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

Diagnosis: Periodontal pocketing.
Treatment: D4341 Deep Gum and Root Cleaning, Lower Left Quadrant, D4341 Deep Gum and Root Cleaning, Lower Right Quadrant, D4341 Deep Gum and Root Cleaning, Upper Left Quadrant, and D4341 Deep Gum and Root Cleaning Upper Right Quadrant.

The insurer is denied coverage for D4341 Deep Gum and Root Cleaning, Lower Left Quadrant, D4341 Deep Gum and Root Cleaning, Lower Right Quadrant, D4341 Deep Gum and Root Cleaning, Upper Left Quadrant, and D4341 Deep Gum and Root Cleaning Upper Right Quadrant.

The denial is upheld. 

This patient is a male with no documented history. The patient presented to the dentist's office for an evaluation. The patient's teeth X-rays were taken and the treating dentist determined that the patient needed D4341 Deep Gum and Root Cleaning, Lower Left Quadrant, D4341 Deep Gum and Root Cleaning, Lower Right Quadrant, D4341 Deep Gum and Root Cleaning, Upper Left Quadrant, and D4341 Deep Gum and Root Cleaning Upper Right Quadrant.

Upon review of the submitted documentation, in particular the periodontal probing and bitewing radiographs, there is minimal if any loss of alveolar bone height affecting these teeth. The increased pocket depths likely represent pseudopocketing due to superficial calculus accumulation and poor oral hygiene.  It is focal and isolated to only a few teeth in these quadrants. There is minimal significant periodontal probing with no periodontal probing over 5mm(millimetres) depth. And there is no documentation of any bleeding on probing. The insurer has correctly applied the clinical criteria in denying scaling and root planing services.

Based on the review above, the coverage for D4341 deep gum and root cleaning lower left quadrant, D4341 deep gum and root cleaning lower right quadrant, D4341 deep gum and root cleaning upper left quadrant, D4341 deep gum and root cleaning upper right quadrant is not considered medically necessary for this patient as the clinical and radiographic documentation do not support or substantiate scaling and root planing services.
	
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 the D4341 Deep Gum and Root Cleaning, Lower Left Quadrant, D4341 Deep Gum and Root Cleaning, Lower Right Quadrant, D4341 Deep Gum and Root Cleaning, Upper Left Quadrant, and D4341 Deep Gum and Root Cleaning Upper Right Quadrant is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe bilateral eye macular degeneration and associated legal blindness, human immunodeficiency virus (HIV) and asthma.
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) from 28 Hours to 63 Hours per Week.
The insurer denied the Increase Consumer Directed Personal Assistance Services (CDPAS) from 28 Hours to 63 Hours per Week.
The denial is overturned. 

The patient is a female with a history of severe bilateral eye macular degeneration and associated legal blindness, human immunodeficiency virus (HIV) and asthma. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 63 hours per week Personal Assistance Services to offer increased activities of daily living support.

Yes, the proposed treatment of 63 hours per week Personal Assistance Services is deemed medically necessary.

An assessment of the patient's functionality and ability to perform activities of daily living was completed and determined that the currently approved plan of 28 hours per week Personal Assistance Services is sufficient to meet the patient's current needs. 

However, recent correspondence from the patient's medical providers indicates that due to progressively worsening visual acuity, the patient is now legally blind in her right eye and almost completely blind in her left eye. In addition, her physician reports that her vision loss is permanent with no hope for recovery. Hence, she is unable to ambulate or perform her activities of daily living without assistance. For these reasons, the proposed treatment of 63 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Chest Pain
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital admission as not medically necessity. 
The reviewer has overturned in whole the health plan's denial. 

This patient is a male with no significant past medical history, who presented to the emergency room (ER) with new onset, exertional chest pain radiating to his left arm for two days. He was admitted initially under an observation level of care to rule out acute coronary syndrome (ACS). However, he continued to experience chest pain associated with dynamic electrocardiogram (ECG) changes consistent with unstable angina.
The patient underwent urgent coronary angiogram and needed stent placement for severe stenosis of the mid left anterior descending (LAD) artery. His echocardiogram showed mildly dilated aortic root. Notable labs showed hyperlipidemia and hypertriglyceridemia and newly diagnosed type 2 diabetes mellitus. The patient also required treatment with intravenous (IV) fluids for acute renal failure. The patient was discharged home in stable condition.
At issue is the Inpatient stay for medical necessity.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Inpatient stay was medically necessary for this patient.
Given the patient's presentation of acute coronary syndrome secondary to unstable angina requiring urgent coronary angiography and coronary stent placement, inpatient admission was medically necessary and in the best interest for patient safety.
This patient presented with acute onset worsening chest pain and dynamic ECG changes consistent with unstable angina. His Heart Score was elevated indicative of an increased risk of major adverse cardiac events for which inpatient admission for evaluation and management is recommended. (1, 2) He was appropriately evaluated and managed requiring urgent coronary angiography and placement of mid LAD coronary artery stent. Based on the 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the management of patients with non-ST-elevation acute coronary syndromes, the standard of care for patients who present with unstable angina is inpatient admission for the aggressive treatment of ischemia to reduce the risk of myocardial infarction and cardiovascular death. (3) For these reasons, an inpatient admission was medically necessary, appropriate and in the best interest for the safety of this patient.
Therefore, the Inpatient stay was medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: CNS (central nervous system) embryonal tumor.
Treatment: Temozolomide.
The insurer denied Temozolomide. 
The health plan's determination is overturned. 

The patient is a girl who presented to a local hospital emergency room unresponsive and apneic with bradycardia. She was intubated and underwent a computed tomography (CT) scan of the brain revealing a large intracranial mass. 

The proposed treatment using Temozolomide is considered a standard of care and is likely to be more beneficial with a lower adverse event risk than cytotoxic chemotherapy for this patient. The Children's Oncology Group protocol for recurrent or progressive medulloblastoma includes Temozolomide in combination with other chemotherapeutic or targeted agents. Single agent oral/PEG(Percutaneous endoscopic gastrostomy) administered Temozolomide is considered a standard of care option in pediatric oncology.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: CNS (central nervous system) embryonal tumor 
Treatment: Temozolomide
The insurer denied Temozolomide. 
The health plan's determination is overturned. 

The patient is a female with a history of central nervous system (CNS) peripheral neuroectodermal tumor (PNET) that was treated with right frontal subtotal resection, extra-ventricular drain placement with ventriculostomies. 

The use of Temozolomide is preferred over the more myelosuppressive treatments such as Cisplatin. Therefore, based on the clinical information provided for review, the current peer-reviewed literature and standards of care in the field, in this case, temozolomide 180 mg/5ml(milligram/milliliter) is more likely to be beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: CNS (central nervous system) embryonal tumor.
Treatment: Temozolomide.
The insurer denied Temozolomide. 
The health plan's determination is overturned. 

The patient is a female who presented with a one day history of vomiting followed by somnolence and bradycardia requiring intubation on the field by Emergency Medical Services (EMS). Imaging in the emergency room (ER) revealed a large bifrontal mass with extension to the basal and prepontine cisterns with mass effect on the brainstem. She underwent emergent external ventricular drainage (EVD) placement and right frontal craniotomy with tumor decompression. 

Temozolomide is likely to be more beneficial than any standard treatment for this child's life-threatening disease. In this case, the family wishes to pursue palliative therapy with the goal of attaining as much disease control as possible, sustaining the life of their daughter as long as possible, but with minimal toxicity given her fragile medical condition and poor long term prognosis related to her disease and her neurologic function. Her highly aggressive metastatic disease coupled with her encephalomalacia/hypoxic brain injury does not render her a good candidate for intensive chemotherapy and, rather, temozolomide would be a better option for her.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic rhinosinusitis.
Treatment: Dupixent.

The insurer denied Dupixent.  The health plan's determination is overturned. 

This is a female patient. The request is for Dupixent for CRS (Chronic rhinosinusitis) with NP (nasal polyps). She has tried nasal steroid spray and stopped as Dupixent was effective for her symptoms. She has nasal polyps on exam.

Dupixent is medically necessary. 

Dupixent is Food and Drug Administration (FDA) approved for CRS (chronic rhinosinusitis) with NP (nasal polyps). The current standard of care for the treatment of CRS with NP includes the use of maintenance therapy with intransasal corticosteroids. Sinus surgery to remove nasal polyps is another treatment option that can be considered when pharmacologic therapies have failed. Relapse after surgery is common, however, and revision surgery is often required.

In the trials for Dupixent that led to its approval for CRS with NP, the co-primary efficacy endpoints were the change from baseline in the nasal polyps score (NPS) and the nasal congestion/obstruction (NC) score. In addition, Dupixent therapy significantly improved endoscopic nasal polyp scores and patient reported nasal congestion symptoms compared with placebo; it also significantly reduced loss of smell, reduced the proportion of patients requiring systemic corticosteroids, and reduced the proportion of patients requiring surgery.

In this case, the patient has tried and failed first line therapies for CRS with NP. Thus, Dupixent is medically necessary. This patient has done well on Dupixent and had resumed her nasal spray. Continuation would be standard of care.
Appeal type: Formulary Exception
Decision: Overturned

Vision
Pharmacy/Prescription drugs

Diagnosis: Glaucoma
Treatment: Lumigan
The insurer denied Lumigan. The health plan's determination is overturned.

The patient is a female with history of open angle glaucoma. The patient is currently being treated with Lumigan, Dorzolamide, and Timolol. Her eye pressure has been controlled on these three medicines. She was previously treated with latanoprost, however, the intraocular pressure remained high.

Glaucoma is a condition when the intraocular pressure is too high for an individual and leads to optic nerve damage and loss of vision. Bringing the intraocular pressure down by medications can help prevent further optic nerve damage and loss of vision.
This patient was treated prior with the formulary drug latanoprost, but the therapeutic effect was not enough to help prevent visual loss. The intraocular pressure was lower on Lumigan, giving a better therapeutic effect and less risk of vision loss.
The patient is currently on three different classes of medications. The latanoprost which is on formulary did not lower the intraocular pressure enough to prevent vision loss. Lumigan, which is non formulary but in the same class of drug as latanoprost was shown to be more beneficial in lowering the intraocular pressure in this patient. The lower the intraocular pressure will help prevent optic nerve damage and vision loss. An exception to the plan's formulary is indicated for this patient
Appeal type: Medical necessity
Decision: Upheld

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

The patient, a male, has a past medical history significant for Parkinson's disease, sleep apnea, mitral valve prolapse, and arthritis.  The patient presented for evaluation of sub-sternal chest pain. 

The patient was hemodynamically stable. Electrocardiogram (ECG) did not reveal acute ischemic changes. The patient was admitted to rule out acute coronary syndrome (ACS). Cardiac troponins were negative. Chest x-ray was unremarkable. The patient was seen in consultation by cardiology specialist. An echocardiogram was obtained, revealing normal left ventricular (LV) systolic function with no wall motion abnormalities. The patient was discharged home with a plan for outpatient stress test.

No, the proposed inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarction (MI) was ruled out by cardiac enzymes, which were negative. Echocardiogram revealed normal wall motion with normal left ventricular (LV) systolic function.  There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. No inpatient stress test was planned and the patient was discharged with a plan for outpatient follow-up. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder. 

Treatment: Inpatient Mental Health Admission. 

The insurer is denied coverage for the Inpatient Mental Health Admission. 

The denial is upheld. 

This female patient has a history of depression and anxiety. She was admitted for inpatient mental health treatment due to worsening of anxiety and depression symptoms. Symptoms included depressed mood, anhedonia, poor concentration, sleeping problems, decreased appetite and ten pound weight loss, tearfulness, anxiety and panic attacks. There was reported increased cannabis use. She had no reported past suicide attempts, psychiatric hospitalizations, or past use of psychotropic medications. She was a victim of domestic violence. The patient's psychiatric diagnosis was Major Depressive Disorder. She worked as a 6th grade teacher. The patient was admitted and was started on Lexapro and Seroquel. She was discharged after treatment. 

 At the time of admission there were no reports of suicidal or homicidal ideation, intent, or plan, severe depressive symptoms with inability to adequately care for basic needs, manic episodes, and psychotic symptoms, self-injurious, aggressive, threatening, or agitated behavior Chart notes did not provide enough specific evidence that this patient was an imminent danger to herself or others or that she was unable to adequately care for her basic needs.  There were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.  
Based on the review of the medical record and literature, inpatient mental health treatment was not medically necessary for this patient.  

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

The carrier's denial of coverage for the inpatient stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is overturned. 

The patient is a female. She has a past medical history significant for HTN (hypertension). She presented to the ER (emergency room) with complaints of left-sided chest pain at rest, radiating to her left arm.

The patient was hypertensive on presentation, with BP (blood pressure) of 163/109. The ECG (electrocardiogram) revealed normal sinus rhythm with left ventricular hypertrophy and ST-T wave abnormalities. Her troponin was elevated at 0.046.

The patient was admitted to telemetry with suspected acute coronary syndrome (ACS). She was seen in consultation by cardiology and the decision was made to proceed with urgent cardiac catheterization.  Angiogram revealed no significant CAD (coronary artery disease), and the patient was treated medically. The troponin release was felt to be secondary to subendocardial ischemia in the setting of uncontrolled hypertension. She was discharged home on medical therapy with a plan for outpatient follow-up.

Yes, the inpatient admission was medically necessary.

The patient presented with new onset chest pain, suggestive of unstable angina. The patient had multiple risk factors for CAD (coronary artery disease), including hypertension, history of tobacco abuse and obesity. The ECG (electrocardiogram) was abnormal, with findings suggestive of ischemia and/or hypertensive heart disease.  Cardiac troponin was elevated, suggestive of myocardial damage.  There was a high index of suspicion for an ACS (acute coronary syndrome), and a cardiac catheterization was performed. Given the presentation, uncontrolled hypertension, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she would not be an appropriate candidate for an ED (emergency department) chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertension, osteoporosis, lung cancer status post left upper lobectomy, dementia and gait ataxia.
Treatment:  Increase Consumer Directed Personal Assistance Services (CDPAS) from 7 Days per Week, 8 Hours per Day; 56 Hours per Week to Consumer Directed Personal Assistance Services 7 Days per Week, 24 Hours per Day, Continuous, Split Shift, by More than One Person; 168 Hours per Week.

The insurer denied the Increase Consumer Directed Personal Assistance Services (CDPAS) from 7 Days per Week, 8 Hours per Day; 56 Hours per Week to Consumer Directed Personal Assistance Services 7 Days per Week, 24 Hours per Day, Continuous, Split Shift, by More than One Person; 168 Hours per Week.  The denial is overturned. 

The patient is a female with a history of hypertension, osteoporosis, lung cancer status post left upper lobectomy, dementia and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 168 hours per week Personal Assistance Services to offer increased activities of daily living (ADL) support.

Yes, the proposed treatment of 168 hours per week Personal Assistance Services is deemed medically necessary.

An assessment of the patient's functionality was performed and revealed that that patient is totally dependent on assistance from others for completion of meal preparation, housework, managing finances, medications, phone use, stairs, shopping, transportation, toilet transfers, toilet use and dressing. In addition, recent correspondence from the patient's medical provider indicates that due to the patient's history of severe Alzheimer's dementia, she is dependent on others for assistance with all activities of daily living. 

For these reasons, the currently approved plan of 63 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. Also for these reasons, the proposed treatment 168 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overactive Bladder.
Treatment: Myrbetriq 25mg OR TB24, Pre-service.
The insurer denied the Myrbetriq 25mg OR TB24, Pre-service.
The denial is overturned.

The patient is a female with overactive bladder. She has requested coverage for Myrbetriq.  The patient's provider states that use of, "ALL anticholinergics are contraindicated due to the present history of irritable bowel syndrome with constipation," as well as, "GERD [gastroesophageal reflux disease] as anticholinergics have been proven to increase esophageal reflux."

Coverage was denied because the patient has not used a formulary agent such as oxybutynin, oxybutynin XL (extended relsease), solifenacin, tropium, trospium ER (extended release), tolterodine and tolterodine ER (extended release).

Yes, the treatment with Myrbetriq is medically necessary.

The use of an anticholinergic agent in the presence of chronic constipation can be problematic, because this class of medication causes constipation.  Myrbetriq is a beta-3 agonist that does not have the risk of constipation. This patient has the FDA (United States Food and Drug Administration)-approved indication for use of Myrbetriq. Myrbetriq represents the safest option for this patient and has a different side effect profile from anticholinergic agents.

This patient has extenuating circumstances of significant constipation. There is a moderate risk of clinical destabilization if an anticholinergic medication is used.