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

Diagnosis: Atrial Fibrillation.
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission.
The denial is overturned.

The patient is a male with a history of chronic obstructive pulmonary disease (COPD) and osteoarthritis (OSA). He was recently diagnosed with metastatic lung cancer with brain metastases. The patient had been scheduled for Gamma knife treatment.

The patient presented to the hospital with complaints of (C/O) chest pain and shortness of breath (SOB). Pain was pleuritic in nature. Vital signs (V/S) at presentation were as follows: temperature 99.4 F (Fahrenheit), heart Rate 73, respiratory rate 32, blood pressure 129/85 mm Hg (millimeters of mercury), oxygen (O2) saturations 97% on 2L (liters) nasal cannula (NC), O2 (oxygen) saturation was 87% on RA (room air) on exertion.

The patient had a computed tomography Angiogram (CTA) performed for high suspicion of a pulmonary embolism (PE). A CTA revealed a pulmonary embolism with possible right heart Strain.

The patient was also found to have new onset of A Fib (Atrial Fibrillation).

Given his metastatic lung cancer with brain metastasis, the possibility of an IC (intracranial) bleed, the presence of a PE with a new onset of A fib, and a possible right heart strain it was decided to admit the patient for AC (anti-coagulant) therapy with intravenous (IV) Heparin.

The patient was admitted to a Telemetry bed.

The patient had an ECHO (echocardiogram) performed which revealed a mild RA (right arterial) and RV (right ventricular) dilatation and also mild PHTN (pulmonary hypertension).

This patient was at high risk for bleeding complications. Moreover, he had a new onset of A fib at presentation. The patient was desaturating on exertion. Also, there was the possibility of right heart strain. Given all the above it was appropriate to admit the patient. He was not stable enough to be treated in any other setting. The patient was treated with IV Metoprolol for A Fib with the rapid ventricular response (VR).

The patient remained stable after admission. He was evaluated by a Pulmonary Critical Care team. The patient's A-Fib converted back to NSR (normal sinus rhythm). The patient was bridged to Oral ACs. Home O2 was arranged, and the patient was discharged home with close follow-up in an outpatient setting.

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

The insurer's denial of coverage for full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetic Ketoacidosis.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay. 
The health plan's determination is upheld.

This case involves a man with a history of methicillin-susceptible staphylococcus aureus (MSSA) bacteremia, type 1 diabetes mellitus with a history of diabetic ketoacidosis, pulmonary hypertension, and intravenous (IV) drug use, who presented to the hospital with left rib pain, abdominal pain, nausea, and vomiting. The patient suffered a fall 2 days before presentation while in the shower, landing on the left chest. Subsequently, he developed epigastric abdominal pain with nausea and vomiting. He has not taken insulin for two days but used IV cocaine. He currently resides in a shelter and is wheelchair-bound.
On assessment, his glucose is 417, with a bicarb of 12, a beta-hydroxybutyrate of 4.4, and an anion gap of 30. Symptoms are consistent with diabetic ketoacidosis (DKA). Imaging showed no rib fractures or pneumothorax. He was being admitted for diabetic ketoacidosis treatment.
The patient's blood pressure was 104/73 millimeters of mercury (mmHg), with a pulse rate of 86 beats per minute (bpm), and respirations of 16/per minute. The rest of the labs show a creatinine of 1, negative troponin, and fairly stable liver function tests.
The medical team started an insulin drip, every 4 hours basic metabolic panel (BMP), and IV saline. The patient was restarted on 160 mg of Methadone, which he uses chronically.
With this appropriate treatment, the patient's labs improved on serial checks. Blood sugars decreased to the 200s, the anion gap normalized, and the bicarbonate improved to 21. When the medical team assessed the patient, they felt he was cleared for discharge. He wanted to leave immediately, refusing to wait for transportation back to the shelter, waiting to sign the Against Medical Advice order. The patient left the hospital.
At issue is the medical necessity for an inpatient level of care.

I uphold, on whole, the health plan's determination of medical necessity.

No. Inpatient hospitalization is not warranted in this case. The patient did not have ongoing medical needs or active comorbidities that warranted inpatient hospitalization. An alternate level of care would have been appropriate for this patient. The patient, in this case, has type 1 diabetes mellitus and endorsed not taking insulin for two days, hence developing diabetic ketoacidosis. After appropriate treatment per DKA protocol with insulin and IV fluids, the anion gap closed, glucose values normalized, and the patient was transitioned to subcutaneous insulin. There is no evidence of severe dehydration, infectious causes of DKA, alteration of mental status, or hemodynamic instability. Within 24 hours of hospitalization, the patient's diabetic ketoacidosis has resolved, and he is deemed stable for discharge. Based on nationally excepted guidelines for the treatment of diabetes, this presentation can be managed under an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crowding and deep bite.
Treatment: D8080 comprehensive orthodontic care.
The insurer denied coverage for D8080 comprehensive orthodontic care.
The denial is upheld.


Upon review of the submitted documentation including two intraoral images, panoramic and cephalometric radiographs from the orthodontist and insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crowding and deep bite. He has recommended orthodontics. The orthodontist has NOT completed the HLD (Handicapping Labio-Lingual Deviation) index, nor has he submitted any other clinical or radiographic information to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining only 23 points on the HLD  index report by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review), it is evident that the patient exhibits 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 Labio-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 does not claim an automatic qualifying condition, nor does he complete the HLD index. This reviewer concurs with the index completed by the insurer attaining a total of 23 points on the HLD index (4 overjet, 6 overbites, 10 anterior crowdings, 3 labiolingual spread) which is below the threshold of 26 points to support 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 needs is a valid approach. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic needs. 

In this case, the orthodontist did not submit adequate or complete information to justify orthodontic care.

D8080 comprehensive orthodontic treatment of the adolescent dentition is not considered medically necessary for this patient.

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

The insurer's denial of coverage for D8080 comprehensive orthodontic treatment of adolescent dentition is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intracept Procedure (interosseous basivertebal nerve ablation).
The insurer denied the Intracept Procedure.
The determination is upheld.

The patient has chronic low back pain which has been present for many years. The pain is mainly axial and impacts his daily living activities. He has been unable to do any of his activities. Prior treatments have included chiropractic treatment. The physical exam of the lumbar spine demonstrated a pain score of 9 out of 10, the strength is full in the lower extremities, and he has pain with extension facet loading. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated multilevel degenerative changes. The Intracept procedure is under review.

The proposed health service or treatment Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has complaints of low back pain and there is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is a lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment of Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intracept Procedure (interosseous basivertebal nerve ablation).
The insurer denied the Intracept Procedure.
The determination is upheld.

The patient has a history of low back pain for several years. He has axial back pain, right greater than left, with no leg pain. His pain is worse with flexion and extension. He had tried pain medications including Tylenol and nonsteroidal anti-inflammatory drugs (NSAIDs) without relief. Chiropractic manipulation provided some improvement. The physical exam (PE) showed back pain with extension and facet loading, pain with flexion. Lumbar magnetic resonance imaging (MRI) images showed findings of Modic changes and facet arthropathy. The patient was recommended to have lumbar medial branch nerve blocks and the Intracept procedure.
The issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment is not likely to be more beneficial than standard treatments for the insured's medical condition.
The Intracept system was designed to treat low back pain from the vertebral body by ablating intraosseous nerves. This patient has a history of back pain. The physical exam revealed positive facet loading tests. MRI images showed findings consistent with Modic changes and facet arthropathy. Current clinical studies support the efficacy of the Intracept procedure for vertebrogenic back pain. However, patients with radiographic evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies. Ref 1. ( table 1 exclusion criteria in this study). The patient was also recommended to have lumbar Medical branch blocks, which is an intervention for facet joint pain. Therefore, this patient is not an appropriate candidate for the Intracept procedure based upon current clinical evidence.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Eliquis. 
The denial is upheld.

This patient is a female with a history of essential hypertension, gastroesophageal reflux disease (GERD), obesity, and total abdominal hysterectomy (TAH)/bilateral salpingo-oophorectomy (BSO). Records indicate that the patient developed palpitations after her TAH and was found to be in atrial fibrillation. At that time, she was started on metoprolol and apixaban for stroke prevention then she converted back to normal sinus rhythm later that day. She was seen in the office by her Cardiologist and records show she was doing well. The electrocardiogram (ECG) revealed normal sinus rhythm. The patient's health plan has denied coverage for prescription benefit exception for Eliquis (apixaban) on the grounds the patient has not met plan criteria documenting contraindication, intolerance, or anticipated adverse reaction to the plan's formulary anticoagulants, warfarin and Xarelto. The patient's provider is appealing this denial.
At issue is the whether the formulary drugs, will be or have been ineffective, would not be as effective as the non-formulary drug, Eliquis, or would have adverse effects.

The health plan's determination is upheld in whole.

The formulary drugs have not been ineffective, would be as effective as the non-formulary drug, Eliquis, and would not have adverse effects.
There is no documentation indicating contraindication, intolerance, or anticipated adverse reaction to the plan's formulary anticoagulants, warfarin and Xarelto. Furthermore, according to the 2019 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation, the formulary anticoagulant, Xarelto, is an appropriate medication to reduce the risk of stroke and systemic embolism in this case. (1) There is no contraindication indicated.
Therefore, the formulary drugs have not been ineffective, would be as effective as the non-formulary drug, Eliquis, and would not have adverse effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I malocclusion. 
Treatment: D8080 - Comprehensive Orthodontic Treatment of the Adolescent Dentition
D8670 - Periodic Orthodontic Treatment Visit. 
The insurer denied the D8080 - Comprehensive Orthodontic Treatment of the Adolescent Dentition and D8670 - Periodic Orthodontic Treatment Visit. 
The denial is upheld. 

The patient is a female with Class I skeletal and soft tissue profiles.  The patient has permanent dentition in Class I malocclusion.  She has mild spacing and rotation in her upper arch and moderate crowding in her lower arch, with a significantly rotated lower left canine. 

No, the requested orthodontic treatment is not medically necessary for this patient. 
The New York State Medicaid Program Orthodontic Criteria requires: 
(a) severe physically handicapping malocclusion with a Handicapping Labio-Lingual Deviation Index score of 26 or higher; or 
(b) have one of the following automatic qualifying conditions: Anterior crossbite, Posterior crossbite, Cleft palate or cranio-facial anomaly, Severe traumatic deviation, Deep impinging overbite with severe soft tissue damage, Impacted permanent anterior teeth where extraction is not indicated, or Overjet greater than nine millimeters with incompetent lips or reverse overjet greater than 3.5 millimeters with reported masticatory or speech difficulties. 

There was no medical evidence provided that the patient has any impairment due to the position of her teeth. Thus, the requested braces are not needed to address eating, speech, breathing difficulties or to prevent permanent damage to the teeth or to the bones or soft tissues of the mouth. In addition, the patient's calculated Handicapping Labio-lingual Deviation Index (HLD) Index score is found to be 14, which does not qualify her for braces. Given all of the above, the braces are not medically necessary as the patient does not have any auto-qualifiers for the requested treatment and the patient did not score 26 on the Handicapping Labio-Lingual Deviation Index. 

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

The health plan made their decision based on the New York State Medicaid Program requirements. Their decision was based on the Handicapping Labio-Lingual Deviation (HLD) Index score and lack of medical evidence to establish a medical reason that braces would be necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endometrial cancer.
Treatment: Lenvima.

The insurer denied coverage for Lenvima.  The denial is upheld.

This is a patient with relapsed endometrial cancer.  She initially completed six cycles of adjuvant chemotherapy and radiation therapy for stage IIIA. A current computed tomography (CT) scan showed disease progression in the bilateral inguinal nodes. A biopsy was performed. Lenvima was recommended. The insurer indicates they cover Lenvima for endometrial carcinoma, if the disease is not microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR). The patient's tumor is diffusely positive for proteins MSH2, MSH6, negative for PMS2, and MLH1 was in progress.

The Food and Drug Administration (FDA) has granted an accelerated approval to the combination of pembrolizumab (Keytruda) and lenvatinib (Lenvima) for the treatment of patients with advanced endometrial cancer who have disease progression following prior systemic therapy. The indication applies to patients who are not candidates for curative surgery or radiation and who have disease that is not MSI-H or dMMR.    

Lenvima is not considered medically necessary for this patient.

There is only an accelerated approval and no literature to support its use in patients, unlike those in the single study upon which accelerated approval was given.

"Lenvatinib is FDA approved for the treatment of radioactive iodine-refractory differentiated thyroid cancer (DTC), unresectable or advanced hepatocellular carcinoma (HCC), and advanced renal cell carcinoma (RCC). It is a multiple receptor tyrosine kinase inhibitor that demonstrates potent antiangiogenic properties." (Padda, I. S., & Parmar, M. 2022)

"On September 17, 2019, the Food and Drug Administration granted accelerated approval to the combination of pembrolizumab (KEYTRUDA, Merck) plus lenvatinib (LENVIMA, Eisai) for the treatment of patients with advanced endometrial carcinoma that is not MSI-H or dMMR and who have disease progression following prior systemic therapy but are not candidates for curative surgery or radiation." (US Food and Drug Administration. 2019)

"INDICATIONS AND USAGE: LENVIMA is a kinase inhibitor that is indicated:

1) For the treatment of patients with locally recurrent or metastatic, progressive, radioactive iodine-refractory DTC. 
2) In combination with everolimus, for the treatment of patients with advanced renal cell carcinoma RCC following one prior antiangiogenic therapy. 
3) For the first-line treatment of patients with unresectable HCC. 
4) In combination with pembrolizumab, for the treatment of patients with advanced endometrial carcinoma that is not MSI-H or dMMR who have disease progression following prior systemic therapy in any setting and are not candidates for curative surgery or radiation." (Levatinib Package Insert)

The health care plan did act reasonably with sound medical judgment. 

The insurer's denial of coverage for Lenvima is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara 90 milligrams (mg) every 4 weeks
The insurer denied: Stelara 90 milligrams (mg) every 4 weeks
The denial is: Overturned

The patient is a female with Crohn's disease. She has failed Remicade and Humira. She started Stelara six years ago. Colonoscopy with biopsies  showed inflammation throughout the colon. Stelara was increased to 90 milligrams (mg) every four weeks, and she has been in remission. The subject under review is the medical necessity for Stelara 90 mg every four weeks.

Stelara 90 mg every 4 weeks is supported as medically necessary in this case by current medical literature. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease [1-3]. Guidelines for the treatment of Crohn's disease recommend the use of Stelara [4]. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response [5-7]. One study showed that dose escalation was required and approximately half of patients, and successful in 61.1% of dose escalation attempts [5]. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted [7]. Additionally, American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy" [4].
In this case, the patient has failed the other biologic medication classes recommended by guidelines for the treatment of Crohn's disease (Entyvio, and the anti-tumor necrosis factor medications Remicade and Humira), failed Stelara every 8 weeks, and had active disease despite the use of Stelara 90 mg every 4 weeks. Decrease of Stelara dosing, or discontinuation of Stelara (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for further surgery, or other complications of Crohn's disease. For all of these reasons, Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.