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

Diagnosis: Dental Issues - symptomatic wisdom teeth
Treatment: D7240 extraction of impacted tooth covered by bone for tooth 16, D9222 general anesthetic - first 15 minutes and D9223 general anesthesia each 15 minutes
The insurer denied the D7240 extraction of impacted tooth covered by bone for tooth 16, D9222 general anesthetic - first 15 minutes and D9223 general anesthesia each 15 minutes.
The health plan's determination is overturned.

The patient is a female who was evaluated for the removal of 4 symptomatic wisdom teeth. Tooth number (#)16 was denied for removal as there was no severe pain or that the tooth was not in a position that it would not erupt by itself. The general anesthesia was also denied as other drugs have not been tried.

The health plan in its determination of medical necessity did not act reasonably, with sound medical judgment and in the best interest of the patient. The wisdom tooth is indicated for extraction and will not erupt on its own. Anesthesia is indicated for the procedure.

The American Association of Oral and Maxillofacial Surgeons (AAOMS) Parameters of Care states that an impacted third molar that is so positioned that it will probably not erupt by the middle of the third decade constitutes pathology with dental and medical consequences. To limit known risks and complications associated with surgery, it is medically appropriate and surgically prudent to remove impacted third molars before the middle of the third decade and prior to complete root development.

An impacted tooth with completed root formation that is totally covered by bone in a patient beyond the third decade that does not meet the following indications for removal should be monitored for change in position and/or development of pathology, which may then indicate its removal. The patient meets this criteria as tooth #16 is an impacted wisdom tooth that is so positioned that it has not and will not erupt by the middle of the third decade. The tooth is also symptomatic. The removal is indicated. The decision to use general anesthesia for a particular dental procedure should only be determined by considering the needs of the patient, the requirements of the operating dentist and the effect on the quality of the dental treatment. The provider has determined that it is needed in this particular case.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headaches.
Treatment: Ajovy
The insurer denied Ajovy.
The determination is upheld.

The patient has a history of chronic migraine headaches.  She has reported having up to 4 migraines/week. She is said to have trialed topiramate at a dose of 50 milligrams (mg) /day but reported no benefit from taking the medication. When she was seen for a neurology consultation, her neurological exam was non-focal. At the time of that consult, she was prescribed Ajovy for migraine prophylaxis. A request had been made for Ajovy. At issue is the medical necessity of Ajovy.

No, it is not medically necessary. According to the current guidance from the American Headache Society on the use of CGRP drugs for migraine prophylaxis, calcitonin gene-related peptide (CGRP) drugs should be prescribed by any licensed physician for patients who have had a trial of at least two-level A/B prophylactic agents for at least 8 weeks each (Ailani etal). In this case, the patient was only noted to have trialed topiramate.
While it would be advisable to avoid the use of valproate in a female of childbearing age, there are other medications supported by guidelines that could be utilized.
Tricyclic antidepressants (TCAs) and venlafaxine are recognized for use in migraine prophylaxis. They are not otherwise contraindicated in individuals with anxiety and depression-rather, the primary use of these classes of medications (serotonin norepinephrine reuptake inhibitor (SNRI), selective serotonin reuptake inhibitor (SSRI), TCAs) is anxiety and depression-as they are primarily antidepressants. There is also no indication of severe lung disease/asthma that would contraindicate a trial of a beta blocker therapy. Beta blockers are not absolutely contraindicated in patients with mild asthma. As Huang et al have shown there is not clear evidence that use of an oral beta blocker is readily associated with increased asthma attacks (when compared to placebo).  More recent literature has otherwise supported the use of cardio-selective beta-blockers (beta-1 selective, in asthmatics).  It would be a different consideration were the member to have moderate/severe asthma rather than a mild form. In as much, the use of Ajovy at this time cannot be said to be readily consistent with the recommendations set forth by professional societies.

The health plan's determination should be upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dysphagia

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is upheld

The patient presented with dysphagia for solids and weight loss. A previous Computed Tomography (CT) scan at another hospital revealed a jugular vein thrombosis and a suggestion of metastatic disease. A CT scan was obtained during this admission and revealed an esophageal mass. An ultrasound was negative for a Deep Vein Thrombosis (DVT) but found a nonvascular mass. An endoscopy with biopsy was performed and revealed a large mass in the proximal esophagus. The mass was partially obstructing, and the patient was placed on a clear liquid diet. A Magnetic Resonance Cholangiopancreatography (MRCP) was negative for a pancreatic mass. An outpatient Positron Emission Tomography (PET) scan was planned. 

Clinical indications for admission per Milliman Care Guidelines (MCG) Gastroenterology General Recovery Guideline (GRG: MG-GAS) includes having severe dysphagia with an additional complication. These additional complications include having caustic ingestion, severe dehydration, inability to manage secretions, severe electrolyte abnormalities, hemodynamic instability, and acute renal failure. The patient did not have these conditions. 

This patient had dysphagia for solids due to an esophageal mass. A workup including endoscopy was needed. However, endoscopy is a procedure that could have been performed on an ambulatory basis. The CT scan and MRCP could also have been done with observation status. The patient was able to tolerate a liquid diet while undergoing the workup. The patient did not meet MCG criteria for admission for Gastroenterology. 

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 hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertension, Type II Diabetes, Chronic Kidney Disease, Hyperlipidemia, Scoliosis, Chronic Low Back Pain, Neuropathic Pain.
Treatment:  Personal care services increase to 12 Hours a day, 7 Days a week, for a total of 84 hours.

The insurer denied coverage for personal care services increase to 12 Hours a day, 7 Days a week, for a total of 84 hours.  The denial is overturned.

The patient's niece requested this increase because the patient is not able to do anything by herself, and the patient has difficulty walking, needs assistance when using the bathroom, and needs assistance with other activities of daily living (ADLs), such as walking, feeding, dressing, grooming, toileting, and bathing.

Personal care services (PCS) for companionship or for safety supervision, without the direct provision of activity of daily living tasks, is not a covered service under the patient's benefit plan.

The physician letter describes a bed bound geriatric patient with limited ability to care for self. The physician also reports swelling and pain to the extremities. There are mobilization issues where the patient is not likely to use a walker. There are issues with incontinence. There is overall deterioration and loss of independence. The requested hours would be medically necessary to ensure safety and management of ongoing problems. 

PCS- 12 Hours a day, 7 Days a week, for a total of 84 hours is considered medically necessary for this patient.

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 personal care services to 12 Hours a day, 7 Days a week, for a total of 84 hours is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertension, Type II Diabetes, Chronic Kidney Disease, Hyperlipidemia, Scoliosis, Chronic Low Back Pain, Neuropathic Pain.
Treatment:  Personal care services increase to 12 Hours a day, 7 Days a week, for a total of 84 hours.

The insurer denied coverage for personal care services increase to 12 Hours a day, 7 Days a week, for a total of 84 hours.  The denial is overturned.

The patient's niece requested this increase because the patient is not able to do anything by oneself, and the patient has difficulty walking, needs assistance when using the bathroom, and needs assistance with other activities of daily living (ADLs), such as walking, feeding, dressing, grooming, toileting, and bathing.

Personal care services (PCS) for companionship or for safety supervision, without the direct provision of activity of daily living tasks, is not a covered service under the patient's benefit plan.

The physician letter describes a bed bound geriatric patient with limited ability to care for self. The physician also reports swelling and pain to the extremities. There are mobilization issues where the patient is not likely to use a walker. There are issues with incontinence. There is overall deterioration and loss of independence. The requested hours would be medically necessary to ensure safety and management of ongoing problems. 

PCS - 12 Hours a day, 7 Days a week, for a total of 84 hours is considered medically necessary for this patient.

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 personal care services to 12 Hours a day, 7 Days a week, for a total of 84 hours is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal bleed
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female with medical history of hypertension. She presented to the emergency department with dark bowel movements for 10 days, dizziness, and generalized weakness. She had been on low-dose aspirin. Vital signs were notable for elevated blood pressure of 151/105 and pulse rate of 118/minute. Physical examination was notable for soft, nontender abdomen and black stool on rectal exam. Labs showed low hemoglobin of 7.9 and hematocrit of 24.1%(percent), and elevated alanine aminotransferase of 67. She was treated with intravenous fluids and pantoprazole. She was transfused with one unit of packed red blood cells. 

The inpatient level of care is not medically necessary, and the care provided could have been provided at a lower level of care. In this case, the patient presented with melena and symptomatic anemia. However, there was no sustained tachycardia or hypotension. Her hemoglobin responded to transfusion. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Esophagogastroduodenoscopy showed an ulcerated mass, but did not show any high-risk stigmata or ongoing bleeding, and no immediate endoscopic intervention was necessary. All of the measures that were undertaken, including monitoring, transfusion, specialist consultations, endoscopy, and proton pump inhibitor therapy, could have been performed in sequence after presentation at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender Dysphoria

Treatment: Gender Reassignment (gender affirming surgery); (Code 19303) Bilateral (right and left) mastectomy; (Code 19350) Bilateral (right and left) nipple/areola reconstruction.

The insurer denied: Gender Reassignment (gender affirming surgery); (Code 19303) Bilateral (right and left) mastectomy; (Code 19350) Bilateral (right and left) nipple/areola reconstruction.

The denial is upheld.

This is a female to male transgender who desires top surgery to continue with gender transition and to treat gender dysphoria. The patient's mental health provider supports the need for the requested surgery but indicates that her practice does not specialize in transgender care. Top surgery is planned. 

The Gender Reassignment (gender affirming surgery); (Code 19303) Bilateral (right and left) mastectomy; (Code 19350) Bilateral (right and left) nipple/areola reconstruction is not medically necessary. 

Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines:

Criteria for Breast/Chest Surgery 
All patients require documentation of persistent gender dysphoria by a qualified mental health professional. 

Criteria for mastectomy and creation of a male chest in FtM (female to male) patients: 
1) Persistent, well-documented gender dysphoria; 
2) Capacity to make a fully informed decision and to consent for treatment; 
3) Age of majority in a given country (if younger, follow the SOC for children and adolescents); 
4) If significant medical or mental health concerns are present, they must be reasonably well controlled. 
Hormone therapy is not a prerequisite. 
Criteria 1 is not met. The patient's mental health professional does not have documented special training or expertise in transgender health care. Therefore, the mental health profession who has evaluated this patient is not the most appropriate to determine the suitability for top surgery. The insurer's rationale for denial is reasonable and based on WPATH standards.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Temporomandibular disorder (TMD)
Treatment: Crown Placement (procedure code D6058) and custom abutment (procedure code D6057)
The insurer denied coverage for Crown Placement (procedure code D6058) and custom abutment (procedure code D6057).
The denial is overturned.

The patient is an adult with temporomandibular disorder (TMD) and is under dental care. The dentist was seeing the patient for treatment of replacing tooth number 31 with a dental implant. The tooth was removed, and the implant was placed. Currently, the dentist has treatment planned for the patient to undergo abutment and crown placement which is the topic of this review.

The healthcare plan approved a dental implant for tooth for 31. The tooth has been removed and the implant placed. However, to use the implant for a functional reason requires placement of the abutment and crown. This really should be included in the entire process, to establish functionality of the implant.      

The crown placement (procedure code D6058) and custom abutment (procedure code D6057) for tooth #31 is considered medically necessary for this patient. The patient has opposing dentition that will over erupt if the lower teeth are not replaced. Moreover, the patient will have difficulty properly functioning without the replacement of these teeth. The teeth were removed due to cracks and replaced with dental implants. The final portion of the implant procedures is the abutment and the crown.

"Teeth are vital sensory organs that contribute to our daily activities of living. Unfortunately, teeth can be lost for several reasons including trauma, caries, and periodontal disease. Although dental trauma injuries and caries are more frequently encountered in a younger population, tooth loss because of periodontal disease occurs in the older population. In the dental implant era, the trend sometimes seems to be to extract compromised teeth and replace them with dental implants." (Clark, D., & Levin, L. 2019).

Most of the available literature gravitates in favor of an internal connection with the incorporation of platform switching to attain satisfactory hard and soft tissue outcomes". (Hariharan, A. S., et al., 2022).

"Results: Traditionally, it was believed that TMDs predominantly affected women of childbearing age, but recent large studies in Europe and the United States have shown that the prevalence of TMD peaks after childbearing age (45-64) and then gradually decreases with age, although not much is known about the disease in older adults". (Yadav, S., et al., 2018).                                                         

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 Crown Placement (procedure code D6058) and custom abutment (procedure code D6057) for tooth #31 is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Dry eye disease. 
Treatment: Restasis 0.05% dropperette. 

The insurer denied coverage for Restasis 0.05% dropperette. 

The denial is upheld. 

 According to the documentation submitted, this is an adult with a history of Dry Eye Disease. The formulary drug (Xiidra) is not likely to cause the patient an adverse reaction.  There is no documentation in the medical records provided for review that the patient has tried and failed or has had an adverse reaction to Xiidra.

The formulary drug has not been ineffective based on the patient's clinical history and based on the medical records provided for review.  There is no documentation that the patient has tried and failed Xiidra.

There is no evidence that Restasis is more effective than the formulary drug, Xiidra.

The formulary drugs are not expected to cause adverse effects. 

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

The formulary drug is not expected to be ineffective.

The non-formulary drug is not expected to be more effective than the formulary alternatives.

The Request for Formulary Exception for Restasis 0.05% dropperette to treat Dry Eye Disease is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer

Treatment: Radiation therapy

The insurer denied coverage for radiation therapy

The denial is upheld

This patient is an adult male with a history of stage IV (4) prostate cancer. He is status post prior Cyberknife stereotactic body radiotherapy (SBRT). He has been recommended to proceed with a course of reirradiation to his prostate. The request is for approval of proton beam radiation therapy.

Reirradiation to the prostate gland has not been proven to yield superior clinical outcomes for management of stage IV prostate cancer. Reirradiation in the member's setting  with proton radiation is not supported by any high-quality clinical outcomes reported in the peer reviewed literature that this reviewer is aware of.      

Radiation therapy is not considered medically necessary for this patient. The use of reirradiation in the member's setting is considered experimental as it is not supported by high quality clinical outcomes. It is not widely employed for similar patients treated in the oncology community nationwide. In a systematic review of therapies for prostate cancer after radiotherapy no studies using proton beam were included. 

According to Wu & Fan, 2022, "Conclusion: Proton Therapy (PT) has several advantages over conventional photon radiotherapy, and novel approaches may increase its efficacy and safety. Large prospective randomized trials comparing photon therapy with proton-based treatments are ongoing and may provide data on the differences in efficacy, toxicity profile, and quality of life between proton- and photon-based treatments for prostate cancer in the modern era.

Advances in knowledge: PT provides excellent physical advantages and has a superior dose profile compared with X-ray radiotherapy. Further evidence from clinical trials and research studies will clarify the role of PT in the treatment of prostate cancer and facilitate the implementation of PT in a more accessible, affordable, efficient, and safe way."

According to Nogueira et al, 2022, "Proton beam radiotherapy (PBT) is a form of external beam radiation used in cancer care that provides the opportunity for better precision in dose delivery than other types of external beam radiotherapy. Owing to its unique deposition characteristics, PBT is potentially superior to photon-based therapy for tumors with complex anatomy surrounded by critically sensitive tissues and for childhood cancers. Proton beam radiotherapy was approved for treatment of cancer in 1988 and, since then, use of PBT has increased in the United States. However, evidence related to the efficacy and effectiveness of PBT varies by cancer site."                                                          

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for radiation therapy services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Pain injection (62323 x 1)
The insurer denied coverage for pain injection (62323 x 1)
The denial is overturned

This is an adult with chronic back pain complaints. The patient underwent epidural steroid injections with reported greater than 80% temporary pain relief. The treating physician is requesting another epidural steroid injection which is under review.

The clinical records support the medical necessity of another epidural steroid injection. The treating physician documents the patient had significant improvement in pain relief (greater than 80 percent). In addition, the request meets the criteria set forth by the insurer (4) including: At least 2 months have passed since the last Epidural Injection (EPI), less than 4 injections have been administered within 12 months, and less than 12 months have elapsed since the initial injection at the level requested. The patient underwent the pre-requisite treatment including physical therapy, analgesic medications and home exercise program.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested epidural steroid injection is medically necessary.

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 pain injection (62323 x 1) is substantiated.