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

Diagnosis: Periapical inflammatory disease
Treatment: Crowns for teeth #s 21, 22, 26, 27, and 28 and fake replacement tooth (pontic) for teeth #s 23, 24, and 25
The insurer denied coverage for crowns for teeth #s 21, 22, 26, 27, and 28 and fake replacement tooth (pontic) for teeth #s 23, 24, and 25
The denial is upheld.

Based on review of the submitted documentation which includes copies of the patient's clinical notes, records, periodontal charting, pretreatment undated bitewing and periapical radiographs (pretreatment), in addition to narrative letter and insurer correspondence, it appears that this patient presented for comprehensive dental evaluation and treatment, The recommended treatment was for a fixed multi-unit bridge extending from teeth #22 -28 after extraction of non-maintainable #23, 24, 25. 

Upon review of the submitted documentation, in particular the radiograph and periodontal charting provided, the patient exhibits non maintainable periodontally involved teeth with periapical inflammatory disease focally. The treating dentist wants to restore the mandibular dentition with a fixed prosthesis from teeth #22 - 28. Although a fixed partial denture is an option in this case, it is not the only viable treatment option. And, in fact, the long span would be a relative contraindication for this bridge given the severe periodontal disease of the remaining proposed abutment teeth which exhibit significant alveolar bone loss and periodontal pocketing. A removable partial denture would be an acceptable viable appropriate alternative to the bridge that has been recommended. A conventional removable partial denture is a standard of care in this clinical circumstance and in general dental practice and would be an acceptable appropriate alternative treatment. Lastly, the alternate benefits provision of the insureds contract is in effect and allows for the least costly alternative therapy, in this case a removable partial denture.

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. Crowns for teeth #'s 21, 22, 26, 27 and 28 and fake replacement tooth (pontic) for teeth #'s 23, 24 and 25 is not considered medically necessary for this patient.

The insurer's denial of coverage for crowns on teeth #s 21, 22, 26, 27, and 28 and fake replacement tooth (pontic) for teeth #s 23, 24, and 25 services is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: constipation.
Treatment: Motegrity.
The insurer denied Motegrity. 
The health plan's determination is upheld.

The patient is a male with constipation. He has had constipation, bloating, abdominal pain, nausea, and vomiting. He has failed bisacodyl, docusate, lactulose, Miralax, senna, and Trulance. Under review is the medical necessity of Motegrity 2 milligrams (mg) daily for the treatment of constipation. 

Motegrity is not supported as medically necessary over the formulary alternative lubiprostone. The American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as lubiprostone (Amitiza) should be used if non-pharmaceutical laxatives fail. Lubiprostone has shown safety and efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain. Motegrity has not demonstrated higher safety or efficacy than lubiprostone in a direct controlled comparison. For these reasons, the request for Motegrity is not supported as medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: lingual fracture of the crown tooth 30
Treatment: Crown on Tooth # 30
The insurer denied Crown on Tooth # 30. The health plan's determination is overturned.

The patient is a female who presents for evaluation and treatment of tooth #30. Provided for review are previous letters of appeal and denial, a single radiographic images, one page of American Dental Association (ADA) claim forms, and correspondence from the treating provider. In question is the medical necessity of a porcelain crown (D2740) for tooth #30.

A Porcelain Crown on Tooth # 30 is medically necessary for this patient.
According to the documentation provided, the patient suffered a lingual fracture of the crown. As such, a direct restoration is not a possibility and thus an indirect restoration with cuspal coverage is required, making the porcelain crown medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperlipidemia.
Treatment: Vascepa.
The insurer denied Vascepa.
The determination is upheld.

The patient has nonobstructive coronary artery disease (computed tomography angiography (CTA) of the coronaries and asymptomatic, moderate carotid disease. She has hyperlipidemia and is treated with atorvastatin 20 milligrams (mg) daily. Lab studies show a total cholesterol of 121, high density lipoprotein (HDL) 48, low density lipoprotein (LDL) 51, and triglycerides 136. Vascepa (icosapent) was prescribed. Per the notes, she had been taking fenofibrate, but this was changed to Vascepa. At issue is the medical necessity of Vascepa.

Vascepa is not medically necessary for this patient. She has hyperlipidemia which is well-controlled on her current regimen. She is not documented to have clinical manifestations of atherosclerotic cardiovascular disease (for example: unstable angina, myocardial infarction, transient ischemic attack, stroke or claudication) or diabetes with other cardiac risk factors in addition to fasting triglycerides of 135-499, which were the criteria for the multicenter trial of Vascepa (REDUCE IT [Reduction of Cardiovascular Events with Icosapent Ethyl - Intervention Trial] - reference 1 below) which led to the drug's indication in the treatment of cardiovascular disease.
The patient does not meet clinical indications for Vascepa. It is indicated:
1) as an adjunct to maximally tolerated statin therapy to reduce the risk of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring hospitalization in adult patients with elevated triglyceride (TG) levels (greater than or equal to (>=) 150 milligrams per deciliter (mg/dL)) and
o	established cardiovascular disease or
o	diabetes mellitus and 2 or more additional risk factors for cardiovascular disease.
OR
1) as an adjunct to diet to reduce TG levels in adult patients with severe (>= 500 mg/dL) hypertriglyceridemia.
The patient does not meet either of these indications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week.

The health plan denied Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week.  The denial is overturned.

The patient is a female with past medical history notable for dementia, hypertension, bleeding ulcerative colitis, urinary incontinence, arthritis, and ambulatory difficulties. Her care team requested an increase in her personal care services from 42 hours per week to 84 hours per week due to a rapid decline in her status this year. The health insurance company approved an increase to 56 hours per week but denied the 84 hours per week request. This denial is the subject of this appeal.

The requested health service/treatment of Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week is medically necessary for this patient. This patient has advanced (and rapidly progressing) dementia and has no urinary continence. She requires assistance for eating, medications, toilet transfers, and changing incontinence pads. These needs cannot be scheduled and need to occur at various scheduled and unscheduled times throughout the day. Especially when it comes to the incontinence issue, it is not reasonable to expect the patient to direct her own CDPAS hours to when she has toileting needs. She has severe, end stage dementia and cannot be her own advocate. The report from the patient representative that she would be found by her caregiver at the start of a shift sitting in old, soiled diapers is evidence of this medical necessity. If this is allowed to continue, she would suffer from skin breakdown, urinary and/or yeast infections, and other adverse medical outcomes. Her basic health needs underscore the medical necessity of this increase in hours.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Saxenda 18MG/3ML (milligrams/milliliter) SC (subcutaneous) SOPN (solution pen injector)
The insurer denied the Saxenda 18MG/3ML SC SOPN.
The denial is overturned.

The patient is a female who reportedly is overweight and has elevated cholesterol. The patient's body mass index (BMI) is over 27. This review is for Saxenda. 

The reason for the prior denial was that the current plan approves the requested medication if the patient is enrolled in a comprehensive weight management program that encourages behavioral modification, calorie control, and increased physical activity with continued follow up for at least six months prior to using drug therapy.

The attending physician (AP) is appealing the denial stating the requested medication is medically necessary.

Yes, the proposed treatment is medically necessary.

The patient has a BMI over 27 along with hypercholesterolemia. The patient is already trying lifestyle changes and activity modification. She has been working on calorie control. The patient has associate hypercholesterolemia and is at risk of diabetes and heart disease. 

The requested medication is approved and supported by current literature for weight loss to reduce cardiovascular events. The requested drug helps to induce and sustain weight loss in patients per literature. The requested medication is medically necessary and appropriate.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The patient has a BMI over 27 and has hypercholesterolemia. She needs Saxenda for weight loss.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tracheitis/tracheobronchitis and chronic respiratory failure

Treatment: Inpatient emergency admission

The insurer denied coverage for inpatient emergency admission.

The denial is upheld.

The patient has a past medical history of cardiac arrest, traumatic brain injury status post trach, and chronic respiratory failure. The patient also has history of seizure disorder, schizoaffective disorder, and obstructive sleep apnea on continuous positive airway pressure. Patient has had multiple admissions in the past few days for congestive changes, and tracheitis and tracheobronchitis. Last discharged with diagnosis of tracheitis/tracheobronchitis.

The patient presented to the emergency department (ED) with complaints of increasing shortness of breath (SOB). As per the patient's friend she had not been suctioning her Trach since her previous discharge as it was uncomfortable. Vital signs at presentation included a temperature of 98.5, heart rate 89, respiratory rate 18, blood pressure 146/73 and oxygen saturations 96% (percent) on room air. The patient was in no acute distress and lungs were clear.

The patient was treated with Albuterol, Mucomyst, Nebulized Bronchodilators, and Budesonide.

White blood cell count (WBC) was normal at 5 thousand, hemoglobin 9.7, and electrolytes within normal limits.

Chest x-rays revealed (CXR) possible right sided opacities vs overlying soft tissue shadows.

The patient improved with treatment in the ED. She was admitted to the hospital with the diagnosis of tracheitis/tracheobronchitis and chronic respiratory failure.

The patient was initially given oral Levaquin twice daily (BD) and Nebulizers.

The patient remained stable after admission and was afebrile and hemodynamically stable. The patient was not hypoxic. They were noted to have had some increased secretions but was otherwise stable. The patient signed out against medical advice.

This patient did not need acute inpatient hospitalization. She was afebrile and hemodynamically stable. Her SOB was related to retained secretions from non-compliance with pulmonary toilet. The patient could have been placed in Observation status which could be for up to 48 hours. This patient could have received pulmonary toilet in the ED and continued on bronchodilators and Mucomyst Nebs. 

Pulmonary toilet could have been reinforced. This patient did not have any clinical signs of pneumonia (PNA). She was afebrile, WBC was normal. The patient was not hypoxic.

The patient was afebrile and hemodynamically stable. Oxygen saturation was 96-97%. Lungs were clear. The patient was awake and alert. The patient likely had some bronchitis. There was no definite PNA. The patient was not continued on antibiotics.

The patient was stable for discharge with aggressive pulmonary toilet, her maintenance medications, and close follow up. 

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

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

Diagnosis: Sickle cell disease, cerebrovascular accidents, acute respiratory distress syndrome. 
Treatment: Continued Rehabilitation Facility. 

The insurer denied the Continued Rehabilitation Facility. 
The denial is overturned. 

The patient is a male with an extensive past medical history to include sickle cell disease with avascular necrosis of the right hip, cerebrovascular accidents, and an anaphylactic reaction to an intravenous infusion complicated by acute respiratory distress syndrome (ARDS) causing significant functional deficits.  The patient was transferred from the intensive care unit to a long term acute care hospital (LTACH), but the care at the long term acute care hospital forward was not approved. 

Yes, the proposed treatment was medically necessary. 

The facility is a long term acute care hospital (LTACH).  The patient was admitted.  The patient has a medically complex list of diagnoses, including multiple intracranial infarcts, avascular necrosis of the right hip, acute respiratory distress syndrome (ARDS) on oscillatory ventilation, acute chest syndrome, etc, requiring acute inpatient care and comprehensive rehabilitation. The ideal level of care for this patient, including the dates of service in question, was in a long term care hospital that provides comprehensive inpatient rehabilitation.  This is a medically fragile child who needs continuous acute monitoring and care and therefore the date of services was medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Degenerative disc disease

Treatment: outpatient procedure (64628 x 1), Intracept Intraosseous Nerve Ablation System

The insurer denied coverage for outpatient procedure (64628 x 1), Intracept Intraosseous Nerve Ablation System

The denial is upheld

This woman has chronic low back pain. She takes Flexeril, Nucynta and Tylenol for pain. She has had Medial branch blocks and radiofrequency ablation (RFA) as well as sacroiliac joint (SI) joint injections. She had a trial of physical therapy (PT). On magnetic resonance imaging (MRI) she has Modic changes at L (lumbar) 5 and S (sacroiliac) 1.  The request is for the RFA of the basivertebral nerve.	

In 2018, Fischgrund and colleagues (1) published a double-blind, sham controlled RCT (randomized control trial) evaluating the Intracept system and RF (radiofrequency) ablation of the Basivertebral nerve for the treatment of chronic low back pain. A total of 225 participants with chronic (>= 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n (number)=78) or treatment (n=147) intervention. In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85C (Celsius) for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Owestry disability index (ODI) of 30 points (on 100-point scale) and a minimum VAS [visual analog scale] of 4 cm (centimeters) (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13%) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance.

The publications to date have been company sponsored and had methodology flaws.  There is no published data on long term complication rates. There is other evidence- based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. The carrier's denial of outpatient procedure (64628 x 1), Intracept Intraosseous Nerve Ablation System should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease
Treatment: Personal Care Services, 24 hrs. a day split shift (two 12-hours shift), 7 days a week 
The health plan denied: Personal Care Services, 24 hrs. a day split shift (two 12-hours shift), 7 days a week 
The denial is: overturned

The patient is a female with severe, end-stage Alzheimer's dementia. She was recently admitted to home hospice services. The patient's care team requested an increase in personal care services to 24 hours per day (split shift) 7 days per week. The health plan denied this request and kept services level at 12 hours per day, 7 days per week. The patient's care team initiated an appeal which is the subject of this review.

The health plan's determination is overturned. 

The requested health service/treatment of Personal Care Services, 24 hours a day split shift (two 12-hours shift), 7 days a week is medically necessary for this patient.
This patient meets criteria for 24 hours per day (split-shift) personal care services. She requires turning and repositioning at least every 2 hours to prevent skin breakdown, which by definition is a level 2 personal care service. Additionally, she has incontinence with complete inability to voice her needs. This means that she must be checked and changed throughout the night to prevent skin breakdown, decubitus ulceration, and infection from developing.
The health insurance denial recommends physical therapy to help with her weakness. This is not likely to help in any way with this patient's needs as she is in the end stages of terminal dementia. They also recommend limiting fluids after 6pm to prevent skin breakdown from her diaper overnight, which is not a realistic expectation in a patient with dementia.
The recommendation by the Hours Evaluation for Paraprofessional Support (HELPS) tasking tool is not helpful in patients who require total dependence for all tasks and their needs cannot be scheduled. It is not appropriate to apply this total of 83 hours per week to a patient such as this, who has continuous unscheduled needs occurring throughout the day and night.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems - Carious lesion.
Treatment: Root canal for tooth #13.
The health plan denied Root canal for tooth #13.
The denial is overturned. 

This patient is a female who has been recommended for root canal treatment of tooth number (#)13. The health plan has denied root canal treatment for tooth #13 because she has 8 or more posterior teeth that are in occlusion.
At issue is the medical necessity of Root canal for tooth number (#)13.

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

Yes, the requested health service/treatment of Root canal for tooth #13 is medically necessary for this patient.
The health plan did not act in the best interest of the patient as determining whether or not root canal treatment is needed based on the amount posterior teeth in occlusion is not valid. The documentation shows that the patient has a large carious lesion that extends to the pulp. The tooth appears to be restorable and treatment on #13 would be indicated as the standard of care.
Understanding previous dental history is a critical step when obtaining information related to the chief complaint. It is important to determine whether a patient has had any recent dental treatment in the area where he or she is experiencing discomfort. It is not unusual for patients who have had a scaling and root planning procedure to experience cold sensitivity due to exposure of dentinal tubules following calculus or cementum removal. The placement of new filling restorations or crown/bridge abutment preparations also needs to be identified as part of the dental history. It is inevitable that any form of tooth reduction by caries formation, caries removal or mechanical preparation causes injury to the pulp. The pulp's capacity to repair is dependent on two factors: the extent of the injury and the existing pulpal health. Studies have shown that crown/bridge abutment preparations produce some of the most damaging effects on the pulp. As a result of this comprehensive testing, the offending tooth would be identified, and a pulpal diagnosis made.
Therefore, the requested health service/treatment of Root canal for tooth #13 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Psoriasis.
Treatment:  Ilumya 100 milligram (MG)/milliliters (ML) subcutaneous (SC) solution prefilled syringe (SOSY).
The insurer denied Ilumya 100 milligram (MG)/milliliters (ML) subcutaneous (SC) solution prefilled syringe (SOSY).
The denial is upheld.

The patient is a female with moderate to severe psoriasis (greater than 25 percent [%] body surface area involvement) that includes the legs, back, and hands. The patient has tried and failed topical clobetasol solution, triamcinolone, and mometasone, as well as Methotrexate and ultraviolet B (UVB) light therapy.  Humira and Cosentyx were not effective, and the biologic agents Stelara, Tremfya, and Skyrizi are contraindicated with the patient's condition. The dermatologist reports that the patient has tried and failed Humira, Otezla, Skyrizi, Stelara, Taltz, and Tremfya.

At issue is the medical necessity of Ilumya 100 milligram (MG)/milliliters (ML) subcutaneous (SC) solution prefilled syringe (SOSY).

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

No, the requested health service/treatment of Ilumya 100MG/ML SC SOSY is not medically necessary for this patient.

The patient has insufficient to no documented treatment failure with, or true medical contraindication to, either Methotrexate, Acitretin, Phototherapy, Otezla, Taltz, Humira, Skyrizi, Stelara, or Tremfya. These alternative first, second, and third-line treatments and medications are medically appropriate for the treatment of this patient's particular clinical condition. Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Ilumya, particularly for a patient with a limited, poorly documented, and insufficiently concluded history of systemic psoriasis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. As per current medical standards of care, Ilumya is not medically necessary. The documentation of Methotrexate and Phototherapy failures are poorly documented, and there is not sufficient or a well-documented course of these therapies to confirm treatment success or failure of past systemic therapies.

Therefore, the requested health service/treatment of Ilumya 100MG/ML SC SOSY is not medically necessary.