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

Diagnosis: Endocrine/Metabolic/Nutritional/Body mass index (BMI) 35.0-35.9, adult
Treatment: Pharmacy/Prescription Drugs/Wegovy
The health plan denied the requested treatment of Wegovy as not medically necessary. The health plan's determination is upheld.

The patient is a man with a history of obesity, fatty liver, and abnormal glucose levels. Apparently, while being treated with Wegovy, he has lost body weight. He is requesting coverage for Wegovy treatment. There is no record that the patient has tried and failed Ozempic, Trulicity, and Victoza, which are the preferred formulary alternatives.
At issue is the medical necessity for the requested treatment of Wegovy.

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

No, the requested health service/treatment of Wegovy treatment is not medically necessary for this patient.
Based on a thorough review of the information provided, there is no evidence that the patient tried and failed the preferred formulary alternatives for Wegovy, which include Ozempic, Trulicity, and Victoza. There is no clear evidence that Wegovy would be more effective or safer than the preferred formulary, especially since Ozempic is the same medication packaged in a different dosage. Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, treatment with Wegovy cannot be substantiated as being medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease.
Treatment: Split-shift 24-hour personal care services (two 12-hour shifts) for a total of 168 hours.
The insurer denied split-shift 24-hour personal care services (two 12-hour shifts) for a total of 168 hours.
The determination is upheld.

The patient has a medical history notable for Alzheimer's disease. The patient is currently approved for 7 hours per day, 7 days per week (49 hours per week) of personal care services. The patient and her care team requested an increase to 2-12 hours per day (split-shift), 7 days per week (168 hours per week), and this request was denied by the health plan.
A letter of support for this appeal was provided by the patient's physician. The letter states that she should have increased home health care due to her diagnosis of dementia. She "is not safe to be left alone or unattended at any time. There is an increased risk of falls and injury." The physician states that her current level of home health care is "inadequate for the current condition." No additional letters or notes were provided for this appeal.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented to person and place only. Cognition was minimally impaired, and she is able to make her needs known. From a functional standpoint, she requires total dependence for housework. She requires maximal assistance for meal preparation, managing finances, and shopping. She requires extensive assistance for managing medications and phone use. For her activities of daily living (ADL)s, she requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for dressing upper body, walking, locomotion, toilet transfer, and toilet use. She requires limited assistance for hygiene, bed mobility, and eating. She is frequently incontinent of urine and continent of stool. She uses pull up diapers for incontinence care. An Hours Evaluation for Paraprofessional Support (HELPS) assessment recommended 44 hours per week to meet her personal care needs. At issue is the medical necessity of split-shift 24-hour personal care services (two 12-hour shifts) for a total of 168 hours.

The requested health service of split-shift 24-hour personal care services (two 12-hour shifts) for a total of 168 hours has not been demonstrated to be medically necessary for this patient.
The patient has worsening dementia with several functional needs. Her assessment recommended 44 hours per week to meet her personal care needs, and she is approved for 49 hours. There is no discussion of unmet personal care needs. The patient's physician did recommend that she have someone with her continuously. However, safety monitoring is not a standalone function of personal care workers (when not otherwise performing personal care tasks).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Malig neoplasm of upper-outer quadrant of right female breast.
Treatment: Proton beam radiation therapy.
The health plan denied the requested proton beam radiation therapy as not medically necessary. 
The health plan's determination is overturned.

This is a female with a stage pT2N2M0 lymph node positive right breast cancer status post-surgical resection and systemic chemotherapy. She has been recommended to proceed with a course of postoperative external beam radiotherapy with curative intent.
At issue is the medical necessity for the requested proton beam radiation therapy.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, proton radiation a standard of care and is medically necessary for this patient.
The treating provider has performed a proton vs. photon plan comparison which reveals that the photon radiation plan cannot provide adequate safety/precision. If delivered, the photon plan would result in an unacceptable and unnecessary risk for cardiopulmonary morbidity and mortality, given that the radiation exposure to the patient's heart and right lung exceeded nationally accepted treatment planning objectives. Proton radiation is able to significantly minimize the exposure to the patient's heart/lung, and also minimize her contralateral breast exposure to limit her risk for radiation induced secondary malignancy. Proton radiation is supported by numerous high quality prospective clinical outcomes for the management of breast cancer. It is endorsed by national guidelines in the patient's setting, including the ASTRO (American Society of Radiation Oncology) Model Policy, because photon radiation is unable to meet nationally accepted planning goals. Proton radiation is routinely utilized throughout the radiation oncology community nationwide for similar young female patients with node positive breast cancer who cannot be treated safely/effectively with photon radiation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Medically Supervised inpatient detoxification 
The insurer denied: Medically Supervised inpatient detoxification
The denial is: Overturned

The patient is a male who presented for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, stimulants (crack cocaine), and cannabis (marijuana) class substances of abuse. He has a history of multiple detoxification treatment episodes with immediate relapse. He was using 1.5 pints of liquor plus beer on a continuous daily basis together with daily use of $50 worth of marijuana and $100 worth of crack cocaine daily.

The patient was admitted for inpatient treatment with the detoxification protocol. He received tapering dosages of Ativan and replacement of vitamins with education and counseling and comfort medications and as needed (prn) medications prescribed for pain, anxiety, and insomnia.

The patient's hospital course progressed without incident. Vital signs remained normal with occasional variability, and the patient reported mild nausea, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished throughout his hospital course. He was socially withdrawn initially but participated in counseling and educational sessions. He received psychiatric consultation and was prescribed risperidone and mirtazapine at clinically appropriate dosages in order to maintain treatment for the schizoaffective disorder and symptoms of anxiety and depression.

The requested supervised inpatient detoxification is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The admission and the continued inpatient level treatment through discharge could not have been safely or effectively provided with lower-level services. Thus, the requested service is medically necessary and is in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of American Society of Addiction Medicine (ASAM) Criteria and application of Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right foot ulcer
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is overturned.

Patient is an adult male with past medical history significant for diabetes mellitus, hypertension, atrial fibrillation, obesity, diverticulitis, and right foot Charcot deformity with chronic ulcer who presented to the emergency department with complaints of fever and right foot ulcer. 

Vitals on presentation included: Temperature 98.1 degrees Fahrenheit, Blood Pressure 148/90 Pulse 73, Respiratory Rate 18, Oxygen (O2) saturation 96% on Room Air. Laboratory results included the following: white blood cell count (WBC) 14.6, hemoglobin (Hgb) 13.5, creatinine 0.80, glucose 121.

The patient was started empirically on intravenous antibiotics for possible right foot infection. X-ray showed soft tissue swelling, but no fracture or dislocation. Infectious Diseases consulted and recommended antibiotics (vancomycin and Zosyn). Right foot wound cultures grew Streptococcus agalactiae and Enterobacter cloacae. Magnetic Resonance Imaging (MRI) of the foot showed acute on chronic changes. The patient underwent a surgical debridement. He remained afebrile, hemodynamically stable, and was discharged to continue outpatient management. Hospital admission was medically necessary for intravenous antibiotics and surgical intervention.

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 the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unstable angina
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is upheld.

Asked to review the case of an adult that presented to the hospital complaining of worsening dyspnea on exertion for a one week period. Past medical history was significant for ischemic heart disease, hypertension, diabetes, obstructive sleep apnea (OSA) and pancreatitis. She was instructed by her cardiologist to go to the hospital after reporting worsening dyspnea. Upon arrival to the hospital vital signs were stable, Blood Pressure 127/84 and Pulse 89. Physical examination was without abnormality. 12 lead electrocardiogram revealed normal sinus rhythm without ischemic abnormalities. Serum troponin was not elevated [0.005 nanograms/ milliliter (ng/ml)]. She was admitted to the hospital and underwent cardiac catheterization. A 95% proximal left anterior descending artery occlusion was noted, and a drug eluting stent was successfully deployed. An 80% in stent restenosis of the right coronary artery was noted. There were no perioperative complications, and the patient was released post procedure. 

Electrocardiogram and serum troponin levels demonstrated no acute ischemia. Percutaneous revascularization was performed. The patient underwent an uncomplicated procedure, and a stent was placed in the proximal left anterior descending (LAD) artery. She was discharged after the procedure.  

Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. (References 1- 4) Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care. (Reference 4)

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion 

Treatment: D8080 braces and D8670 monthly visits

The insurer denied coverage for braces and monthly visits

The denial is upheld 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, ectopic eruption, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 30 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 24 points. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 30 points to justify orthodontic care. Of note is that the dentist scored both anterior crowding AND Ectopic eruption. As per the HLD requirements/instructions the dentist was to score only ONE of the two conditions, whichever is most severe. Removing 6 points for ectopic eruption results in a score of 24 points based on the dentist's assessment if index completed accurately. This reviewer concurs with the HLD index of the insurer also attaining 24 total points (3 overjet, 6 overbite, 10 anterior crowding and 5 labiolingual spread).

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 D8080 braces and D8670 monthly visits x 12 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Skyrizi
The insurer denied Skyrizi.
The determination is upheld.

The patient has psoriasis. She has failed cortisone creams, Protopic, and Eucrisa. The prescriber is a dermatologist. The medication under review for medical necessity is Skyrizi.

The requested health treatment of Skyrizi is not medically necessary for this patient.

According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines such as methotrexate are effective treatments for the management of psoriasis (1, 2).

Within the peer-reviewed literature, West, et al (2016) conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2 percent (%) [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint. Thus, methotrexate is an effective first-line treatment for the management of psoriasis (3).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Human immunodeficiency virus
Treatment: Serostim
The insurer denied Serostim.
The health plan's determination is upheld. 

The patient is a male with human immunodeficiency virus (HIV), anxiety, depression, and crystal methamphetamine abuse. It is stated that to have wasting and hypogonadism. At his visit on 3 months prior, the patient's Vital Signs were: Height 174.6 centimeter (cm), Weight 88 kg (kilograms), blood pressure (BP) 120/72, Pulse 70. The calculated body mass index (BMI) was 28.86. Medications at that time were Dovato, Androgel, Tadalafil, Acyclovir, Trazadone, Fish Oil, Valerian, and Somatropin (Serostim). Exam noted the patient to be well nourished and well developed. In the assessment and plan, it is listed that the patient has Wasting Disease and notes patient history of weight loss and to continue Serostim. The note also notes BMI "above normal" and that the patient was counseled on maintaining a healthy weight by healthy eating, portion control, and exercise.

Serostim is not medically necessary for this patient.

The request for the medication appears to be based on the patient's subjective feeling of improvement in energy levels and alleviation of his neuropathic, carpal tunnel, and cubital tunnel symptoms. However, he does not meet the approved guidelines for use of this drug. He is also most recently noted to have a BMI "above normal" and was counseled on healthful diet and exercise to maintain a healthy weight. He does not currently have wasting syndrome and his BMI is > (greater than) 27, so he does not meet criteria for continuation of therapy. In addition, the records do not provide a pretreatment BMI and there is no indication that he has failed any alternative therapies (though noted that he has been diagnosed as hypogonadal and receiving Androgel).

Based on provided documentation the request for Serostim is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, stroke with gait ataxia, coronary artery disease, diabetes mellitus, insomnia, anxiety, and incontinence.
Treatment:  Personal care aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week.

The insurer denied coverage for personal care aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week.  The denial is overturned.

This is an older patient with a history of progressive dementia, stroke with gait ataxia, coronary artery disease, diabetes mellitus, insomnia, anxiety, and bowel/bladder incontinence. The Uniform Assessment System (UAS) - New York Comprehensive Community Health Assessment Report notes that the patient's cognition is severely impaired; there are behavioral disturbances including wandering, hallucinations, and aggressive behavior. Assistance is needed with all activities of daily living (ADLs), including total dependence for personal hygiene, dressing and toilet use. Maximal assistance is needed for bed mobility, walking, locomotion, and toilet transfers. The patient's overall self-sufficiency is noted to have deteriorated. An increase in personal care aide (PCA) services to split-shift is requested.

The medical records and associated documents show continued deterioration with lack of support by family members. The patient's daughter who lives at home has a documented disability and has problems caring for self. Other family members are not available and live at a distance. The night log showed difficulty behaviors, periods of confusion and falls. The report that an unsafe condition is present has credence. The patient is at high risk for fracture and the incontinence is not adequately managed at the current level of support. It would be appropriate to have the requested service.

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 personal care aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Daytime sleepiness, observed apneas and snoring.
Treatment: Facility-Based Sleep Study Services.
The insurer denied: Facility-Based Sleep Study Services.
The denial is upheld.

The patient is an adult male. The service under review is facility-based sleep study services. This was denied as not medically necessary. This decision is being appealed. Per the patient's letter, symptoms include daytime sleepiness, observed apneas and snoring. Per the clinic note there is no mention of these symptoms; asthma, high cholesterol, and anxiety are noted without mention of a sleep study. Body mass index (BMI) was normal at 22.8.

The proposed facility-based sleep study services were not medically necessary.

According to Clinical Practice Guidelines by the American Academy of Sleep Medicine [ref 1], either polysomnography or home sleep apnea testing can be used for the diagnosis of obstructive sleep apnea (OSA) in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe obstructive sleep apnea (OSA). If a single home sleep apnea test is negative, inconclusive or technically inadequate, polysomnography can be performed for the diagnosis of obstructive sleep apnea (OSA). This patient did not have a home sleep apnea test prior to the in-lab sleep study. It is recommended that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of obstructive sleep apnea (OSA) in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to a 
neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke, or severe insomnia. This patient does not have any of these medical conditions that would make a home sleep apnea test inappropriate.