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

Diagnosis: Cognitive Impairment 
Treatment: Personal Care Services Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week 
The insurer denied Personal Care Services Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week. 
The health plan's determination is upheld. 

The patient is a female with past medical history of dementia, coronary artery disease, constipation, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), hypothyroidism, chronic anticoagulation, permanent pacemaker, osteoarthritis, diabetes mellitus (DM) type 2, vitamin B12 deficiency, insomnia, hearing loss, urinary incontinence, and bowel incontinence who had been assigned PCA (personal care assistant) services. 

Personal Care Services Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week are not medically necessary for this patient. 
There is no documentation of overnight care needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. There is no documentation that the patient's residence does not have the appropriate space for a PCA to sleep. There is no documentation of the medical necessity of turning and repositioning every two hours. There are no specific overnight care logs documenting the activities of daily living (ADL) assistance needs in the overnight hours or the frequency of such need. 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, PCA services 24 hours/day, 7 days/week, split shift, to total 168 hours/week are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Wegovy. 

The health plan denied: Wegovy. 
The determination is upheld. 

The patient is a female being prescribed Wegovy for the treatment of obesity.
Office visit notes provided for review. The notes state that she was titrated up to the Wegovy 2.4 milligrams (mg) dose and has lost 49 pounds since starting the medication. Her weight at that visit was 58.97 kilograms (kg), and her body mass index (BMI) was 25.39. Follow up visit notes state that she lost an additional 6 pounds (55 pounds total), and her BMI had decreased to 24.35. 

The health plan denied coverage for the recertification of the medication because the patient's BMI did not meet the prescribed criteria. The plan only authorizes treatment with Wegovy if patients have a BMI greater than (>) 27 (among other criteria).
The patient provided a letter of support for this appeal. The letter states that her starting BMI was 34.95 when she began treatment. She also had comorbid conditions including sleep apnea, dyslipidemia, coronary artery disease, and impaired fasting glucose. She states that the medication is indicated for both the treatment of obesity and the maintenance of weight loss and should therefore be covered. 

At issue is the medical necessity of Wegovy. 

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

The requested health service/treatment of Wegovy is not medically necessary for this patient. 

The health plan requires certain criteria for the initial coverage and recertification of Wegovy. For both initial coverage and recertification, the plan requires a BMI of 27 or greater and covers a maximum of 2 years of total therapy. Although the medication is approved for the maintenance of weight loss and obesity, its Food and Drug Administration (FDA) approval is on the basis of these criteria that are outlined in the plan. The patient has achieved a normal body mass index. Therefore, it has not been established that ongoing treatment with the medication is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Braces (D8080)

The insurer denied coverage for Braces (D8080). 

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 overjet, overbite, and anterior crowding among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 30 total points. 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 attaining only 22 points on the HLD index by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant 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 second portion of the index arriving at 30 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic 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. 

Reverse denial as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval. 

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 D8080 braces is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congenital central diaphragmatic hernia. 
Treatment: Private Duty Nursing: 24 hours per day, 7 days per week shared by RN (Registered Nurse) and LPN (Licensed Practical Nurse) (4224 units). 
The insurer denied Private Duty Nursing: 24 hours per day, 7 days per week shared by RN and LPN (4224 units). 
The health plan's determination is overturned. 

The patient is a female infant born prematurely at 36-6/7-days' gestation with complex medical history significant for congenital central diaphragmatic hernia (stomach and spleen in the thoracic cavity) status post repair, resultant congenital short esophagus and gastroesophageal reflux disease status post gastrojejunostomy (GJ) tube placement, pituitary gland plus syndrome, clival encephalocele and oral teratoma with cleft palate status post resection, pulmonary hypoplasia, hiatal hernia status post resection, nystagmus with visual impairment, sialorrhea, concern for auditory impairment, vertebral anomalies with decreased cervical range of motion, history of tethered cord status post release, and global developmental delay. 

Private Duty Nursing: 24 hours per day, 7 days per week shared by RN and LPN (4224 units) are medically necessary for this patient. This fragile female infant has numerous medical needs due to the complexity of her clinical condition and both functional and anatomic abnormalities. She requires constant monitoring with attention to breathing, feeding tolerance, fluid management, neurologic status, and skin integrity. Even during subacute hospitalization, she developed infections at the site of her nasal dermoid, developed tethered cord symptoms requiring release, and experienced GJ tube dislodgement requiring acute hospital-based management. She was intubated for the first five months of her life, now with chronic lung disease complicating pulmonary hypoplasia. The level of care required to maintain this infant's health and allow her to achieve her functional best level of development is far beyond what can be provided by trained layperson caregivers. The requested private duty nursing services are medically necessary and appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth. 
Treatment: Partial Lower Denture. 
The insurer denied: Partial Lower Denture. 
The denial is overturned. 

The patient is an adult female requesting a lower partial denture. Recently, the patient had teeth #17 and #30 extracted. The prior denial by the health plan was due to "more than 8 posterior teeth in occlusion". 

The proposed treatment is medically necessary. 

According to the x-rays presented, the patient has only 6 posterior teeth in occlusion (numbers 4, 5, 12, 21, 28 and 29). This is below the eight posterior teeth in occlusion threshold that is needed for partial denture approval. The case has medical necessity as the patient needs the partial denture to chew properly.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left elbow fracture
Treatment: Physical therapy
The health plan denied physical therapy. The denial is upheld.

The patient is an adult male with left elbow pain. He suffered a left elbow fracture requiring ORIF (open reduction internal fixation) last year. He was referred for post-operative physical therapy. His therapy for the dates of service under review was denied coverage by the health plan. This denial is the subject of review.

The patient had physical therapy for two months following a left distal humerus fracture requiring ORIF (open reduction internal fixation). He continued to demonstrate loss of ROM (range of motion). His pain improved. His strength was functional. He was able to transition to a home exercise program. Continued physical therapy for the dates of service under review was not likely to result in significant improvement in his condition. His therapy could have been completed in a less intensive setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

Patient is an adult who presented to the hospital with complaints of chest pain - pleuritic type, shortness of breath (SOB), and dry cough.  The patient had been diagnosed with Influenza and bronchitis / pneumonia a week prior.  She was treated with steroids and Doxycycline but was not feeling better, so she came to the emergency department (ED).

Vital signs at presentation: Temperature 97.8 degrees F (Fahrenheit), Pulse 87, Respirations 18, Blood Pressure 174/89. Oxygen (O2) saturation on room air 98% (percent).  She was in no acute distress.  Lungs revealed bilateral wheezing. Heart sounds were normal.  She was alert and oriented to person, place and time with a non-focal neurological exam.

Labs were within normal limits. Electrocardiogram (EKG) showed no acute changes. Chest x-ray was normal. Influenza and Respiratory syncytial virus (RSV) panel were negative. The patient was admitted to the hospital with a diagnosis of Asthma Exacerbation.  She was treated with steroids, and Duo Nebulizer. No antibiotics were started.  The patient was described to be in no acute distress and sitting comfortably.  Other than wheezing on lung exam there were no other positive findings.

The patient remained stable after admission and was discharged home the next day with outpatient follow up.  This patient did not need acute inpatient hospitalization.  She could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation could be up to 48 hours.  This patient was stable hemodynamically, not hypoxic, with no evidence of Influenza or pneumonia. She was tolerating food and fluids. This patient could have been kept in Observation and then discharged home on oral medications once she remained stable.

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left sided flank pain
Treatment: Inpatient admission 
The insurer denied coverage for inpatient admission.
The denial is upheld. 

This is an adult male who presented to the emergency department with complaint of left sided flank pain due to a renal stone for one week and demonstrated no distal movement on repeated radiology studies. Patient was taken to operating room for a cystogram, laser lithotripsy and stent placement. The patient improved postop (postoperative) and was discharged home. The insurer has denied coverage for the inpatient admission as not medically necessary. There were no serious medical issues or complications. Per Milliman Care Guidelines (MCG) Health (26th) renal colic and kidney stones, patient fails to meet indications for admission to inpatient care. Also, per Milliman Care Guidelines (MCG) Health (26th) Urologic surgery or procedure GRG (General Recovery Care Guidelines): patient is noted to have met the GRC discharged parameter within 24 hours post procedure. As per guidelines, this procedure is performed in the ambulatory surgery setting.

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

Diagnosis: herniated cervical and lumbar disks and pain

Treatment: increase in Consumer Directed Personal Assistance Program (CDPAP) Personal Care Services (PCS)- Housekeeping/Personal Attendant (Level 1 and Level 2) to 4 hours per day, 6 days per week

The insurer denied coverage for increase in Consumer Directed Personal Assistance Program (CDPAP) Personal Care Services (PCS)- Housekeeping/Personal Attendant (Level 1 and Level 2) to 4 hours per day, 6 days per week

The denial is overturned


The patient is an adult female with past medical history of herniated cervical and lumbar disks, polymyalgia rheumatica, bilateral rotator cuff tendinitis, vertigo, hypertension, and pain and right-sided sciatica. She is having neuropathic pain in her arms, hands, and right leg. This is affecting her ability to accomplish activities of daily living without assistance.

Her primary care provider's request for increased home care hours is detailed and compelling. Her symptoms are worsening, now preventing her from performing upper body activities of daily living (ADLs) and walking without pain.  She is unable to tolerate repetitive movements in her arms (required for dressing, cooking, cleaning, etc.). 

An increase in Consumer Directed Personal Assistance Program (CDPAP) Personal Care Services (PCS)- Housekeeping/Personal Attendant (Level 1 and Level 2) to 4 hours per day, 6 days per week is considered medically necessary for this patient. 

"The Future of Home Health project sought to support transformation of home health and home-based care to meet the needs of patients in the evolving U.S. health care system." (Landers et al., 2016).

"As healthcare professionals, we must recognize the importance of home health aides in supporting older adults at home. Home health aides' consistent and longitudinal presence and care of patients uniquely positions them to identify subtle changes in patients' health and wellness, potentially preventing disease exacerbations and hospitalizations. However, despite possessing this vital information, communication of clinical changes to medical teams is frequently difficult as most home health aides work for agencies unaffiliated with the patients' primary care providers." (D'Cruz et al., 2022).

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 an increase in Consumer Directed Personal Assistance Program (CDPAP) Personal Care Services (PCS)- Housekeeping/Personal Attendant (Level 1 and Level 2) to 4 hours per day, 6 days per week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

Patient is an adult with a history of chronic obstructive pulmonary disease (COPD) / Asthma , gastroesophageal reflux disease (GERD) and Polysubstance abuse. She presented to the emergency department (ED) with complaints of shortness of breath (SOB), wheezing and chest tightness of 3 days duration. The patient was given Duo Nebs X 3 by emergency medical services (EMS).

At presentation to the ED the patient was afebrile and hemodynamically stable.  Oxygen (O2) saturation was 95-96%.  Lung exam revealed bilateral wheezes.  In the ED she was given intravenous (IV) steroids and continued on Duo Nebs.

The patient was admitted to the hospital for asthma exacerbation.  She was afebrile, respirations 18, Pulse 82 and in no acute distress.  Maintained O2 saturations 95-98 % throughout hospitalization.  Lab results were within normal limits.  Chest x-ray showed no acute infiltrates.

The patient was continued on Combivent, Spiriva, Symbicort and was also given IV steroids.
As the patient had some hoarseness Ear, Nose and Throat (ENT) was consulted. The patient had no stridor.  Laryngoscopy was consistent with Reinke's edema related to smoking and GERD. 

She remained stable after admission. As notes from the next day indicate; the patient was ambulating in hallway on oxygen at 2 liters via nasal canula.  She remained stable on Spiriva / Symbicort / steroids and pain medications as needed (PRN).  The patient was subsequently switched to oral (PO) steroids and discharged home the next day.

This patient did not need acute inpatient hospitalization. She could have been placed under observation status.  Observation can last for up to 48 hours. The patient had improved after treatment in ED.  By the next day she was ambulating freely in the hallway. Was on PO medications. She could have been switched to PO steroids and then discharged home. She had been seen by ENT for her hoarseness and was cleared for discharge by ENT.

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.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Home Care/ Personal Care HHC Level II 
Personal Care Services per 15 Minutes to 112 Hour(s) per Week
The insurer denied: Increase Home Care/ Personal Care HHC Level II Personal Care Services per 15 Minutes to 112 Hour(s) per Week
The denial is overturned.

This elderly female patient has diagnoses that include dementia, diabetes, and hypertension. Denial of an increase in home care / personal care services to 112 hours per week is being appealed. The health plan has approved 41 hours per week. Uniform Assessment System (UAS) evaluation completed last month shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, and shopping; maximal assistance with transportation; extensive assistance with phone use, bathing, personal hygiene, dressing, and toilet transfer; limited assistance with walking, locomotion, toilet use; and bed mobility; and supervision with eating. The patient has bladder incontinence. 
A letter from the patient's provider notes the patient's ability to perform activities of daily living (ADLs) continues to diminish due to her chronic conditions. An increase to 84 hours per week is recommended. 
A letter from another provider notes the patient's cognitive impairment limits her daily function. She also has physical limitations. She requires assistance with activities of daily living. She has behavioral disturbance due to dementia. She lives alone. Her son provides assistance, but it is insufficient. 
A letter from the patient's son notes the patient has frequent overnight needs that will not allow an aide to get five hours of uninterrupted sleep. He cannot provide informal support. She wanders. She has had multiple falls and needs help getting up.
A statement from New York State notes the patient requires assistance during her waking hours, which is 16 hours per day. She lives alone.

The proposed treatment is 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. This patient has multiple chronic conditions. Denial of an increase in home care / personal care services to 112 hours per week is being appealed. The health plan has approved 41 hours per week. Uniform Assessment System (UAS) evaluation completed last month shows the patient requires assistance with all activities of daily living (ADLs), except eating. She has bladder incontinence. Appeal statements support her need for assistance with all activities of daily living. The patient lives alone and does not have sufficient informal support. The information provided shows that this patient has significant limitations in functioning. The information supports the need for assistance during her waking hours. The approved personal care services of 41 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 112 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urticaria
Treatment: Xolair 900 milligrams (MG) every four weeks
The insurer denied: Xolair 900 milligrams (MG) every four weeks
The denial is overturned.

The patient is an adult female with urticaria, treated with multiple antihistamines and systemic steroids. The provider is requesting Xolair 900 milligrams (mg) every four weeks. The patient has been well controlled on Xolair for three years with dose titration to 450 milligrams every two weeks. The health plan denied the requested dosage as it is not within Food and Drug Administration (FDA) recommended dosing.

The proposed treatment is medically necessary.

Dose optimization of biologics is commonly performed in diseases for which these medications are used. Omalizumab (a recombinant, humanized anti-immunoglobulin-E antibody) is the only approved treatment for antihistamine refractory chronic spontaneous urticaria (CSU). However, approximately 30 percent of patients remain symptomatic at licensed doses of omalizumab 150 milligrams and 300 milligrams, even after a treatment period of over six months. In the recent years, there have been several studies on updosing of the drug, suggesting that the individualized approach for urticaria treatment with omalizumab is useful. Reports mainly show that updosing/dose adjustment evaluated with the assessment of disease activity (Urticaria Activity Score) and control (Urticaria Control Test) achieves better clinical response to omalizumab with a good safety profile in a pool of patients with chronic spontaneous urticaria.
This patient is established on this dosing regimen with good control and therefore the requested dose is medically necessary given the support in current literature.