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

Diagnosis: Asthma.

Treatment: Ventolin HFA 108 (90 Base) MCG/ACT in aerosol.

The insurer denied coverage for Ventolin HFA 108 (90 Base) MCG/ACT in aerosol

The denial is upheld.

The patient is a female with a history of severe persistent asthma. In addition, the patient has morbid obesity and autism. The patient has been maintained on montelukast and Advair 230 strength 2 puffs twice daily (BID). The patient's last hospitalization for status asthmaticus was around 3 years ago. There are notes indicating that the patient has a history of vaping and smoking in the past. The patient has required administration of a bronchodilator prior to exercise. The medical record indicates that the patient has had nervousness and side-effects when administered a bronchodilator in the past. The patient is being considered for monthly intramuscular asthma controller therapy, such as Xolair. The patient is prescribed Ventolin hydrofluoroalkane (HFA) per provider, but the patient's insurer is denying coverage indicating that an alternative generic beta agonist albuterol is available on formulary. 

As per medical record, there is an alternative medication (albuterol generic form of Ventolin) on formulary which will provide suitable replacement for Ventolin HFA and should continue to provide adequate control for this patient's asthma. If this alternative bronchodilator is administered according to guidelines, then the degree of jitteriness experienced should not be different from the prescribed Ventolin HFA medication. It should be noted that this patient is on twice a day long acting bronchodilator therapy, which may increase the risk of adverse effects when additional albuterol is administered prior to exercise. Optimizing this patient's asthma control with therapeutic intramuscular therapy such as Xolair can help control the risk of this patient's side-effects, such as jitteriness. Otherwise, albuterol is a suitable alternative beta agonist inhaled form of the prescribed Ventolin HFA medication and provides similar benefits and similar risk of jitteriness and irritability as Ventolin HFA.

Based on the review of the medical record and literature, Ventolin HFA is not considered medically necessary for this patient.

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

The insurer's denial of coverage for Ventolin HFA 108 (90 Base) MCG/ACT in aerosol to treat asthma should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Blocked maxillary canines
Treatment: Braces (D8080)
The insurer denied the Braces (D8080).
The denial is overturned. 

The patient is a female.  The request is for dental benefits for orthodontic treatment (Braces).  The dental clinical summary describes a patient who presents with a class II skeletal relationship, severe crowding in maxillary arch, and overbite and overjet of four millimeters.

Yes, the proposed treatment of orthodontic therapy (braces) is medically necessary.

The severity of the crowding is very pronounced and evident, as it is supported by the x-rays and photos.  Both maxillary canines are fully blocked out of the arch and are non-functional in this patient's chewing/masticatory process.

The canine plays a very major role in the functional guidance of the overall dentition, as well as in masticatory function as the main tooth for ripping and tearing food - a critical step in the beginning of the digestion process.  If this condition is left untreated, it can and will lead to long-term effects that will adversely affect the patient's ability to have a normal chewing function.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines.

Treatment: Formulary Exception for Nurtec oral disintegrating tablet (ODT). 

The insurer denied coverage for the Formulary Exception for Nurtec ODT.

The denial is upheld. 

This is a female patient with a history of migraines. The patient's migraines did not respond to previous treatment including Imitrex before seeing her current provider.  The patient had been responding well to Nurtec oral disintegrating tablet (ODT).  Her migraines were reported to be debilitating and this medication was noted as working well.  The provider noted Nurtec ODT was medically necessary.

The formulary drugs are not likely to cause the patient an adverse reaction.

There is no documentation of formulary migraine drug prescriptions being tried and ineffective based on the submitted documentation.

The requested drug, Nurtec ODT, could be more effective than the formulary drugs, as calcitonin gene-related peptide (CGRP) blockers, in general, are more potent migraine treatments than the listed formulary drugs.  However, given the absence of documentation of formulary drug prescription and efficacy (or absent efficacy), the case for a non-formulary drug use is not established.

The insurer's denial of Formulary Exception for Nurtec ODT is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sjogren's Syndrome.

Treatment: Intravenous Immune Globulin to Treat Sjogren's Syndrome.

The insurer denied coverage for Intravenous Immune Globulin to Treat Sjogren's Syndrome.

The denial is upheld. 

This is a female patient diagnosed with disabling autoimmune gastrointestinal (GI) dysautonomia and medically refractory immune-related painful small fiber neuropathy.  Her severe GI dysmotility affected her esophagus, stomach, and colon.  It caused greater than 20% loss of body weight.  She had impaired esophageal peristalsis, delayed gastric emptying, and colonic inertia.  She had been forced to eat a very limited liquid-based diet and utilized a carbon dioxide (CO2) gas powered enema to evacuate her bowels.  In addition to the gastroparesis she had exquisitely painful small fiber neuropathy that had not responded to narcotics, Lyrica, amitriptyline, and a spinal cord stimulator.  Sjogren's was a known cause of both dysautonomia and painful small fiber neuropathy, often in conjunction.  The prevalence of these syndromes was relatively high in Sjogren's and the patient also had antiganglioside antibodies.  No other explanation had arisen and she had not responded to symptomatic therapy through academic GI motility practices nor an academic pain specialist.  Her dysautonomia, neuropathy, and rheumatologic symptoms had not responded to mycophenolate, Plaquenil, or rituximab.  There were no standard controlled studies to guide the treatment of autoimmune dysautonomia or Sjogren's small fiber neuropathy.  There were ample case series showing benefit of intravenous immunoglobulin (IVIG) for autoimmune gastroparesis and small fiber neuropathy.  The provider requested IVIG based on what had worked repeatedly in case series.  Her gastrointestinal dysfunctions were profound and she was at risk for entering disability or having medical consequences of malnutrition.  The patient was to be reevaluated after 4 months of therapy and if she had benefit, the provider noted that they would provide supportive evidence for continued therapy.
 
The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The Pre-Service Request for Intravenous Immune Globulin to Treat Sjogren's Syndrome is not considered medically necessary for this patient. 

Peer-reviewed literature indicates that IVIG is safe and effective in a subset of patients with autonomic disorders and evidence for autoimmunity.  Up to Date, in a review of treatment of Sjogren's with extraglandular findings, does not recommend use of IVIG.  They only recommend it among other approaches in the setting of leukopenia patients who develop infections.  In patients with small fiber neuropathy their review notes that there are only small series, essentially case reports.  In sum, there is a paucity of literature to support the efficacy of IVIG for the patient's condition. 

The carrier's denial of coverage for the Pre-Service Request for Intravenous Immune Globulin to Treat Sjogren's Syndrome is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Symptomatic varicocele.

Treatment: Coil embolization (vascular embolization or occlusion code 37241).

The insurer denied coverage for coil embolization (vascular embolization or occlusion code 37241).

The denial is overturned. 

This is a male patient with a diagnosis of symptomatic left varicocele, swelling of left testicle and scrotum, discomfort, inability to have intercourse.  The patient was evaluated with a computed tomography (CT) scan of the abdomen/pelvis.  The patient chose to have left varicocele embolization for treatment of this condition.  The insurer has denied coverage for coil embolization of varicocele, stating that the procedure has not been proven effective and is therefore considered investigational.  

As per literature review, varicocele embolization is one of the standard surgical approaches to treat a symptomatic varicocele.  The other approaches include open surgery or laparoscopic surgery.  Embolization is approved by the Food and Drug Administration (FDA) for the treatment for symptomatic varicocele.  This procedure avoids the pain of an incision and a general anesthesia.  Embolization of a varicocele does carry a fairly high recurrence rate (13%), but is usually more of a pain-free approach except for minor pain, swelling at the vascular access site.  Embolization also has the least risk of a postoperative hydrocele compared to all of the surgical approaches.  Thus, many patients prefer to have symptomatic varicocele treated in this fashion. 

Based on the review of the medical record and literature, this patient is a good candidate for embolization of his symptomatic varicocele.  Embolization of the varicocele by Interventional Radiology is currently considered standard of care for surgical treatment of a symptomatic varicocele.  While it is often effective, recurrence rate is 13% compared to 15% for a retroperitoneal surgical approach.  Embolization also carries negligible risk of postoperative hydrocele (0%) compared to 8% for retroperitoneal surgical approach.  The neurosurgical approach to varicocele has only 1% recurrence rate and 0.4% hydrocele rate, but not everyone will choose the surgical approach when presented with all of the treatment options.

The coil embolization (vascular embolization or occlusion code 37241) is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for a coil embolization (vascular embolization or occlusion code 37241) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Symptomatic varicocele.

Treatment: Coil embolization (vascular embolization or occlusion code 37241).

The insurer denied coverage for coil embolization (vascular embolization or occlusion code 37241).

The denial is overturned. 

This is a male patient with painful left varicocele confirmed by ultrasound.  The patient reported that he has flare-up of pain, left testicular swelling, and decreased ability to have intercourse for more than 10 months.  The patient was referred to interventional radiology (IR) for a left varicocele embolization (CPT code 37241), but the procedure is being denied by the insurer as experimental.

As per Puche-Sanz, et al (2014), "Percutaneous retrograde embolization as a primary treatment for painful varicocele is a clinically effective option with a high success rate that can be maintained in the long term, especially in patients with high pre-operative pain."

As per Talaie, et al (2016), "Varicocele embolization is a safe and durable technique which provides pain relief and improved fertility in a well-chosen patient population... Indications for treatment of varicocele are an area of ongoing debate.  Some indications have gained wide clinical acceptance, while others remain controversial.  There is clear evidence that a patient with orchialgia and an associated ipsilateral varicocele will benefit from varicocele treatment including percutaneous embolotherapy.  Treatment of varicoceles is indicated in cases of aesthetic concerns, infertility, testicular pain, and testicular volume loss in the pediatric population.  In their recent review of literature, Halpern, et al concluded that orchialgia is an indication for percutaneous embolization of the varicocele.  Percutaneous embolization is a viable option for this group of patients, particularly given the inflammation and pain associated with surgery."

There is extensive literature supporting the use of the embolization procedure for the treatment of painful varicoceles.  The Society of Interventional Radiology has extensive literature supporting the effectiveness and safety of the embolization procedure.  The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.  Numerous peer-reviewed articles confirm an improved clinical outcome following left varicocele embolization.  In this case, the patient does not have known relative contraindications such as contrast allergy, bilateral varicoceles, or under a certain age to make this procedure an inappropriate choice of treatment.  It is appropriate to do the embolization procedure to treat scrotal pain.  Therefore, this patient is a good candidate for a coil embolization (vascular embolization or occlusion code 37241).     

The coil embolization (vascular embolization or occlusion code 37241) is likely to be more beneficial than any of the standard treatments/procedures for this patient

The carrier's denial of coverage for a coil embolization (vascular embolization or occlusion code 37241) should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Personal Care Services, 24 hours a day, 7 days a week (live-in). 

The insurer denied Personal Care Services, 24 hours a day, 7 days a week (live-in).  The denial is overturned.

The patient is a female with a past medical history significant for heart disease, osteoarthritis, hypertension and gastric carcinoma with metastases. The patient is currently approved for 12 hours a day 7 days a week Personal Care Services. She is requesting 24 hours a day, 7 days a week live-in. This review is a for the medical necessity of personal care services 24 hours a day 7 days a week, live-in.

The health plan's determination is overturned.

The requested health service is medically necessary for this patient.

The patient is a female with a past medical history significant for heart disease, osteoarthritis, hypertension and gastric carcinoma with metastases.

Services were denied by her insurance stating time is not provided when there are no tasks are being done, for companionship or for safety supervision. There is no medical necessity for the patient to be up at night.

Uniform Assessment System (UAS) State of New York was reviewed. Many of the task listed are noted to be extensive or maximal assistance. Progress note states that the patient has a terminal diagnosis with progressive nausea and deterioration. Progress note states that the patient's has had further functional decline and can barely get up by herself now.

The patient's underlying medical condition of gastric carcinoma with metastatic disease is a progressive condition. The last evaluation was not an in-person evaluation. Recent progress notes state that the patient's condition has significantly deteriorated. This would be expected based upon her underlying diagnosis. Therefore, it is reasonable and medically necessary for the patient have additional services especially at night. Her functional ability to transfer and walk has declined. Therefore, additional services to help with these unpredicted needs, such as transfers and ambulation would be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 
The denial is upheld. 

This female patient has a history of iron deficiency anemia, fibroid uterus, ectopic pregnancy status post salpingectomy, and migraines who presented to the Emergency Department (ED) with complaints of shortness of breath and chest tightness since 5 days prior to presentation. The patient reported she was exposed to cleaning materials and dust which she stated she was severely allergic to. She also reported she was cooking fried fish 2 days prior to presentation and her symptoms got worse. She had been using Flonase and Zyrtec but her symptoms did not get any better so she presented to the ED. The patient was admitted on for asthma exacerbation. Intravenous (IV) steroids and nebulizer treatments were given. Respiratory pathogen panel (RPP) was negative. She was on albuterol as needed (PRN) and prednisone since admission. Symptoms improved significantly and she reported feeling better. The patient was discharged. 

This patient did not need acute inpatient hospitalization. She had some baseline hyperreactive airways and exposure to the bleach cleaning agent triggered an acute bronchospastic episode in her. 

The patient was otherwise hemodynamically stable, moving air well, and was not hypoxic. There was no evidence of pneumonia on pneumothorax on chest x-ray. The patient was tolerating oral intake. 

This patient could have been placed on observation status (which could be for up to 48 hours)  while diagnostic testing and treatment were initiated. The patient remained stable after admission. The patient could have been switched to oral steroids and bronchodilators and was discharged home after a period in Observation status with further close follow up in outpatient setting. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

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 inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, Coronary Artery Disease.
Depression, Polyneuropathy and Urinary Incontinence.
Treatment: Increase Personal Care Aide (PCA) Level 2: 4 hours per day - 6 days per week for A Total Of 24 Hours Per Week
The insurer denied the Increase Personal Care Aide (PCA) Level 2: 4 hours per day - 6 days per week for A Total Of 24 Hours Per Week.
The denial is upheld. 

The patient is a female with a history of Hypertension, Coronary Artery Disease, Depression, Polyneuropathy and Urinary Incontinence. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). An appeal review was requested for potential approval of 24 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

No, the proposed treatment of 24 hours/week Personal Assistance Services is not deemed medically necessary.

This is a female with a history of Hypertension, Coronary Artery Disease, Depression, Polyneuropathy and Urinary Incontinence. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). However, an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that the currently approved plan of 12 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. Specifically, the assessment revealed that the patient has family/caregiver support as her daughter lives with her and is available to assist her after work with her ADLs (activities of daily living) and IADLs (instrumental activities of daily living). Furthermore, the patient is self-directing, able to bathe herself with some assistance and has a cane, walker, shower chair and personal emergency response system in her home which can assist with any emergency/safety needs.

There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment 24 hours/week Personal Assistance Services is not deemed medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II Diabetes Mellitus (without Complications).
Treatment: Formulary exception for Januvia (sitagliptin).

The insurer denied the Formulary exception for Januvia (sitagliptin).  The denial is upheld.

The patient is a male with type II diabetes. He has tried and failed metformin 500 mg (milligrams) twice daily. He has been on Januvia 100 mg daily, and his glucose levels have been stable. The request for Januvia is under review. The prior request was denied, as the patient does not have a documented trial of Tradjenta.

No, the health plan should not cover the Formulary exception for Januvia (sitagliptin).

This is a male with type 2 diabetes. He has tried and failed metformin. He is currently stable on Januvia. The formulary alternative is Tradjenta. Januvia and Tradjenta are in the same drug class. This patient does not have a documented trial or contraindication to Tradjenta. Tradjenta is expected to be equally safe and effective in this clinical situation as compared to Januvia. The American Diabetes Association clinical guidelines do not recommend the use of Januvia over Tradjenta in this clinical situation. Therefore, no, the health plan should not cover the formulary exception for Januvia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia and arthritis. 
Treatment: Personal Care Aide (PCA) Level 2 Services, live-in per diem, 24 hours per day, 7 days per week. 

The insurer denied coverage for Personal Care Aide (PCA) Level 2 Services, live-in per diem, 24 hours per day, 7 days per week. 

The denial is overturned. 

This is a female patient with a past medical history of vascular dementia, deforming and crippling osteoarthritis, atherosclerotic heart disease, hypertension, hyperlipidemia, urinary retention, recurrent urinary tract infections and a stroke resulting in loss of bladder control.  The patient has had an indwelling Foley catheter since the stroke. A telephonic New York State Department of Health's Uniform Assessment System (UAS-NY) notes that the patient lives alone in a 4 bedroom private home. The patient requires assistance with her activities of daily living and instrumental activities of daily living due to cognitive impairment and osteoarthritis. Her primary caregiver passed away. 

The patient is totally dependent for meal preparation, ordinary housework, managing finances, phone use, stairs, shopping, dressing her lower body and toilet use. The patient has an indwelling catheter, and she wears diapers and liners. The patient needs maximum assistance with managing medications, transportation, bathing, personal hygiene, dressing her upper body and toilet transfer. She needs extensive assistance with walking, bed mobility and locomotion. The patient uses an assistive device for locomotion indoors. 

The patient has severe dementia which along with arthritis and debility causes impairment in all activities of daily living. The patient has a urinary catheter. She does not have bowel incontinence. Proper emptying of the Foley bag and maintenance of the Foley catheter in a clean and dry environment is important to prevent infection, which has already occurred. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's interpretation of the medical necessity of 24-hour care in this case. 

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services, live-in per diem, 24 hours per day, 7 days per week is overturned. The medical necessity is substantiated.