).   

The heart catheterization was uncomplicated and the patient was stable throughout. Cardiac catheterization is considered safe and appropriate in an outpatient setting. No care was given that required a higher level of care.

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. The cardiac care provided did not require inpatient level of care. There was no complex care that required inpatient care. 

Milliman criteria requirements for inpatient level of care were not fulfilled. The patient did not meet criteria for unstable angina.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appropriate level of care determination based on sound medical judgement is in best of interests of patient
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: epigastric abdominal pain

Treatment: inpatient emergency admission

The insurer is denied coverage for inpatient emergency admission

The denial is upheld. 

This male patient has a history of sinus surgery, tobacco and marijuana

Patient had subjective symptoms with no substantiation from clinical findings or laboratory values. In addition, the presentation is the third time with a benign course of his illness established from previous hospitalizations. In this setting, 24-hour observation to provide symptomatic relief is appropriate.

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

The carrier's denial of coverage for inpatient emergency admission is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hereditary Angioedema

Treatment: Takhzyro

The insurer is denied coverage for Takhzyro.

The denial is overturned. 

This female patient has a history of hereditary angioedema (HAE).

Given that the plan did not provide a list of formulary drugs, the non-formulary drug being denied is appropriate especially given that it has been effective for this patient previously. The denial doesn't state what clinical information/evidence was missing/not provided. However, the screening documents clearly indicate that the diagnosis was correct. Given that the patient has HAE with certainty, and that she was not responding to Firazyr and that she had responded to Takhzyro, it is hard to imagine what other clinical information/evidence was missing.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the Takhzyro is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention deficit hyperactivity disorder (ADHD). 
Treatment: Adderall. 

The insurer is denied coverage for Adderall. 

The denial is overturned. 

This female patient has a history of attention deficit hyperactivity disorder. 

Amphetamine-dextroamphetamine extended release is United States Food and Drug Administration (FDA) approved for ADHD. The patient has ADHD. The  medication is appropriate for the treatment of ADHD. Additionally, the patient was stable on 20 milligrams for one month per the note, which supports that the medication is appropriate. The medication amphetamine-dextroamphetamine extended release 20 milligrams is considered medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for Adderall is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperglycemic. 
Treatment: Acute inpatient stay. 

The insurer is denied coverage for acute inpatient stay. 

The denial is overturned. 

This female patient has a history of Crohn's disease, gestational diabetes, prior episodes of mild pancreatitis, depression and anxiety. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient presented with abdominal pain, shortness of breath, rectal bleeding, and diarrhea and ultimately was found to have an extremely elevated blood glucose of 872. Her blood glucose continued to be elevated and at a dangerous level while she was inpatient; however, it decreased from 872 to 263 prior to the patient's discharge and the endocrinologist reported the expectation that it would continue to normalize with the patient's new drug regimen. Therefore, the inpatient stay was medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for acute inpatient stay is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Short Stature. 
Treatment: Humatrope. 

The insurer denied the Humatrope. 
The determination is upheld. 

The patient is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). His past medical history is significant for developmental delay, coronal hypospadias, obsessive compulsive disorder and the diagnosis of Tourette syndrome. His reported mid parental height is 170.3 centimeters (cm) (67 inches). His growth chart shows that his height was around the 10 percentile (%tile). His weight was around the 50 %tile, dropped to around 25 %tile, and 10 %tile. His evaluation showed an unremarkable comprehensive metabolic panel (CMP), thyroid function test (TFTs), celiac screen, pubertal follicle-stimulating hormone (FSH), luteinizing hormone (LH) and testosterone. Insulin-like growth factor (IGF) -1 and insulin-like growth factor binding protein-3 (IGFBP-3) were normal. 
He was evaluated in the pediatric endocrinology clinic. At that time, his height was 143 cm (6.71 %tile:-1.5 standard deviations (SD)) while his weight was 37.4 kilograms (kg) (17 %tile -1.0 SD). The clinical impression was familial short stature. His growth was followed and on the  follow up visit, his height was 149.9 cm (5.65 %tile:-1.58 SD) while his weight was 36.4 kg (3%tile:-1.95 SD). The clinical impression was familial short stature. 
He underwent GH stimulation testing and his peak growth hormone (GH) response was 18.3 nanograms/milliliter (ng/ml). Treatment with GH was recommended under the indication of idiopathic short stature, At this most recent follow up visit, his height was 153.4 cm (2.77 %tile:-1.92 SD). He was Tanner stage V for pubertal development.
At issue is the medical necessity of Humatrope. 

The requested service is not medically necessary for this patient. 

Although this patient's growth slowed down and he dropped height percentiles, it was associated with a significant drop in weight percentile suggesting nutritional growth retardation (NGR) rather than idiopathic short stature. NGR patients may cease to gain appropriate weight and fail to grow in height even without exhibiting body weight deficits for height. His slow growth cannot be considered idiopathic. 
Although overall this patient has grown at a rate of 5.1 cm per year in 2 years which is less than expected, considering the fact that he was in puberty; however, his slow growth was associated with poor weight gain suggesting familial short stature complicated by nutritional growth failure. Besides that,  at his most recent follow up visit, he was Tanner stage V for pubertal development suggesting that he has almost finished his growth and any intervention at this point is unlikely to improve his adult height.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied Implant placement. 
The denial is upheld in whole. 

The patient is a female who presented to the office of her dental provider for evaluation and treatment of missing teeth numbers (#) 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 30, 31. The patient reports difficulty with her partials with speaking and eating. The treatment of Implant placement in tooth # 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 30, 31 has been planned. The health plan has denied the treatment plan.
At issue is the medical necessity of Implant placement, Tooth 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 30, 31. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Implant placement, Tooth 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 30, 31 is not medically necessary for this patient. 
The documentation shows that the patient does use a denture currently but does not eat with the denture. There may be the need to make a new or better fitting denture that allows for better function. There are multiple options for replacing teeth. Dentures, partial dentures, and implant supported teeth or prosthesis are all possible options. There is no evidence in the documentation that there is any issue with the current denture, did not state for how long the current denture has been in use, did not describe the relationship of the denture flange relative to the border of the soft palate, nor is there documentation of any attempts at adjustment of the denture. There is currently not enough support for utilization of implants as the standard of care for this patient as there has been only minimal examination of the patient to make the recommendation that implants are required. 
Therefore, the requested health service/treatment of Implant placement, Tooth 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 30, 31 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: altered mental status

Treatment: hospital admission

The insurer is denied coverage for hospital admission.

The denial is overturned. 

This female patient has a history of migraines, bipolar disorder, and post-traumatic stress disorder (PTSD).

The MCG- Milliman Criteria Guidelines for Psychiatric Disorder: Common Complications and Conclusions reports that one meets criteria for hospitalization if one is a danger to self or others and not manageable at a lower level of care, if they have severe behavioral health issues such as hallucinations, or if a less restrictive level of care is not considered feasible until acute intervention is done. This was the case with this patient as she was considered to have severe psychiatric symptoms including altered mental status, increased confusion, memory issues, inability to remember things, slurred speech, cognitive difficulties, difficulty completing tasks, difficulty concentrating, and disorientation to date and month, as well as difficulty remembering conversations, so she was considered unable to care for her basic needs. She reportedly could not be treated at a less restrictive level of care as a less restrictive level of care was not considered feasible until acute intervention in this hospital was done. She reportedly had a high Depakote level of 105 and elevated ammonia level which was considered a possible etiology of altered mental status. She was considered in need of 24-hour hospital treatment as she could not care for her basic needs due to these symptoms and was considered a danger to self as a result. The medical records reported that she was not at her baseline. The medical records supported that she required 24-hour hospital treatment due to her severe psychiatric symptoms including altered mental status and delusional thinking. 

Notes reported that she had worsened confusion and slurred speech, was tangential, and Depakote was being held. She was seen by a psychiatric consultant who recommended that she restart Depakote at 500 milligrams (mg)  instead of 1000 mg per day as her last Depakote reportedly was 57. She reportedly improved in her mental status and was discharged with recommendations for sooner outpatient mental health and neurological appointments. The medical records provided enough specific evidence to support that she could not care for her basic needs due to altered mental status with possible rule out of hepatic encephalopathy and that she required inpatient hospital treatment as she continued with altered mental status. She reportedly was discharged after improving her mental status. It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient then.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Multiple sclerosis. 
Treatment: Vumerity. 

The insurer is denied coverage for Vumerity. 

The denial is overturned. 

This male patient has a history of multiple sclerosis (MS). 

Per the documentation from the treating physician, the patient cannot take injectable platform agents (Betaseron, copaxone, Glatopa, and glatiramer) as they are not appropriate given the severity of his MS and the need for more biologically active agents.  Aubagio is also not appropriate as the member may father a child and per Food and Drug Administration (FDA) guidelines, people should not be taking Aubagio while fathering a child.  Gilenya is relatively contraindicated given the patient's hypertension. Finally, the member has some irritable bowel symptoms which makes Vumerity a better choice than dimethyl fumarate. 

Diroximel fumarate (DRF) (Vumerity) is a novel oral fumarate approved for relapsing forms of multiple sclerosis (MS). DRF demonstrated significantly improved gastrointestinal (GI) tolerability versus dimethyl fumarate (DMF) with fewer days of Individual Gastrointestinal Symptom and Impact Scale (IGISIS) scores greater >2, GI adverse events (AEs), and treatment discontinuations due to GI AEs as shown in the new analysis of EVOLVE-MS-2 trial data. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for Vumerity is overturned.  The medical necessity is substantiated.