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

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Surgical Services (All). 
The insurer denied Outpatient procedure-removal of thyroid and parathyroid glands. 
The denial was overturned. 

The patient is a female with an enlarged thyroid. A sonogram was done showing 2 enlarged right nodules and a fine needle aspiration (FNA) was performed showing cytology Bethesda 3 atypia. The plan is for a right thyroidectomy, possible total thyroidectomy with possible neck dissection. The ultrasound shows an enlarged right lobe of the thyroid recommending a needle aspiration to rule out possible malignancy. A computerized axial tomography (CAT) scan was done of the nasopharynx and also noted an asymmetric enlargement of the right thyroid lobe. In office endoscopy was done without overt pathology except for nasopharyngeal fullness.
At issue is the medical necessity of Outpatient procedure-removal of thyroid and parathyroid glands.

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

The requested health service/treatment of Outpatient procedure-removal of thyroid and parathyroid glands is medically necessary for this patient.
This client has an enlarged thyroid along with thyroid nodules. A biopsy was done which showed atypia. FNA biopsies of the thyroid can show atypia, but surgical removal of the thyroid may confirm the atypia or can also show cancer. If the thyroid is removed in total the parathyroid glands have to be located and potentially removed and replanted. A patient can have thyroid cancer and be otherwise asymptomatic. The FNA did show atypia. Cancer may still be present in an asymptomatic patient and in a patient who has an FNA that does not show cancer and does show atypia. The surgeon is making an informed decision regarding surgery based upon the ultrasound, and the atypia on FNA. This client's history is consistent with the surgery being medically necessary.
Therefore, the Outpatient procedure-removal of thyroid and parathyroid glands is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied the Dupixent.
The determination is upheld.

The patient has atopic dermatitis (AD). The body surface area affected is 70%. She has tried and failed betamethasone, tacrolimus, and Eucrisa. The medication under review is Dupixent.

The requested health treatment of Dupixent is not medically necessary for this patient.
Based on the evidence-based literature, the Dupixent is not medically necessary. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the generic medicines such as methotrexate are effective treatments for the management of atopic dermatitis (1, 2).
Within the peer-reviewed literature, in 2018, Gerbens et al writes "Methotrexate (MTX) and Azathioprine (AZA) seem to be effective and safe as maintenance treatments in moderate to severe AD up to 5 years" (3) Shah et al 2018 writes "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk" (4). There are several published studies that show that methotrexate is effective and safe for moderate-severe atopic dermatitis (5-8). The evidence-based literature is consistent. There are no unique clinical circumstances to this particular patient that would make Dupixent medically necessary. The patient has no true contraindications to the use of the preferred generic medications. The coronavirus (COVID) pandemic is not a true contraindication to the use of methotrexate. The preferred agents, such as methotrexate, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hepatitis C. 
Treatment: Epclusa 400/100 mg daily for 12 weeks. 

The insurer denied Epclusa 400/100 mg daily for 12 weeks. 
The determination is overturned. 

The patient has chronic Hepatitis C, genotype 1a and human immunodeficiency virus coinfection. A FibroScan showed liver stiffness of 7.8 kilopaschals (kPa), consistent with F1 fibrosis. A liver ultrasound in showed a mildly echogenic liver consistent with a history of parenchymal liver disease. The viral load was 7,740,000 international units per milliliter (IU/mL) and genotype was 1a. He was treated with Epclusa for 12 weeks with sustained virologic response. He had a negative Hepatitis C viral load. He subsequently reacquired Hepatitis C; he notes a high-risk exposure. His viral load was 9,660,000 IU/mL, and genotype was 1a. At issue is the medical necessity of the requested Epclusa 400/100 mg daily for 12 weeks for the treatment of chronic Hepatitis C.
The requested Epclusa is medically necessary. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic Hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage [1]. The guidelines recommend that non-cirrhotic genotype 1a patients (in patients such as this patient, in whom no prior therapy has failed) should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 [Sofosbuvir/Velpatasvir Fixed Dose Combination for 12 Weeks in Adults With Chronic HCV Infection] trial [2]. Multiple other studies are cited to support the use of Epclusa [3,4]. American Association for the Study of Liver Diseases (AASLD) / Infectious Diseases Society of America (IDSA) guidelines cite data showing reduced survival with delayed treatment [5]. The formulary alternative, Vosevi, is only recommended in patients who have failed prior therapy-that does not describe the patient in this case. For these reasons, treatment of Hepatitis C is needed, and the requested treatment with Epclusa for 12 weeks is supported as medically necessary for the treatment of this patient's hepatitis C infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Achilles bursitis/tendonitis.
Treatment: Durable medical equipment (Cam walker boot).

The insurer denied coverage for durable medical equipment (Cam walker boot).  The denial is overturned.

The patient has chronic medical problems including cardiovascular disease, chronic obstructive pulmonary disease (COPD) and osteoarthritis.   She was seen by a podiatrist complaining of a 7-week history of sharp, aching pain and swelling to the right Achilles tendon.   The diagnosis was Achilles bursitis/tendonitis.  The treatment plan included compression bandages, stretching, ice, supportive shoes, and steroid medication.  She was seen for follow-up evaluation, with a reported 40% (percent) pain improvement and requested additional treatment options for pain relief.   The doctor provided a Cam walking boot to her right lower extremity which is currently under review.  

The provision of the Cam walker boot was clinically appropriate and medically necessary.   A Cam walker boot is indicated for various conditions including severe ankle sprain, severe ankle or foot fracture, or recent surgery for the foot or ankle; additional indications include soft tissue injuries e.g. Achilles tear/rupture, Achilles bursitis/tendonitis and plantar fasciitis.  The patient's soft tissue injury is appropriate for off-loading with a Cam boot which can benefit healing, recovery and pain relief; while limiting pain exacerbations and maintaining her ability to ambulate.  

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

Based on the above, the medical necessity for the durable medical equipment (Cam walker boot) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Head injury
Treatment: Inpatient stay
The insurer denied the inpatient stay. 

The health plan's determination is upheld. 

This case involves a man brought into the hospital via Emergency Medical Services (EMS) as a level 2 trauma after an unwitnessed fall in the backyard. The patient suffered head trauma and had a loss of consciousness. He regained consciousness 5 minutes later and was brought into the hospital for further evaluation. Glasgow Coma Scale was 15. He had a left occipital scalp hematoma 2 centimeter (cm), with a superficial laceration. Trauma imaging included a computed tomography (CT) scan of the head, which showed mild subarachnoid hemorrhage in the right Sylvian fissure and sulcal area of the right parietal lobe, as well as a small subdural hematoma. A computed tomography (CT) scan of the cervical spine did not show fracture or dislocation. Neurosurgery was consulted, intravenous (IV) fluids were given, and a repeat computed tomography (CT) scan of the head was ordered for 4 hours after the initial one.

Based on the provided documentation, admission to the inpatient level of care is not necessary. In this case, the patient presented to the hospital with syncope/fall. By the time of arrival, he had a Glasgow Coma Scale score of 15, had no focal neurologic deficits, and is only experiencing radiographic abnormalities of mild subarachnoid hemorrhage and a very thin subdural hematoma. After evaluation by neurosurgery, he was deemed stable and monitored on the surgical floor and not in an Intensive Care Unit (ICU) setting. Repeat imaging was stable. The syncope evaluation did not reveal life-threatening conditions. The patient is not chronically anticoagulated; therefore, he was at a lower risk for ongoing bleeding. The entire hospitalization was less than 24 hours, and the patient was deemed stable for release from the hospital. Therefore, a lower level of care is appropriate for this presentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Areata.
Treatment: Xeljanz 5 milligrams (mg).

The insurer is denied coverage for Xeljanz 5 milligrams.  The denial is upheld. 

This female patient has a history of alopecia areata.

The documentation provided does not indicate that the patient has failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, diphenylcyclopropenone (DPCP), calcipotriene, and anthralin. (1-11)  Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata, further studies are needed to demonstrate the long-term efficacy and safety of Xeljanz.  It is noted that the Food and Drug Administration (FDA) released a statement finding increased risk of deep vein thrombosis and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10mg twice daily (bid). (1)  

The standard of care for treatment of alopecia areata would necessitate an attempt to use the above mentioned non-systemic options for the treatment of alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possible improve alopecia areata, including light therapy, squaric acid, DPCP, and anthralin. (7-11)

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 Xeljanz 5 milligrams is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior Crossbite with Gingival Attachment Loss.
Treatment:  Insertion of braces and adjustment of braces.

The insurer denied coverage for insertion of braces and adjustment of braces.  The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist has recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss and other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. 

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, a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of
crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is not met, as there is no evidence of gingival attachment loss or gingival recession; therefore, evidence does not support comprehensive orthodontic care using this criterion.  In this case, the clinical circumstance does not meet criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 18 points (3 overjet, 3 overbite, 10 anterior crowding, 2 labiolingual spread).

The healthcare plan acted reasonably and with sound medical Judgment in the best interest of the patient. 

The insurer's denial of coverage for the insertion of braces and adjustment of braces is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tonic-clonic seizure

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay.

The denial is overturned. 

This male patient has a history of neurofibromatosis.

With a history of neurofibromatosis, there is increased risk of having tumors in the brain. This may not have been seen on computed tomography (CT) done in emergency room (ER). He would need magnetic resonance imaging (MRI) with contrast.

The fact that he had a second witnessed seizure in the ER puts him at a very high risk for recurrent seizure. In addition, they had given him Ativan, which would have made him very drowsy with recurrent seizure. The first 24 hours are very crucial, and they need to be observed in the hospital.

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

The carrier's denial of coverage for inpatient stay is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient rehabilitation (sub-acute rehab level 2). 
The denial is upheld.

The patient is a male who underwent bilateral total hip arthroplasties and was admitted to Subacute Rehab. The subject under review is the medical necessity for continued inpatient rehabilitation (sub-acute rehab level 2).

All documentation was reviewed. Continued stay at inpatient rehabilitation, Subacute Rehab level 2, is not medically necessary for this patient. Documentation fails stop support ongoing skilled nursing need, physician oversight and continued Subacute level of physical therapy (PT)/occupational therapy (OT). The patient is at a functional level where he is safe to discharge to a lower level of care. For example, the patient was modified independent (MODI) for sit to stand transfers and standing. Additionally, he was able to ambulate 100 feet (') with wheeled walker (WW) and supervision. Physical therapy progress notes also documented that the patient was MODI for transfers. His records show that he lives in a 1 story home with 1 step to enter and therapy noted that the patient could negotiate 4 steps with bilateral handrails stand by assist (SBA). Documentation continued to show progress, the patient was ambulating 150' with WW MODI, and MODI with hygiene/grooming, simple meal prep and tub bench transfer. The patient appeared to plateau as gait distance continued to be 150' with WW MODI and hygiene/grooming, tub bench transfer remained MODI. While the patient had regressed to negotiating 3 steps with bilateral crutches with SBA, he lived in a home with only 1 step to enter making discharge appropriate - especially since he was negotiating 4 steps with supervision. Ambulation distance fluctuated between 100 feet and 150 feet with SBA to MODI but, again, this is appropriate distance for discharge to a lower level of care. Lastly, despite the physician's assistant noting concerns for urinary tract infection (UTI) and start of treatment for UTI this does not support a continued inpatient subacute rehab stay as the medically was medically stable and antibiotic was one daily and given by mouth. For all of these reasons the patient was safe to discharge to a lower level of care and it was not medically necessary for continued stay at Subacute Rehab level 2.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an increase in PCA hours. 
The denial was upheld. 

The patient is a female with a past medical history significant for hypertension, generalized weakness, gait abnormality, urinary incontinence, syncope, hyperlipidemia, multiple falls, and history of nontraumatic subarachnoid hemorrhage. She has had several falls resulting in hospitalization.  The plan has approved 84 hours a week of services. The patient is appealing that decision.
At issue is the increase in Personal Care Assistance (PCA), 24 hours per day (two split shifts), 7 days per week, a total of 168 hours per week.

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

The requested health service/treatment of  Increase in Personal Care Assistance (PCA), 24 hours per day (two split shifts), 7 days per week, a total of 168 hours is not medically necessary for this patient.
The patient's family requested additional services which were requested because the patient has dementia and frequent falls in the middle of the night. The health plan denied additional services due to medical necessity. The patient has multiple medical problems and generalized decline in her overall health status in regard to gait and cognitive abilities. She currently receives 84 hours a week of services to help with her activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. She is dependent on services for most of the tasks.
There was notation that the patient did have a fall earlier in the summer resulting in a fracture. This occurred when the patient was confused and when outside. While this is a concern however, for services, there must be a demonstrated need for ADLs or IADLs above and beyond observation and preventing falls. Services for preventing falls and observation are typically included in the provided services allowed for under the evaluation. Specifically, a service must be performed such as in an ADL or IADL. PCA services for watching the patient in the middle of the night without performing a medically necessary ADL would be considered observation and typically not considered medically necessary. The documentation provided did not note specific needs for 12 hours a day, 7 days a week, split shift beyond those services.
Therefore, the requested health service/treatment of  Increase in Personal Care Assistance (PCA), 24 hours per day (two split shifts), 7 days per week, a total of 168 hours is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity.
Treatment: Liver Biopsy.

The health plan denied the requested liver biopsy as not medically necessary.  The health plan's determination is upheld.

This patient is a female with a history of morbid obesity who underwent laparoscopic Roux en y gastric bypass, at which time a wedge liver biopsy was performed. Preoperative liver function tests (LFTs) and/or history or clinical concern related to fatty liver/ non-alcoholic steatohepatitis (NASH) / nonalcoholic fatty liver disease (NAFLD) was not provided for review. Pathology revealed subcapsular wedge biopsy with mild steatosis and no fibrosis.

At issue is the medical necessity of the liver biopsy performed.

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

There is currently a lack of any national guideline from the American Society for Metabolic and Bariatric Surgery (ASMBS) or large high level prospective trial or randomized controlled trial (RCT) documenting any benefit from routine liver biopsy during bariatric surgery. There is no clear outcomes benefit to perform liver biopsy in patients with normal synthetic liver function tests (LFTs) or who do not carry a clinical diagnosis of NASH, as most patients will not undergo subsequent re-biopsy of the liver to actually document improvement/progression. Separately, there remains controversy over the best method of liver biopsy. In general, when overall liver evaluation is sought, a long core needle biopsy (performed via tru cut or core needle) can provide better information about the parenchyma and can include multiple passes, 1 to 2 centimeter (cm) in length by about 0.2 cm in width. Although wedge liver biopsy will afford a larger amount of overall liver tissue (tissue sample), it is often taken from the edges of the left lobe of the liver (which is more steatotic) are often subcapsular, and therefore may give the false impression of increased fibrosis. Although both are generally safe procedures, there are known complications that can occur, primarily bleeding, that do not support routine practice without a clear clinical indication of how the information is going to be tracked, or utilized, given that most patients will improve any degree of NASH/NAFLD after successful bariatric surgery/weight loss.