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

Diagnosis: Dizziness/Near Syncope
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the emergency department with concerns of fever, chills, and watery diarrhea for two days followed by a fall. No loss of consciousness noted. Pertinent history included liver cirrhosis secondary to non-alcoholic steatohepatitis (NASH), chronic kidney disease stage 3, and obesity.

Intravenous fluids were provided. The patient was placed in the hospital thereafter with an impression of presyncope and fall, acute kidney injury on chronic kidney disease (CKD) stage 3, and microscopic hematuria. Treatment plan included empiric antibiotics, intravenous fluids, telemetry, echocardiogram, and carotid ultrasound. No events overnight were noted. Hemodynamics were stable and the patient was without complaints. Diagnostics were pursued and treatment plan remained relatively unchanged. Echocardiogram revealed a left ventricular ejection fraction (LVEF) 55-60% and grade 1 left ventricular diastolic dysfunction (LVDD). Carotid ultrasound relatively unremarkable. The patient was discharged with a diagnosis of dizziness and near syncope.

The patient presented with concerns of dizziness and resultant fall in the setting of subjective fever and watery diarrhea. A comprehensive evaluation was performed in the emergency department which found the patient to be afebrile, hemodynamically stable, without significant electrocardiographic or radiographic findings, and with an acute kidney injury. Orthostatic vital signs were negative. Treatment plan included intravenous fluids, empiric antibiotics, and diagnostic testing. An echocardiogram, telemetry, and carotid ultrasound were essentially unremarkable. Following observation care, the patient was asymptomatic and hemodynamically stable. No other issues or complications were documented. Moreover, clinical indications for admission to inpatient care were not met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall
Treatment: Inpatient  Admission
The insurer denied: Inpatient l Admission
The denial is upheld.

The patient is a female who presented to the emergency department with concerns of fever, chills, and watery diarrhea for two days followed by a fall. No loss of consciousness noted. Pertinent history included liver cirrhosis secondary to non-alcoholic steatohepatitis (NASH), chronic kidney disease stage 3, and obesity.

Intravenous fluids were provided. The patient was placed in the hospital thereafter with an impression of presyncope and fall, acute kidney injury on chronic kidney disease (CKD) stage 3, and microscopic hematuria. Treatment plan included empiric antibiotics, intravenous fluids, telemetry, echocardiogram, and carotid ultrasound. No events overnight were noted. Hemodynamics were stable and the patient was without complaints. Diagnostics were pursued and treatment plan remained relatively unchanged. Echocardiogram revealed a left ventricular ejection fraction (LVEF) 55-60% and grade 1 left ventricular diastolic dysfunction (LVDD). Carotid ultrasound relatively unremarkable. The patient was discharged with a diagnosis of dizziness and near syncope.

The patient presented with concerns of dizziness and resultant fall in the setting of subjective fever and watery diarrhea. A comprehensive evaluation was performed in the emergency department which found the patient to be afebrile, hemodynamically stable, without significant electrocardiographic or radiographic findings, and with an acute kidney injury. Orthostatic vital signs were negative. Treatment plan included intravenous fluids, empiric antibiotics, and diagnostic testing. An echocardiogram, telemetry, and carotid ultrasound were essentially unremarkable. Following observation care, the patient was asymptomatic and hemodynamically stable. No other issues or complications were documented. Moreover, clinical indications for admission to inpatient care were not met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia.

Treatment: Tooth 19 D6190 radiographic/surgical implant index, by report, D4266 gum surgery for tooth 18, and D4266 gum surgery for tooth 19.

The insurer denied coverage for Tooth 19 D6190 radiographic/surgical implant index, by report, D4266 gum surgery for tooth 18, and D4266 gum surgery for tooth 19.

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, narrative report from dentist, narrative report from primary care physician, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the mandible. The dentist has recommended the surgical implant index and guided tissue grafts presumably in preparation for endosteal implant placement. The dentist is requesting these services due to acid reflux and reported mastication issues. The insurer has denied the aforementioned services stating that the clinical situation does not meet necessity criteria and since the medical records received do not demonstrate such a condition therefore no benefit is available. The patient is appealing the decision.

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in the maxilla and mandible. The patient is edentulous in the #18 and #19 sites. Impacted teeth #17 and #32 are noted. In this case, in order to restore occlusal and masticatory efficiency, an alternative appropriate treatment would include a conventional removable partial denture. Further the documentation provided does not support, justify, or substantiate the requested treatment. Therefore, as removable partial dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures, grafting and implant index services are considered elective and not medically necessary.

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

The insurer's denial of coverage for Tooth 19 D6190 radiographic/surgical implant index, by report, D4266 gum surgery for tooth 18, and D4266 gum surgery for tooth 19 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Narrow arches, moderate crowding in the maxilla, severe crowding in the mandible, deep bite, Class I malocclusion.
Treatment:  D8080 Braces, D8670 Monthly Visit (x12).

The insurer denied D8080 Braces, D8670 Monthly Visit (x12).  The denial is upheld.

The member is a young adult male with no known medical or dental history.  The member has permanent dentition and evidently healthy bone.   He has straight (Class I) soft tissue and skeletal profile.  Both dental arches are U-shaped (narrow).  There is moderate crowding in the maxilla and severe crowding in the mandible.  The member has a deep bite, rotated/mal-positioned second molars, and Class I malocclusion.  There is approximately three millimeters overjet and approximately 90% overbite.  Anterior crossbite is present at the upper left lateral incisor and lower left canine. The member does not have open bite.  Caries may be present in molar teeth as shown in the photographs.

The proposed D8080 braces and D8670 monthly visit (x12) are not medically necessary.
Per the New York State Medicaid Program Dental Policy and Procedure Code Manual, orthodontic procedures are covered for members under 21 years of age, and who exhibit a severe physically handicapping malocclusion in the permanent dentition.  The orthodontic benefit is once per lifetime.  

Per the DentaQuest Policy and Procedure Guidelines and Regulations New York Office Reference Manual, the member must also have a Handicapping Labio-lingual Deviation (HLD) Index score of 26 or higher or one of the automatically qualifying conditions.

This member does not have any automatic qualifying conditions.  While there is crossbite of individual anterior teeth, there is no evident clinical attachment loss and recession of the gingival margin.  The member also has a deep overbite, but this overbite is not considered to be an impinging overbite that causes severe soft tissue damage.  The Handicapping Labio-lingual Deviation (HLD) Index score calculated for this patient is 23, which is not considered a severe physically handicapping occlusion.  Additionally, there was no documentation about nor any other medical need for braces.  For these reasons, orthodontic treatment is not considered medically necessary for this member.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overactive bladder 
Treatment: Myrbetriq tablet (Tab) 
The insurer denied Myrbetriq tablet (Tab). 
The denial is upheld. 

This patient is a female with a diagnosis of overactive bladder. She has requested coverage for Myrbetriq 25 milligrams (mg) for continued use. She has tried Oxytrol, Vesicare and oxybutynin. She has a history of glaucoma.

At issue is the medical necessity of Myrbetriq tablet (Tab).

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

No, the requested health service/treatment of Myrbetriq Tab is not medically necessary for this patient.

Per the American Urological Association (AUA) "Guideline Statement 11, If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a 3-adrenoceptor agonist may be tried. Clinical Principle."

The Plan's formulary agent, Toviaz, is an acceptable treatment alternative with a low risk of potentially risky destabilization. Use is contraindicated for uncontrolled narrow angle glaucoma. The documentation did not support that she had this condition.

Therefore, the requested health service/treatment of Myrbetriq Tab is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Multiple Sclerosis
Treatment: Mavenclad
The insurer denied the Mavenclad.
The determination is upheld.

The patient was recently diagnosed with relapsing remitting multiple sclerosis. The patient is treatment naive and has not used any disease modifying treatment. She has previously completed a course of steroids and is using vitamin D supplementation. Treatment with Mavenclad is the subject of this review. The drug was denied because the member has not tried and failed any of the available formulary alternatives. The provider appealed the determination. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

While the patient has not used any of the available formulary agents for treatment of relapsing-remitting multiple sclerosis (RRMS), all of the agents are Food and Drug Administration (FDA) approved for treatment of RRMS and are therefore effective. As noted above, there is not direct comparative data in order to determine if the available formulary agents are as effective as Mavenclad. However, the available data suggests that Gilenya (fingolimod), interferons (Rebif, Betaseron) and likely Aubagio and diemethylfumarate have similar efficacy. All of the formulary alternatives are from different classes of drugs and will have different but manageable side effects as compared to Mavenclad. 
There is no documentation provided to show that the patient has tried and failed any of the available formulary alternatives including Aubagio, Betaseron, Copaxone, Gilenya, glatiramer, Glatopa, Rebif or dimethyl fumarate.
There is a lack of head-to-head comparison for Mavenclad (cladribine) and all of the available formulary alternatives. However, the manufacturer does indicate that cladribine is generally recommended in relapsing remitting multiple sclerosis (RRMS) patients who have had an inadequate response to, or are unable to tolerate, one or more therapies for relapsing-remitting multiple sclerosis (RRMS). In this instance, the patient has not tried and failed any other therapies. Another study showed that cladribine demonstrated comparable effectiveness on relapse activity to fingolimod in patients with highly active relapsing multiple sclerosis.
One comparative study concluded that cladribine is an effective therapy for relapse-onset multiple sclerosis. Its effect on relapses is comparable to fingolimod and its effect on disability accrual is comparable to interferon  (beta) and fingolimod.
Appeal type: Medical necessity
Decision: Overturned

Central nervous system
Home health care

Diagnosis: dementia
Treatment: home health care
The insurer denied Personal Care Aide (PCA) Services: 8 Hours per Day, 7 Days per Week - Total of 56 Hours per Week. The health plan's determination is overturned. 

The patient is a male with past medical history of hypertension, dementia, coronary artery disease, urinary incontinence, diabetes mellitus type 2, and gastroesophageal reflux disease (GERD) who had been assigned PCA (personal care aide) services based on a video assessment performed assessing the patient at total assistance with tasks of ordinary housework while maximum assistance with tasks of meal preparation and shopping. With tasks of stairs, transportation, bathing, and dressing lower body, the patient was assessed at extensive assistance while limited assistance with tasks of managing finances, dressing upper body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at supervision with task of managing medication while independent with tasks of phone use, bed mobility, and eating. There was a request to increase PCA services.

Personal Care Aide (PCA) Services: 8 Hours per Day, 7 Days per Week - Total of 56 Hours per Week are medically necessary for this patient.
There is documentation from the patient's medical provider of worsening cognitive and functional status. There is documentation from the patient's medical provider of medical necessity of increased PCA services. Although the insurer stated the patient did not have a change in assistance needs when comparing the recent assessments, the patient did have an increase in assistance needs with tasks of managing medication, phone use, and personal hygiene. The plan incorrectly assumed that the patient's wife could provide informal help which she was no longer able to provide. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's assistance needs cannot be met with adaptive equipment or medical supplies. The patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 8 hours/day, 7 days/week, to total 56 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vitiligo.
Treatment: Xeljanz.
The insurer denied: Xeljanz.
The denial is: Upheld.

The patient is a female with vitiligo. She has tried and failed tacrolimus ointment and triamcinolone cream. She has also failed phototherapy. The subject under review is the medical necessity for Xeljanz for this patient.

The health plan's determination is upheld.

The requested health treatment of Xeljanz is not medically necessary for this patient. Xeljanz would be considered a cosmetic treatment according to the medical literature, as it is to treat skin discoloration (vitiligo). According to the dermatologic literature, vitiligo is a pigmentary skin condition. (1-3) Bolognia et al. writes that "The most common presentation of vitiligo is totally amelanotic (i.e., milk- or chalk-white) macules or patches surrounded by normal skin...Vitiligo is usually asymptomatic."(1) Treatment is not medically necessary because it is considered a cosmetic skin condition. It does not cause any functional impairment or symptoms.
Further, Xeljanz is not Food and Drug Administration (FDA)-approved for the treatment of vitiligo. There are no large, evidence-based, published trials in the medical literature documenting its efficacy for the treatment of vitiligo. 
Xeljanz would not be medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine
Treatment: Nurtec
The insurer denied Nurtec. The health plan's determination is upheld. 

The patient is a male with chronic migraines. Treatment with Nurtec ODT (oral disintegrating tablet) is the subject of this review.

Nurtec is not medically necessary for this patient. The documentation indicates that the patient has used sumatriptan. There is no documentation that the patient failed treatment with sumatriptan or that sumatriptan caused an adverse side effect. Furthermore, there is no documentation that the patient has a medical condition that would make the use of triptans absolutely contraindicated.
In a letter of medical necessity the provider writes, "Nurtec has proven to be safe, effective, and is Food and Drug Administration (FDA) approved for the treatment of Chronic Migraine." However, this statement is incorrect. Nurtec ODT is only FDA approved for the acute treatment of migraine and the preventative treatment of episodic migraine. The literature only supports the use of this drug for these indications as well.
As such, there is no medical reason provided why the patient cannot use triptans, If the drug is intended for preventative treatment of migraine, Nurtec ODT is not FDA approved for the patient's condition as it can only be used for episodic migraine.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a male with history of three days of cough and increased respiratory effort. The patient demonstrated continued increased work of breathing and concerning lab findings in the emergency department and was found to be in need of admission.

Yes, the inpatient hospital admission was medically necessary.
The patient demonstrated signs of respiratory distress on exam and lab values. The patient had intercostal muscle use, nasal flaring, with tachypnea (increased respiratory rate). These physical findings as well as the lab values showing the potential of hydrogen (pH) and carbon dioxide (CO2) values as well as the basic electrolytes show signs of respiratory distress. As such, with minimal to no improvement in the emergency room and a concerning exam, the patient could not be discharged and required further monitoring and care. The patient had signs of respiratory distress after a three to four day course of nasal congestion and cough at home. To ensure appropriate care of this respiratory illness, the patient required an inpatient stay. The denial is overturned.

No, denying the admission was not in the best interest of the patient.
The patient demonstrated laboratory and clinical signs of respiratory distress and required inpatient admission. The admission was medically necessary to appropriately care for the child and prevent respiratory failure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thoracic outlet syndrome
Treatment admission for current procedural terminology (CPT) 71552 - magnetic resonance imaging (MRI) of the chest without and with contrast
The insurer denied coverage for CPT 71552 - MRI of the chest without and with contrast
The denial is overturned

This patient presented with a history of bilateral upper extremity symptoms (upper extremity numbness, and tightness pain in the neck/trapezius) for the past seven years, with recent worsening. Per the office visit note from Vascular Surgeon, a review of the patient's history noted a question of subclavian steal syndrome, and an arterial duplex showed triphasic flow in the bilateral upper extremities. The patient was assessed as having possible neurogenic thoracic outlet syndrome. A chest x-ray showed no acute infiltrate and no cervical ribs were seen. MRI of the chest with and without contrast is requested. The insurer has denied coverage for CPT 71552 MRI of the chest without and with contrast as not medically necessary. In their Final Adverse Determination letter, they write that the records do not show that the patient has had a chest x-ray as the first study for the problem. The decision is based on their guidelines for thoracic outlet syndrome. The provider is appealing.

As of the date on which the determination letter was filed, the patient had not had a chest x-ray. The chest x-ray was apparently done later that day. The patient has now had a chest x-ray, and the findings do not provide adequate diagnostic information. Now that the chest x-ray has been performed, the MRI scan qualifies as medically necessary.      

Diagnosis of this condition can be difficult. Imaging studies, including chest x-ray and MRI are performed, along with clinical evaluation including detailed physical examination and evaluation of response to physical therapy and other interventions. The use of MRI is compatible with the standards of care established in the medical literature as well as the common practice of specialists in the United States and elsewhere treating this condition. 

According to Chang et al (2021), "MRI can identify a fibrotic band, edema, or high signal intensity of the brachial plexus due to compression by the former [32-34]."

According to nationally recognized experts Frieshlag et al (2014), "most patients will already come with chest x-ray and MRI," indicating the routine use of these tests for diagnostic purposes. 

According to Khalilzeda et al (2020), "Based on our experience, a combination of computed tomography angiography and MRI (with postural maneuvers) effectively demonstrate thoracic outlet syndrome abnormalities."                                                         

The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. 

The insurer's denial of coverage for current procedural terminology (CPT) 71552 - magnetic resonance imaging (MRI) of the chest without and with contrast is overturned. Medical Necessity is substantiated.