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

Diagnosis: Pneumonia
Treatment: Skilled Nursing Facility

The health plan denied: Continued Skilled Nursing Facility
The determination is: Upheld

The patient is a male who was admitted to the skilled nursing facility (SNF) from the hospital after being hospitalized for pneumonia with sepsis and acute kidney injury. He was discharged from physical and occupational therapy as has been independent or achieved maximal potential in most activities of daily living and therapeutic functional activities.
At issue is the medical necessity of continued skilled nursing facility admission.

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

No, the requested health service/treatment of continued skilled nursing facility is not medically necessary for this patient. This patient was admitted to the SNF from the hospital after being hospitalized for pneumonia with sepsis and acute kidney injury. Per the physical and occupational therapy notes, he was working with physical therapy. The patient has made consistent gains towards the goal of independence in activities. Per the most recent notes, the patient exhibits independence and/or improvement in most activities of daily living and therapeutic functional activities. Per both the physical and occupational therapy notes, the patient has achieved maximal potential. In addition, according to the medical provider notes, his acute illness for admission has resolved and his co-morbidities are well controlled. Therefore, without an ongoing benefit from therapy (physical/occupational), the requested health service/treatment of continued skilled nursing facility is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis 

Treatment: Taltz

The insurer denied coverage for Taltz

The denial is overturned

The patient is an adult patient with a diagnosis of psoriasis and psoriatic arthritis. The patient has failed multiple systemic therapies, including Narrowband Ultraviolet B (NBUVB), Otezla, Remicade, Methotrexate, Stelara, Humira, Enbrel, Cosentyx, and Skyrizi. The patient was noted to have rapid clearance with one Taltz injection. The requested medication is Taltz.

Based on the submitted documentation, Taltz is medically necessary. The patient has failed numerous systemic therapies for control and management of his psoriasis and psoriatic arthritis. Taltz is Food and Drug Administration (FDA) approved for treatment of psoriasis vulgaris and it is reasonable to attempt this treatment option. The joint American Academy of Dermatology and the National Psoriasis Foundation (AAD-NPF) guidelines for psoriasis treatment with biologics states that Taltz is recommended for monotherapy in the treatment of psoriasis with a strength of recommendation of "A" -the highest recommendation. In this case, Taltz is a reasonable next therapy for the treatment of the patient's disease and is medically necessary. Based on the submitted documentation, Taltz is approved, and the decision is overturned in whole based on the current evidence-based medical literature.

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 Taltz is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: D5213 Partial upper denture; D5214 Partial lower denture; D2751 white glass with metal crown, Tooth #6, 7, 10, 11, 14, 20; D3310 Nerve treatment, Teeth 6, 7, 10, 11; D3320 Nerve treatment, Tooth #20; D3330 Nerve treatment, Tooth #14; D2954 Ready-made post, Tooth #20.
The insurer denied D5213 Partial upper denture; D5214 Partial lower denture; D2751 white glass with metal crown, Tooth #6, 7, 10, 11, 14, 20; D3310 Nerve treatment, Teeth 6, 7, 10, 11; D3320 Nerve treatment, Tooth #20; D3330 Nerve treatment, Tooth #14; D2954 Ready-made post, Tooth #20.
The determination is overturned.

This is a male patient who presented for the treatment of missing teeth as well as treatment for teeth numbers (#) 6, 7, 10, 11, 14, 20. Included for review are previous letters of denial and appeal, explanation of benefits, radiographic images, and claim forms. Previous denials have been on the basis that the adjacent teeth are not healthy enough to support a partial denture, stating that the teeth either have large decay or not enough bone support. The root canal therapy was denied on the same basis that the teeth are not healthy. For the crowns it is noted that the teeth are healthy but later state that the teeth are unhealthy. An explanation of benefits stated that the treatment was denied on the basis that the treatment was excessive, that partial dentures are only covered when there are less than eight teeth remaining,
At issue is the medical necessity of the treatment of (D5213 Partial upper denture; D5214 Partial lower denture; D2751 white glass with metal crown, Tooth #6, 7, 10, 11, 14, 20; D3310 Nerve treatment, Teeth 6, 7, 10, 11; D3320 Nerve treatment, Tooth #20; D3330 Nerve treatment, Tooth #14; D2954 Ready-made post, Tooth #20).

Yes. The requested services are medically necessary. Based on the provided documentation the patient is missing teeth in the maxilla and mandible, making the replacement necessary. The remaining teeth are adequate and healthy enough to support the prosthesis based on bone level and ability to have restorations. As for the crowns and root canal treatments, these treatments are necessary due to the loss of tooth structure which will not be retained with direct restorations and hence require root canals for posts and retention to allow for crowns to replace the missing cusps and tooth structure. The entire requested health service/treatment of Dental services (D5213 Partial upper denture; D5214 Partial lower denture; D2751 white glass with metal crown, Tooth #6, 7, 10, 11, 14, 20; D3310 Nerve treatment, Teeth 6, 7, 10, 11; D3320 Nerve treatment, Tooth #20; D3330 Nerve treatment, Tooth #14; D2954 Ready-made post, Tooth #20) is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatic cancer
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld. 

The patient presented with abdominal pain. He was afebrile and hemodynamically stable. There was no abdominal rebound or guarding. There was no leukocytosis. A computed tomography (CT) scan showed a pancreatic mass with liver metastases. The gastroenterologist advised doing an endoscopic ultrasound (EUS) with fine needle biopsy. Pancreatic and liver biopsies were done. He also had a small testicular abscess that did not need an incision and drainage and was treated with an oral antibiotic. 

Medical necessity was determined using Milliman Care Guidelines (MCG) M-05 for Undiagnosed Abdominal Pain. Clinical indications for admission include hemodynamic Instability, peritoneal signs, inability to maintain oral hydration after observation care, and bacteremia. The patient did not have these conditions. 

MCG A-0099 lists clinical indications for an endoscopic ultrasound. This test is indicated for a suspected pancreatic neoplasm with the need for a definitive diagnosis. However, the procedure is listed as Ambulatory Care. 

This patient required a workup including EUS (endoscopic ultrasound) and fine needle biopsies. However, this procedure could have been done on an ambulatory basis. The testicular finding could have been treated with pain medications and an oral antibiotic as an outpatient. He did not meet MCG criteria for admission for Undiagnosed Abdominal Pain. 

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Universalis
treatment; Xeljanz
the insurer denied Xeljanz. 

The health plan's determination is upheld. 

The patient is a female with alopecia areata universalis, who has regrown all of her scalp hair as well as her eyelashes and eyebrows while on Xeljanz. The patient has previously failed oral, topical, and intralesional steroids. The patient previously had suffered eye irritation and inflammation after losing her eyebrow and eyelash hair.

Xeljanz is not medically necessary for this patient.
While it is understandable to consider Xeljanz (tofacitinib) for this patient's condition, it is not standard of care at this time, and merits further study before being presumed acceptable for widespread clinical use. At this time, the long-term safety of this medication is not as confirmed.
Alopecia areata is notoriously difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, contact allergen treatment and related therapies have all resulted in variable and unsatisfactory outcomes, and self-resolution is often the only choice a patient has (along with hairpieces) for severe cases.

The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of alopecia areata, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with a specific dosing of Xeljanz.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plantar Fasciitis
Treatment: Custom Shoe Inserts
The health plan denied: Custom Shoe Inserts
The determination is: Upheld

The patient is a male who presented for evaluation of his arch pain. He was complaining of bilateral plantar foot pain when walking distance. He has a history of a few months of trying "pre-fabricated" inserts but with minimal improvement in daily symptoms. On exam, he had normal foot morphology. There is limited ankle dorsiflexion with a tight posterior muscle groups and plantar fascia. The patient was diagnosed with plantar fasciitis bilaterally. The patient was recommended plantar fascial and calf stretching exercises. The patient was also prescribed custom molded orthotics. The patient then returned complaining of an early recurrence of plantar discomfort when walking and standing. The exam was unchanged from the previous exam. The patient was diagnosed with plantar fasciitis. He was recommended more stretching exercises and prescribed more custom molded orthotics.
At issue is the medical necessity of the custom shoe inserts.
The health plan's determination of medical necessity is upheld in whole.
No, after review of the medical documentation, the custom shoe inserts are not medically necessary for this patient. There is insufficient documentation of an adequate trial of conservative treatment by the patient. The patient returned to clinic with a mild flare up of his plantar fasciitis. There is no evidence that the patient has tried anti-inflammatory medications and stretching exercises for 3 months since the flare up of pain. Custom orthotics are not to be used as a first line treatment. Thus, the custom shoe inserts are not considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection 
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This adult female patient presented to the emergency room (ER) with dyspnea, myalgias and dysuria, and a history of lymphadenopathy for years. The patient's heart rate (HR) was 101 beats per minute (bpm), blood pressure (BP) was 90/60 with a temperature of 98 degrees Fahrenheit (F). There were no orthostatic pressures done. An exam showed lymphadenopathy. The patient's labs showed a hemoglobin (Hgb) of 7.9 and the urinalysis was positive; the patient was admitted and given intravenous (IV) antibiotics and discharged 1.5 days later. 

This patient presented with an uncomplicated urinary tract infection (UTI). The patient was not hypotensive or tachycardic. The patient had anemia but was not bleeding and did not have hemolysis. The two year history of lymphadenopathy does not warrant the acute level care for hospitalization and can be done on an outpatient basis.  

As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal surgery 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is an adult female who was admitted for lumbar (L) 4-5 decompression and fusion. The patient was given a full-course of pre-operative antibiotics prior to the procedure. The denial was based on the presumption that a full admission was not warranted and the perioperative course was not complicated.  

The records confirm that the patient had L4-5 fusion and had normal postoperative course. On post-operative day one it was noted the claimant received intravenous (IV) fluid and her labs showed hemoglobin of 10 and leukocytosis with white blood cell count of 17. She was evaluated by physical therapy (PT) and she was able to walk with a rolling walker for 15 feet. She was given IV and oral pain medicine and pain was rated three out of ten (3/10). Patient-controlled analgesia (PCA) was discontinued on post-operative day 1. Documentation provided for review did not contain any extenuating circumstances to support the patient would require an inpatient admission. She could have safely been managed at a lower level of care. 

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Significant tooth fracture
Treatment: Core build up and crown (procedure codes D2950, D2740/2790) for tooth number 30
The insurer denied coverage for core build up and crown (procedure codes D2950, D2740/2790) for tooth number 30
The denial is overturned.

Based on the submitted documentation which includes copies of chart progress notes, bitewing and periapical radiographs, and narrative letter from the dentist, in addition to insurer correspondence, it appears that this patient presented for dental care with pain affecting tooth #30. A distal cross fracture was identified with significant structural coronal loss. The dentist is requesting placement of core buildup and full coverage crown due to significant tooth fracture. 

Upon review of radiographs and chart progress notes, these support the recommended treatment. Tooth #30 exhibits a large distal cusp loss with coronal fracture. Prosthetic rehabilitation would require a core buildup. There would then be ample coronal structure remaining after core buildup. This tooth will then have adequate coronal structure for support of a full coverage crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of crown which would have an excellent long-term prognosis with the recommended treatment. Further, the clinical situation meets the insurer criteria for approval. 

The clinical and radiographic documentation supports this service, and they would be a standard of care in general dental practice.

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 core buildup and crown (procedure codes D2950, D2740/2790) for tooth number 30 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The health plan's determination is overturned. 

This is a female diagnosed with obesity. Under review is the use of Wegovy. 

Wegovy is medically necessary for this patient.

Wegovy (semaglutide) is a GLP1R (glucagon-like peptide-1 receptor) agonist that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity. Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. This medication is now available for the treatment of obesity in the form of Wegovy.

The standard of care requires that the patient is participating in lifestyle modification. It also requires that the patient has a body mass index (BMI) of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia. The patient has an approved BMI and is participating in lifestyle modification. The patient has not been successful despite several months of therapy with Qsymia. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: an acute neurologic injury

Treatment: Outpatient Speech Therapy (10 Outpatient visits)

The insurer denied coverage for Outpatient Speech Therapy (10 Outpatient visits)

The denial is upheld.

The documentation provided in this case does not fill the conditions required for medical necessity.  While it is clearly documented that the patient experienced an acute neurologic injury  requiring a craniotomy, extra ventricular drain (EVD) and eventual ventriculoperitoneal shunt (VPS), she underwent appropriate therapy at an acute inpatient rehabilitation hospital, followed by outpatient therapy.  In the case of speech pathology treatment, the notes provided indicate cognitive therapy goals and evidence of improvement, use of internal and external strategies for attention and short-term memory, as well as independence with home exercise program.

Documentation of medical necessity for speech-language pathology includes the following:

1) Functional assessment individual item and summary scores (and comparisons to prior assessment scores) from commercially available therapy outcomes instruments other than those listed above; or
2) Functional assessment scores (and comparisons to prior assessment scores) from tests and measurements validated in the professional literature that are appropriate for the condition/function being measured; or
3) Other measurable progress towards identified goals for functioning in the home environment at the conclusion of this therapy episode of care.

The documentation provided consists of progress notes, which state appropriate measurable goals, however, without the initial and any follow up assessments, the case for medical necessity is unclear.  There is no baseline data provided, nor any standardized/evidence-based tools to measure progress (against an unknown benchmark).

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 Outpatient Speech Therapy (10 Outpatient visits) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple sclerosis.
Treatment: Increase Consumer and Self-Directed Personal Assistance Services to 24 Hours per Day Split Shift (Two 12 Hour Shifts), 7 Days per Week, for a Total of 168 Hours per Week.
The insurer denied: Increase Consumer and Self-Directed Personal Assistance Services to 24 Hours per Day Split Shift (Two 12 Hour Shifts), 7 Days per Week, for a Total of 168 Hours per Week.
The denial is upheld.

The patient is an adult male. Denial of increase consumer and self-directed personal assistance services to 24 hours per day split shift (two 12-hour shifts), 7 days per week, for a total of 168 hours per week is being appealed. He lives with his father. The health plan denied an increase in hours based on the following: Uniform Assessment System evaluation performed 5 months ago showed assistance needed with meal preparation, housekeeping, laundry, shopping, bathing, toileting, dressing, personal hygiene, bed mobility, and eating. He needs help walking and uses a wheelchair and walker for locomotion. The plan recommends physical and occupational therapy to improve ADLs (activities of daily living) and ability to complete personal care.

The requested Increase Consumer and Self-Directed Personal Assistance Services to 24 Hours per Day Split Shift (Two 12 Hour Shifts), 7 Days per Week, for a Total of 168 Hours per Week is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase consumer and self-directed personal assistance services to 24 hours per day split shift (two 12-hour shifts), 7 days per week, for a total of 168 hours per week, is being appealed. Uniform Assessment System evaluation completed 5 months ago shows the patient needs assistance with meal preparation, housekeeping, laundry, shopping, bathing, toileting, dressing, personal hygiene, bed mobility, eating, and walking. There are no clinical records or appeal statements. The information provided does not support the medical necessity for requested live-in consumer and self-directed personal assistance service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental malocclusion.

Treatment: D8080 braces.

The insurer denied coverage for D8080 braces.

The denial is upheld.
 
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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. 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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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 is not substantiated.