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

Diagnosis: diabetic ketoacidosis
Treatment; Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

The patient is a male with past medical history of type one diabetes, coronary artery disease (CAD) / coronary artery bypass graft (CABG), and seizure disorder, who presented for abdominal pain and hyperglycemia. Review of system was negative for additional clinical symptoms. The patient was admitted for diabetic ketoacidosis. 

The inpatient admission was medically necessary. The care could not have been safely rendered at a lower level.
The documentation supports the inpatient level of care based on the presence of clinical signs and symptoms consistent with dehydration and Diabetic Ketoacidosis (DKA). DKA can be a life-threatening medical emergency. The patient had a significantly elevated plasma glucose, decrease in serum bicarbonate, and an elevated anion gap. As such, inpatient level of care for intravenous (IV) fluids, electrolyte stabilization/monitoring and intravenous insulin were necessary for the entire length of stay. Without proper hydration and aggressive insulin treatment, patients can rapidly re-enter the DKA phase requiring intensive level of care or insulin drip and close monitoring. In this case, the patient had evidence of DKA, poorly controlled diabetes and associated hyperglycemic crisis. The Inpatient level of care is justified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied braces and monthly visits (12 units). 
The denial is overturned. 

The patient is a male with a Class I occlusion with 3 millimeter (mm) overjet. He has a 100% overbite, and the cephalometric radiograph indicates he is biting on his palate. He has moderate maxillary spacing and minor mandibular crowing. He is missing a mandibular incisor. He is treatment planned for orthodontics to correct his malocclusion which was denied by the plan on the basis that treatment is not medically necessary. 

The health plan's determination is overturned. 

His overbite is deep and there appears to be some recession developing on the lingual gingival margins of the upper central incisors. His cephalometric radiograph shows the lower incisors are contacting the palate in occlusion. There is scientific evidence correlating deep anterior overbite with gingival contact and periodontal disease. [1] 
The patient's occlusion is causing his lower incisors to contact right at the lingual gingival margin of the maxillary incisors. This is a traumatic occlusion. Not only does it have a positive correlation with periodontal disease, but studies also indicate an increased appearance of periodontal radiolucencies on the maxillary incisors. [1] It is believed these periodontal lesions are related to gingival surface injury and food impaction due to the deep bite. [2] Therefore, correcting the patient's malocclusion with orthodontic treatment will create a clinically significant improvement in the patient's periodontal health. Braces and monthly visits (12 units) are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision. 
Treatment: Surgical Services. 
The insurer denied upper eyelid surgery. 
The denial is overturned.

The patient is a female who presented for blepharoplasty. The patient has symptomatic ptosis which is improved when lifting her eyebrows/eyelids. Marginal reflex distance is 1 millimeter (mm) right eye and 1.5 mm left eye. There was a visual improvement of 400% in the right eye and 150% in the left eye with elevation of the eyelid on visual field testing. The subject under review is the medical necessity for upper eyelid surgery. 

The requested upper eyelid surgery is medically necessary for this patient.
The patient has documented ptosis with a marginal reflex distance less than 2 mm. She also has demonstrated loss superior visual field which can be improved significantly with lifting the eyelid up.
Superior visual field loss can be a significant impairment to ones quality of life. A superior eyelid surgery would be medically necessary to improve this patients ptosis and improve her quality of life.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cow's milk allergy
Treatment: Xolair
The insurer denied Xolair.
The health plan's determination is overturned. 

The patient is a woman with asthma and anaphylactic reaction to cow's milk and is under the care of an allergist/immunologist. She used Xolair 300 milligrams (mg) every 4 weeks to tolerate cow's milk oral immunotherapy successfully. A trial off Xolair saw recurrence of her cow's milk allergy. Continuation of Xolair 300 mg every 4 weeks is under review.

Xolair has proven its benefit for this patient. Xolair has made cow's milk oral immunotherapy possible, safe, and effective. A trial of Xolair cessation failed. In order to reduce this patient's episodes of anaphylaxis due to cow's milk, Xolair continuation is medically necessary and in the best interest of the patient despite its current off-label use.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids.
Treatment: Surgery (myomectomy or hysterectomy using power morcellation).
The insurer denied Surgery (myomectomy or hysterectomy using power morcellation).
The denial is upheld.

The patient is a female who presented complaining of menopausal symptoms. Her hormonal testing was consistent with menopause. She was interested in hormone replacement therapy. The patient has a known fibroid uterus for which she underwent embolization. The patient was not complaining of any symptoms related to her fibroid. The provider told the patient that if she was to receive estrogen replacement therapy for her menopausal symptoms then the fibroid may grow. The patient underwent a hysterectomy for dysfunctional bleeding and an enlarged uterus. The procedure performed was a laparoscopic total hysterectomy; it was done in conjunction with a laparoscopic colpopexy.

No, the health plan should not cover the proposed treatment.

The patient was menopausal. In addition, she did not have any symptoms related to her fibroid. With menopause, the fibroid will shrink in size. Based on the submitted information, the patient underwent a hysterectomy because she was concerned that receiving hormone replacement therapy may grow the fibroid. This is not an accurate representation as there are multiple treatments that could manage this patient's menopausal symptoms without growing her fibroids.

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.

There was no clinical indication for a hysterectomy in this patient as she has an asymptomatic fibroid. The patient could have just been observed.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids.
Treatment: Surgery (myomectomy or hysterectomy using power morcellation)
The insurer denied Surgery (myomectomy or hysterectomy using power morcellation).
The denial is upheld.

The patient is a female with symptomatic uterine myomas who underwent a total laparoscopic hysterectomy with power morcellation of the uterine myomas. Coverage was denied because power morcellation is considered to be experimental given the lack of proven long term safety.

No, the health plan should not cover the proposed treatment.

Although the patient is pre-menopausal since she has not been without a period for one year or longer, there is no documentation to show that she is not at risk of sarcoma or that she was counseled on the risk of morcellation and its potential impact if she had a sarcoma. That is, the patient would not meet exception criteria given the above noted facts for power morcellation. Outside of exception criteria, power morcellation is considered to be experimental given the lack of proven long term safety.

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.

There are no data to show that power morcellation is safe given the associated risk of sarcoma in one out of 300 myomas and the fact that power morcellation lacks safety data from well conducted prospective studies.
Appeal type: Formulary Exception
Decision: Overturned in Part

Diagnosis: Sickle Cell Anemia. 
Treatment: Jadenu. 

The insurer denied Jadenu.  The denial is upheld.

The patient is a This is a female with sickle cell anemia. The patient has iron overload. Jadenu has been requested but was denied, as the patient has not failed the formulary alternatives.

The health plan's determination is upheld.

There is a paucity of evidence that the formulary option, deferiprone is inferior to deferasirox (Jadenu). The former does carry the potential side effect of agranulocytosis, but this can be mitigated by following the Food and Drug Administration (FDA)-recommended weekly neutrophil counts. The patient has no documented contraindications to deferiprone therapy, such as severe liver dysfunction. The two agents have not been compared directly with regard to safety or efficacy, and both are considered reasonable options in the peer-reviewed literature (NEJM) and by the authors of UpToDate. There is no reason why the patient cannot use the formulary alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Skyrizi Pen 150 milligrams/milliliter (mg/ml) injection.

The insurer denied coverage for Skyrizi Pen 150 milligrams/milliliter (mg/ml) injection.  The denial is upheld.

The patient is a male with a diagnosis of psoriasis. The patient has failed therapy with topical steroids and calcipotriene. The requested medication is Skyrizi.

Based on the submitted documentation and the standard of care, Skyrizi is not medically necessary. The patient has failed topical therapy and has no true contraindications to numerous appropriate available treatment modalities, which would make the use of Skyrizi medically necessary. There is no comparative, controlled head-to-head studies showing that Skyrizi has a superior efficacy or safety profile to reasonable alternatives such as Humira or phototherapy.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, alternative effective treatments for the management of psoriasis are available and appropriate for this patient. 

There is no documentation to suggest that Skyrizi would be more effective than available formulary alternatives. The patient is reported to have an elevated ALT (alanine transaminase), which would still not preclude the use of biologics known to effectively treat psoriasis. The appeal is upheld in whole.  

The insurer's denial of coverage for Skyrizi Pen 150 milligrams/milliliter (mg/ml) injection (inj) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the emergency department (ED) with abdominal pain. Significantly, the patient had undergone Roux en Y gastric bypass. He was tender in the epigastrium with radiation to the right lower quadrant for 4-days. His initial evaluation included lab data that identified a normal white blood cell count (WBC) count of 9.1 thousand (K). A computed tomography (CT) scan identified a 4 x 3.5-centimeter (cm) phlegmon of the distal colon. He was treated with intravenous (IV) antibiotics, intravenous (IV) fluid and nothing by mouth (NPO) status. A surgical consultation was obtained. He was admitted to the hospital. The patient was receiving IV antibiotics and he was maintained with NPO (nothing by mouth) status. He was receiving IV fluid. He had abdominal tenderness and was receiving pain medications. The patient had less abdominal tenderness and he was started on a clear liquid diet. The WBC count was down to 6.9 K. He demonstrated continued clinical improvement with less midepigastric tenderness and no peritoneal signs. Once he demonstrated tolerance of the diet he was discharged from the hospital. Further outpatient follow up was planned.
At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was medically necessary and consistent with the standard of care. The patient presented with an acute inflammatory process that manifested with abdominal pain. The CT scan showed a phlegmonous mass in the pericolic area. The patient was appropriately admitted to the hospital. At this time, based on his presenting condition, his post-surgical state (having undergone gastric bypass surgery), the CT scan findings, and the reasonable clinical expectation that he would require at least 2-nights in the hospital during a period of NPO status and provision of IV antibiotics, it was appropriate to admit him to an inpatient status. The patient was treated with IV fluids and IV antibiotics with clinical improvement. The records provide a complete and thorough justification for an inpatient level of care. There was also the reasonable expectation that had this therapy not been provided then his clinical condition could have deteriorated with adverse clinical outcome. He was discharged from the inpatient setting with plans for further outpatient follow up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain

Treatment: Lidocaine 5% Patch

The insurer denied coverage for Lidocaine 5% Patch
The denial is upheld

This woman has a history of depression, bilateral osteoarthritis status post partial left knee replacement, sacroiliitis, and chronic lumbar herniated discs. The request is for continuation of Lidoderm patches for low back pain and sacroiliitis.

Santana et al. (1) conducted a literature review of the use of Lidoderm patches for low back pain:

A systematic search method revealed seven articles that fit the inclusion criteria. For each study, efficacy, effectiveness, and adverse events data was extracted. We found no randomized controlled trials with substantial evidence to support the use of 5LP (5% lidocaine patch) in CLBP (chronic low back pain), despite the presence of nonrandomized noncontrolled trials suggesting its effectiveness for relief of pain. Future randomized controlled trials with clinically useful outcomes are needed to assess the efficacy, effectiveness, and safety of 5LP for CLBP more appropriately.

A Cochrane review of Lidoderm patches for neuropathic pain (2) did not find robust evidence for off-label use:

This review found no evidence from good quality randomized controlled studies to support the use of topical lidocaine to treat neuropathic pain, although individual studies indicated that it was effective for relief of pain.

The requested medication would be an off-label use which is not supported by evidence-based studies.

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

The insurer's denial of coverage for the medication Lidocaine 5% Patch is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyshidrotic eczema
Treatment: Dupixent 300 milligrams per 2 milliliters (300 mg/2 ml) subcutaneous (SC) solution prefilled syringe (SOSY)
The insurer denied coverage for Dupixent 300 mg/2 ml SC SOSY
The denial is upheld

The patient is a male with a diagnosis of dyshidrotic eczema affecting the toes and feet. The patient has failed therapy with clobetasol and eucrisa. The patient is suspected of possibly having an environmental dermatitis and is on allergen immunotherapy. The patient was recently given tacrolimus ointment to start but we do not have follow up yet as to this new treatment modality as it was recently started. The notes indicate that a dermatologist discussed light therapy, but he has yet to start light therapy. The documentation provided does not indicate that the patient has a diagnosis of atopic dermatitis. The requested medication is Dupixent.  

Based on the submitted documentation, the use of Dupixent is not medically necessary. Dupixent is not currently Food and Drug Administration (FDA) approved for dyshidrotic eczema. Furthermore, the patient has not failed tacrolimus ointment or localized light therapy. The documentation provided does not provide any absolute contraindications to treatments commonly used for and known to improve dyshidrotic eczema, including tacrolimus ointment, light therapy, and methotrexate.  

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

The insurer's denial of coverage for Dupixent 300 milligrams per 2 milliliters (300 mg/2 ml) subcutaneous (SC) solution prefilled syringe (SOSY) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 
Treatment: Inpatient Hospital Stay 
The insurer denied the inpatient hospital stay. 
The denial is upheld.

The patient is a male with a past medical history significant for nephrolithiasis who presented to the emergency department with complaints of right flank pain and upper abdominal pain. The right flank pain was intermittent. It started approximately five months before the presentation. The upper abdominal pain became worse within 4-5 days before the presentation. The patient described the pain as moderate in intensity. He denied fever, dysuria, hesitancy, and urinary incontinence. They recommended endoscopic ultrasound and biopsy of the ambulatory lesion. Additional laboratory studies such as carcinoembryonic antigen (CEA) and chronological age (CA) 19-9 were sent. The patient was seen by a gastrointestinal (GI) specialist and underwent a colonoscopy. The study was interpreted as unremarkable.

During the hospital stay, liver function tests (LFTs) were checked on several occasions. They were trending down. It was suggested that the patient likely passed a stone. Since the patient's pain improved, he was discharged home in stable clinical condition.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

There was no compelling clinical reason the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.

Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.

The abdominal pain was most likely related to a passing biliary stone and was not associated with hemodynamic instability or peritoneal signs on exam.

There was no evidence that the abdominal pain was the result of serious medical conditions such as aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, or intestinal obstruction.

There was no mention that the abdominal pain was associated with bacteremia or toxic megacolon.

The evaluation of the abdominal pain did not require the patient not to eat or drink for an extended period of time.

Furthermore, it was clearly indicated that the patient's clinical condition was improving steadily.

The hospital stay was within the scope of an inpatient care, to perform serial abdominal exams and ensure improvement in the patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, dementia and multiple thyroid nodules.
Treatment: Increase Personal Care Aide (PCA) Services to the Amount of 84 Hours per Week.
The insurer denied the Increase Personal Care Aide (PCA) Services to the Amount of 84 Hours per Week.
The denial is overturned.

The patient is a female who reportedly has multiple co-morbidities including diabetes mellitus (DM), hypertension (HTN), coronary artery disease (CAD), claudication of right lower extremity, dementia and multiple thyroid nodules. The request is for an increase in personal care services. The patient has progressive functional decline. She lives alone. She needs help with all her activities of daily living (ADLs). 

This is a review for an increase in personal care aide (PCA) services to 84 hours per week.

Yes, the proposed increase in personal care aide services to 84 hour per week is medically necessary.

This patient has multiple comorbidities and needs help with all her activities of daily living (ADLs). She lives alone on the second floor. She has recent functional decline in the past 90 days due to a fall and leg fracture. She has urinary incontinence as well. She has difficulty walking and is having dizziness on ambulation. She needs reminders for her medications. She needs more hours to ensure safety. 

The health plan approved personal care aide services, level II: six hours per day - seven days per week, for a total of 42 hours per week is not enough to meet this patient's needs.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient needs extended hours.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Above knee amputation. 
Treatment: Durable Medical Equipment (L5856 x1 -electric knee-shin swing/stance). 
The insurer denied the Durable Medical Equipment (L5856 x1 -electric knee-shin swing/stance). 
The denial is upheld. 

The patient is a male with history of LEFT Above-knee Amputation (AKA) Transfemoral amputation. He is using an AKA (above knee amputation)-prosthetic. He is complaining of instability with current non-electric knee-component of his AKA (above knee amputation)-prosthetics. He is therefore asking for an electric Knee-shin, because he cannot afford any instability, as this will pose a risk to him in his functionality, which requires the ability to walk backwards, take sidesteps, make rapid changes in direction, step over obstacles and ascend stairs. He is retired and walks regularly, including walking his dog. 

The request is for an electric Knee-shin stance phase (a microprocessor knee) component to his AKA (above knee amputation) prosthetics. 

The patient had AMPnoPro (Amputee Mobility Predictor without prosthesis) test performed, which confirmed his K3 (Ability or potential to ambulate with variable cadence) functional level. He has been able to use a loaner microprocessor knee component with improved functionality. 

The patient has a Below-Knee-Amputation (BKA) on the RIGHT side, making him a double amputee. 

No, the requested Durable Medical Equipment (L5856 x1 -electric knee-shin swing/stance) is not medically necessary. 
The requested electric knee-shin, MPK (microprocessor-controlled prosthetic knee) microprocessor component for his AKA (above knee amputation)-prosthetics is not medically necessary, as this is mainly for the convenience of the patient. 

This is not medically necessary, as the new component is mainly for the convenience of the patient. It is not consistent with the type of prosthetics for normal use. It is not consistent with basic prosthetics under generally accepted standards of medical practice. It is not the most conservative type of prosthetics available for an AKA (above knee amputation) amputee's safe and effective management, and alternatives with the basic mechanical component will meet the needs of the patient for normal ambulation and gait. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The requested electric Knee-Shin is not medically necessary, as there is an alternative knee component that can do the same job.  Denying this request is not reasonably expected to affect the patient's health adversely.