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

Diagnosis: Dementia.
Treatment: Increase Home/Personal Care HHC Level 2 Per 15 Minutes to 24 Hours Per Day (split shift).

The insurer denied: Increase Home/Personal Care HHC Level 2 Per 15 Minutes to 24 Hours Per Day (split shift).  The denial is overturned.

This elderly female has medical conditions that include dementia, weakness, arthritis, insomnia, and incontinence. She lives alone. Denial of increase home/personal care to 24 hours per day (split shift) is being appealed. The health plan approved live in services. Uniform Assessment System evaluation completed two months ago shows moderately impaired cognition and functional status: total dependence with all ADLs, (activities of daily living) except maximal assistance with bed mobility and eating. She is incontinent of bowel and bladder. 
An appeal statement from New York State reports the member began hospice care three months ago. 
She requires assistance with all ADLs (activities of daily living). Her condition is declining, and she needs help with using the bathroom every 2-3 hours per night and repositioning during the night. She requires frequent diaper changes due to incontinence. 
A letter from her Provider notes the member needs total assistance with ADLs (activities of daily living). She needs to be repositioning every 3-4 hours. She wakes up every 2-3 hours with neurocognitive impairments. Logs are provided supporting frequent nighttime assistance with toileting.

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This member has multiple chronic conditions and has recently been admitted to hospice care. Denial of increase home/personal care to 24 hours per day (split shift) is being appealed. The health plan approved live in services. Uniform Assessment System evaluation completed two months ago shows the member requires maximal assistance to total dependence with all ADLs (activities of daily living). She is incontinent of bowel and bladder. The appeal statements support the member is dependent with all ADLs (activities of daily living) and requires frequent assistance with toileting, transfers, and turning/repositioning. The appeal statements and nighttime logs support toileting every 2-3 hours. This member has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed increase home/personal care to 24 hours per day (split shift) is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Diabetes

Treatment: Mounjaro 15mg/0.5mL Pen

The insurer denied coverage for Mounjaro 15mg/0.5mL Pen

The denial is overturned
 

According to the medical records, the patient has a history of Type 2 diabetes mellitus (DM) requesting Mounjaro which is under review. The letter by the doctor notes the patient has been successfully treated with Mounjaro (terzepatide) for a year "after trialing alternative therapies and medications such as Ozempic and Trulicity." Thus, formulary drug(s) have been ineffective based on the patient's clinical history.

Furthermore, a study in the New England Journal of Medicine comparing tirzepatide vs semaglutide concluded that "tirzepatide was noninferior and superior to semaglutide with respect to the mean change in the glycated hemoglobin level from baseline to 40 weeks. "  In addition, as per Up to Date- "Among the longer-acting Glucagon Like Peptide 1 (GLP-1) receptor agonists, small differences in glucose control favor tirzepatide over subcutaneous semaglutide (1 mg), liraglutide or subcutaneous semaglutide over exenatide once weekly, and subcutaneous semaglutide over dulaglutide  or liraglutide. Glycemic control appears to be similar with liraglutide and dulaglutide [39] and with oral semaglutide and liraglutide."

The requested drug would be more effective than the formulary drug. 

The formulary drugs are expected to cause adverse effects.

The formulary drugs were tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non- formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Mounjaro 15mg/0.5mL Pen to treat diabetes is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Nodules.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of hypertension. His presenting complaints were hiccups and a sore throat; the patient was told to present to the emergency department by his pulmonologist due to bilateral pulmonary nodules seen on a computed tomography (CT) scan of the chest performed one month prior. The physical exam was unremarkable. Lab results were unremarkable. Radiology was notable for bilateral pulmonary nodules, innumerable, with mediastinal lymphadenopathy. The patient was admitted to an inpatient level of care and underwent a bronchoscopy which revealed findings consistent with sarcoidosis. At issue is the medical necessity of an inpatient stay.

The requested health service of inpatient level of care was not medically necessary.
The patient presented with an abnormal chest CT scan performed one month prior at an outside facility, without symptoms beyond hiccups. The chest CT was highly concerning for malignancy, granulomatous disease, or atypical infection, but without significant symptoms such as severe shortness of breath or signs such as hypoxia or hemodynamic instability a lower level of care would have been an appropriate avenue to continue the patient's diagnostic workup on an urgent basis and monitor symptoms. The inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other
Treatment: Genetic (DNA) testing for inherited disorders
The health plan denied: Genetic (DNA) testing for inherited disorders
The determination is: Overturned

The patient is a female who underwent panorama genetic testing screening for risks relating to common genetic disorders such as trisomy 21 and trisomy 18. At the time of the testing, the patient was 12 weeks pregnant.
At issue is the medical necessity of genetic (deoxyribonucleic acid [DNA]) testing for inherited disorders.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of genetic (DNA) testing for inherited disorders is medically necessary for this patient. The result is very sensitive for given risk estimation for chromosomal disorders that result in major anomalies and require frequent monitoring, ultrasounds, and further testing and imaging during pregnancy. If the results were to show high risk for certain chromosomal abnormalities, follow up with more parental testing to confirm diagnosis is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit

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

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified impacted canines among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index choosing the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated on the HLD index. 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 by internal reviewers attaining a score of 18 points. 

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 Labio-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. 
In this case, the treating orthodontist completes the HLD index, choosing the impacted permanent anteriors criterion to justify orthodontic care. The clinical circumstance as documented meets this criterion for approval of care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 braces and D8670 monthly visit is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral foot pain.
Treatment: Durable Medical Equipment (CPT L3000 x 2- custom shoe inserts).

The insurer denied Durable Medical Equipment (CPT L3000 x 2- custom shoe inserts).  The denial is upheld.

The patient is a teenage female, who presented with bilateral foot pain. She was diagnosed with Pes planus deformity, as well as bilateral plantar fasciitis. She was prescribed custom orthotics.

The custom foot orthoses are not medically necessary.

Custom foot orthoses are not superior to over-the-counter orthotics, injections, physical therapy, NSAIDs (nonsteroidal anti-inflammatory drugs), oral, steroids, and various stretching exercises. Plantar fasciitis can be treated with many options other than customer orthotics. There are no prospective, randomized, clinical trials demonstrating the superiority of custom orthotics over over-the-counter orthotics, physical therapy, injection, oral steroids, and NSAIDs (nonsteroidal anti-inflammatory drugs).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Intraosseous basivertebral nerve ablation. 
The health plan denied Intraosseous basivertebral nerve ablation. 
The determination is upheld. 

The patient is a male with low back and leg pain. He has a diagnosis of lumbar radiculopathy documented on numerous clinical notes. Magnetic resonance imaging (MRI) of the lumbar (L) spine shows Lumbar 5 - Sacral 1 (L5-S1) listhesis with nerve impingement and osteophyte formation. His provider has recommended intraosseous basivertebral nerve ablation. 
At issue is whether the proposed health treatment is likely to be more beneficial than any standard treatment for the patient's condition. 
The health plan's determination regarding the proposed health treatment is upheld in whole. 
The proposed health treatment is not likely to be more beneficial than any standard treatment for the patient's condition. The patient has clear radiculopathy per the clinical records and L5-S1 listhesis and facet degeneration and stenosis, which is likely the cause of pain. These findings would not improve with the intervention requested. Therefore, the proposed health treatment would not be beneficial for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is a female child with no significant past medical history who presented with a fever for 1 week, 4 days of decreased oral  intake, also decreased urine output. Had leukocytosis of 16,700 in emergency room, Rocephin intravenous given, patient admitted. Mother refused to have catheterized urine specimen done in emergency room. Patient refused to pass urine, so no urinalysis or culture could be obtained. Patient had fever, dehydration and was admitted. Urinalysis was finally collected after one dose ceftriaxone, showed leukocytes/ bacteria (1+). Patient's fever came down, oral intake and urine output improved, labs improved, patient was stable for discharge. 

Per Milliman Care Guidelines (MCG) Health (24th) Urinary Tract Infection-Pediatric, the patient fails to meet clinical indications for admission for inpatient care. These include age < 2months, hemodynamic instability, bacteremia, altered mental status that is severe or persistent, urinary obstruction, renal or perinephric abscess, etc. Urinary Tract infection was never proven by positive urine culture.

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


Diagnosis: Central Sleep Apnea
Treatment:  Pacemaker Device for Diaphragm
The insurer denied the Pacemaker Device for Diaphragm.
The determination is overturned.

This is a male patient with a history of morbid obesity and severe central sleep apnea, as well as mild obstructive sleep apnea. He has been intolerant to continuous positive airway pressure (CPAP). He has symptoms of fatigue, daytime hypersomnolence, and memory and concentration problems. The medical necessity for a transvenous phrenic nerve stimulator is under review issue.

Based on the documentation provided, the requested service is medically necessary.
This patient has severe symptomatic central sleep apnea (CSA). The Remede System is a fully implantable system that is implanted transvenously for phrenic nerve stimulation and treatment of CSA. Its use is patients with CSA has been shown to be safe and to result in sustained improvements in key sleep parameters, sleep symptoms and quality of life. It is Food and Drug Administration (FDA) approved for the treatment of moderate to severe central sleep apnea. Unlike with obstructive sleep apnea, continuous positive airway pressure is of limited benefit in CSA and there are limited alternative treatment options. Thus, use of the Remede System is medically necessary in this symptomatic patient.
The medical literature supports its use in this situation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee Problem/Pain
Treatment: Inpatient emergency admission
The health plan denied: Inpatient emergency admission
The determination is: Upheld

The patient is a female with a bucket-handle tear of the left medial meniscus. She underwent arthroscopic repair of the meniscal tear under spinal anesthesia. She was monitored for a period of time, received physical therapy instruction for crutch-walking, and was discharged to home. At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of hospital admission is not medically necessary for this patient. Arthroscopic surgery under spinal anesthesia is usually performed as an outpatient procedure, and there were no complications that required a higher level of care or prolonged monitoring. There was minimal risk of compartment syndrome, and there were no worrisome complaints or physical findings that would require more intensive evaluation or emergency treatment. The patient was able to learn safe crutch-walking quickly, and pain was adequately controlled with oral analgesics. The care provided to the patient was not consistent with an inpatient level of care and could have been provided at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Distress
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female infant born full term who was sent to the emergency department (ED) from the pediatrician's office for evaluation of respiratory distress secondary to bronchiolitis. She had been seen in the emergency department (ED) two days prior, and labs and a chest x-ray were obtained, she was diagnosed with a viral respiratory infection, and she was discharged home. In the pediatrician's office, she was noted to have increased work of breathing with retractions and wheezing. She was given two albuterol treatments prior to arrival at the ED. She was still feeding well with baseline urine output. There was a family history of asthma in both parents and two siblings.  The examination was significant for no acute distress, non-toxic appearance, moist mucous membranes, tachypnea, wheezing, brisk capillary refill, and no focal neurologic deficit. She was given three nebulized albuterol treatments and dexamethasone with some improvement. A urine culture from the previous visit was equivocal for a urinary tract infection (UTI), so she was given a dose of Keflex. Rapid viral screening was negative. She was subsequently admitted to the pediatric floor for ongoing management of bronchiolitis and reactive airway disease. She was stable overnight, with no need for supplemental oxygen, no desaturations, no further tachypnea, and no retractions. She was feeding well. A chest x-ray was unremarkable. She was receiving nebulized saline every six hours and normal saline nasal drops with suctioning as needed. She was subsequently deemed stable for discharge. At issue is the medical necessity of an inpatient stay.

An acute inpatient hospital admission was not medically necessary.
This female infant presented with wheezing and tachypnea complicating an upper respiratory infection. She responded well to bronchodilators in the ED and was admitted for further care. While it was reasonable to monitor her in the hospital for improvement versus decompensation, she was overall hemodynamically stable with no need for supplemental oxygen, no difficulty with feeding, no dehydration. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Learning and cognitive deficits
Treatment: Consumer Directed Personal Assistance
The insurer denied: Consumer Directed Personal Assistance
The denial is upheld.

This adult female patient has learning and cognitive deficits. She is requesting assistance with basic home needs. The denial of consumer directed personal assistance is being appealed. 
Uniform Assessment System (UAS) evaluation completed eight months ago shows independent cognition and functional status: total dependence with housework and managing finances, and 
independent with other activities of daily living (ADLs). The patient is continent of bowel and bladder.

The proposed treatment is not medically necessary. 

Personal assistance services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Uniform Assessment System (UAS) evaluation completed eight months ago, shows the patient is independent with activities of daily living. She needs assistance with housekeeping and managing finances. Personal assistance services are not indicated when no tasks are being performed or for supervision. The proposed consumer directed personal assistance is not 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 had a history of pancreatitis and presented with abdominal pain and constipation. She previously had an extensive workup including endoscopic ultrasound (EUS) and Magnetic Resonance Cholangiopancreatography (MRCP). She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. An abdominal ultrasound showed an enlarged pancreatic duct but this was present on a previous exam. The lipase was currently 99 with normal up to 60. The impression was that her symptoms were related to both chronic pancreatitis and constipation. The Magnetic Resonance Cholangiopancreatography (MRCP) was repeated. Intravenous (IV) hydration was given and her symptoms improved. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-250 for Pancreatitis. Clinical indications for admission include having acute pancreatitis. In this case, the patient's symptoms were more consistent with chronic pancreatitis. The lipase was only mildly elevated and the abdominal ultrasound was consistent with chronic pancreatitis. The Magnetic Resonance Cholangiopancreatography (MRCP) was done a day prior to discharge and mild inflammation was present. However, the patient's symptoms had already improved. The gastroenterologist advised that the Magnetic Resonance Cholangiopancreatography (MRCP) was stable from the prior exam. Clinical indications for admission for chronic pancreatitis include inability to maintain oral hydration after observation care, evidence of infection, severe pain, hemodynamic instability, severe dehydration, acute renal failure, altered mental status, and severe electrolyte abnormalities. The patient did not have these conditions. 

This patient had a history of recurrent pancreatitis and now presented with symptoms that were most consistent with chronic pancreatitis. Intravenous (IV) hydration, a bowel regimen, and pain medications could have been given with observation status. She did not meet criteria for admission for Pancreatitis. 

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 the inpatient admission is not substantiated.