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

Diagnosis: Skin Disorders-eczematous dermatitis .
Treatment: Pharmacy/Prescription Drugs-Dupixent.
The health plan denied the request for the prescription drug Dupixent. 
The health plan's determination is upheld.

The patient is a female with eczematous dermatitis with lichenification of the trunk and extremities. The patient has tried 0.1% Triamcinolone cream. Eucrisa was tried.
The health plan coverage of Dupixent is under review for medical necessity.

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

No. The patient has no documented treatment failure with, or true medical contraindication to, either more potent topical steroids, and/or the topical calcineurin inhibitor tacrolimus, and/or standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil). Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature reviews [1-4], the requested Dupixent is not medically necessary and does not meet the health plan coverage requirements.
Dupixent is being used out of convenience, and not medical necessity; convenience and/or preference of the provider and/or patient is not the same as true medical necessity. First-line and second-line topical and systemic therapies have not yet been tried to date, so that the conclusion that Dupixent is medically necessary cannot be made. Accordingly, the health plan acted reasonably, in the best interest of the patient, and with sound medical judgment, in denying coverage of Dupixent at this time.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Episodic Migraine

Treatment: Nurtec

The insurer denied coverage for Nurtec 

The denial is overturned

According to the documentation submitted, this is the case of a female patient. The patient has been under the care of her neurologist for the treatment of episodic migraine without sura with status migrainosus. The neurologist is requesting coverage of Nurtec for the patient. 

The patient has tried two triptans and they have not been effective. The neurologists states that she has tried sumatriptan and rizatriptan with insufficient benefit. Since she has already tried and failed two triptans, a drug with a different mechanisms of action such as Nurtec is more likely to be effective than another triptan. Nurtec is Food and Drug Administration (FDA)-approved for migraine treatment and is medically appropriate for this patient. 

The insurer's denial of coverage for Formulary Exception for Nurtec is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis

Treatment: Inpatient Hospital Services

The insurer denied coverage for inpatient hospital services

The denial is upheld 

This is the case a female patient with a past medical history of chronic pelvic pain, severe dysmenorrhea, posterior leiomyoma, seizures, pneumothorax, iron deficiency anemia, alcoholic gastritis, and asthma, who presented to the Emergency Room (ER) with the complaint of intermittent emesis and associated polydipsia. In the ER, she was tachycardic. She had a history of gynecological disease and was awaiting a hysterectomy. There was no abdominal rebound or guarding. The white blood cell (WBC) count was 20.3. The renal function was normal. The lactate level was 6.72.  A computed axial tomography (CAT) scan revealed colitis. Antibiotics were given. A colonoscopy showed a small area of colitis. The tachycardia and leukocytosis resolved. 

Clinical indications for admission for Gastroenteritis (M-170) include having a severe infection such as bloody diarrhea, peritoneal signs, severe abdominal pain, hemodynamic instability, severe vomiting, severe dehydration, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient was found to have colitis. She required intravenous (IV) hydration and antibiotics. The repeat complete blood count (CBC) showed a WBC of 9.6. The tachycardia resolved. She responded to ER treatment and could have received care with Observation status. The colonoscopy could have been done on an outpatient basis. Afterwards, she could have been discharged on a course of oral antibiotics as an outpatient. She did not meet Milliman Care Guidelines criteria for admission for gastroenteritis. 

The healthcare plan acted reasonably and with sound medical judgment. An inpatient stay was not medically necessary. 

The insurer's denial of coverage for the inpatient hospital services is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pre-molars. 
Treatment: Surgical removal of teeth #21 and #28. 

The insurer denied the Surgical removal of teeth #21 and #28. 
The denial is upheld. 

The patient is a male patient who is having pre-molars removed. Surgical extractions (D7210) have been billed for teeth #21 and #28, and have been denied. 

No, the requested health service is not medically necessary. 

The radiograph shows that the teeth are intact with no caries. However, even if the crown of the tooth fractures during the extraction, and the removal of the exposed root is elevated and/or removed with forceps even if a periosteal flap is completed, the appropriate American Dental Association (ADA) code is D7140, extraction, erupted tooth or exposed root (elevation and forceps removal). If, in addition to the flap, bone is removed, or the roots are sectioned in order to remove the roots, then the surgical extraction code is D7210. 

Code D7210 would only be justified with an operative report showing that bone removal was required. There is no such documentation evident in the records that were submitted for review. Therefore, given that the patient did not meet the requirements for code D7210 for teeth #21 and #28, D7210 for teeth #21 and #28 was not medically necessary. The teeth could have been extracted under a less intensive code. 

D7210 would require an operative report showing that bone removal was required. There is no such documentation for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted wisdom teeth. 

Treatment: Cone Beam computed tomography (CBCT) capture and interpretation with field view of both jaws, with or without cranium. 

The insurer denied coverage for cone beam CT capture and interpretation with field view of both jaws, with or without cranium. 

The denial is overturned. 

This patient was evaluated by his dentist and oral and maxillofacial surgeon (OMS) for impacted wisdom teeth that are symptomatic and temporomandibular joint (TMJ).  The patient's lower wisdom teeth roots are overlying the inferior alveolar canal (IAN) on panoramic radiograph.  Due to the need to remove the wisdom teeth and the proximity of the IAN to the roots, a cone beam computed tomography (CBCT) was ordered to verify nerve position. 

The cone beam CT capture and interpretation with field view of both jaws, with or without cranium is considered medically necessary for this patient. 

In this case, it is clear that the inferior alveolar nerves are close to the roots of both 17 and 32. Tooth 32 is symptomatic and requires removal.  The nerve and root overlap.  A CBCT is medically appropriate to view the IAN and the nerves proximity to the roots of both 17 and 32 in preparation for surgery.  A CBCT will allow the surgeon to treatment plan this surgery with the least amount of morbidity.  Therefore, this request for cone beam CT capture and interpretation with field view of both jaws, with or without cranium is medically necessary. 

Borgonovo, et al. "The 3D reconstruction software provide surgeons with an additional planning tool, offering: immediate and neat visualization of the noble structures that have to be respected and their localization in the three spatial planes; the exact morphology of the relevant root apex; a 360 view of the relationship between the IAN and the third molar and the exact point in which the root is in relationship with the canal." 

Weiss et al., notes, "CBCT provides coronal and sagittal dimensions of the relationship of the IAN and the mandibular third molar, which allows the clinician to appreciate the IAN proximity in a vertical, lateral, and depth dimension." 

Baqain, et al., "The use of CBCT provides a better understanding of the anatomic relationship between M3M [mandibular third molar] roots and the IAC [inferior alveolar canal]." 

The insurer's denial of coverage for cone beam CT capture and interpretation with field view of both jaws, with or without cranium is reversed. Medical necessity is substantiated. 

The health plan did not act reasonably with sound medical judgement in the pat interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Maxillary and mandibular crowding. 
Treatment: Braces. 

The insurer denied braces. The health plan's determination is upheld. 

The patient is a female with severe maxillary and mandibular crowding and several unerupted permanent teeth. The orthodontist mentioned in the diagnosis that tooth # (number) 6 and #11 are impacted. The patient is treatment planned for 24-30 months of comprehensive orthodontics. 

Braces are not medically necessary for the patient at this time. She is in the process of losing her remaining primary teeth as they are replaced with permanent teeth. Research indicates the following risk factors for impacted canines in patients over 10 years of age:
1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does not have this, as shown in the panoramic radiograph.) 
2) The canines cannot be palpated and occlusal development is advanced (occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption.) 
3) The lateral incisor is proclined and tipped distally (Photographic evidence does indicate tipped lateral incisors.) 
4) On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor. (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided.) 
The patient does have maxillary and mandibular crowding and treatment may be indicated in the future. However, the patient only exhibits one of the criteria to suspect her canines are, in fact, impacted. There are less invasive treatments (extraction of #5 and #12) to assist eruption of 6 and 11. For this reason, braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: coronary artery stenosis
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This patient is a woman who presented to the hospital for scheduled percutaneous intervention for a right coronary artery stenosis. Stents had been placed in her left anterior descending and left circumflex arteries. Upon presentation, her blood pressure was 111/63 with a heart rate of 71 beats/minute. Her electrocardiogram showed no acute changes. Her right coronary artery was successfully stented. During the procedure, the stent dislodged and was retrieved with a snare without complications. Post-procedure, the patient developed transient hypotension with systolic blood pressures of 70-85. She was treated with  intravenous fluid and her blood pressure increased to 98/58. She was admitted to the hospital for overnight observation. 

The inpatient level of care was not medically necessary.
This patient presented for elective percutaneous coronary intervention. She was stable upon presentation, without acute ischemic electrocardiographic changes. Other than stent dislodgment, which was treated during the procedure without adverse events, the procedure was uncomplicated. Post-procedure she had transient hypotension that responded to intravenous fluid bolus.
While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. Per the 2018 update to this document, with the exception of patients with ST segment elevation myocardial infarction, most stable patients can be discharged post- percutaneous coronary intervention (PCI) on the day of the procedure provided they are at their baseline functional and mental status and all of their baseline comorbidities are stable. Certain patients may remain in the hospital on observation status following PCI for a number of medical reasons such as prolonged or adverse effects from sedation, fluid or electrolyte imbalance, or ongoing pain, bleeding, ischemia, or dysrhythmia after the procedure.
In this instance, given the patient's transient hypotension, overnight observation post-procedure was a reasonable approach. However, it did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal class of III with a hypoplastic maxilla.
Treatment: Braces (comprehensive orthodontic treatment).
The insurer denied coverage for braces (comprehensive orthodontic treatment).
The denial is upheld.

According to the documentation submitted, this is the case of a female patient who presented for dental evaluation. The handicapping labio-lingual (HLD) score was 17. The patient had a skeletal class of III with a hypoplastic maxilla. There was a normal vertical growth pattern, permanent dentition, moderate maxillary spacing, moderate mandibular spacing, undersized maxillary lateral incisors, and an anterior crossbite with gingival attachment loss. The treating Orthodontist recommended comprehensive orthodontics with full maxillary braces and full mandibular braces. The patient does not exhibit a severe physically handicapping malocclusion and the HLD score is below 26. 

The patient does not meet the required HLD score. The provider states that the patient automatically qualifies as there is an anterior crossbite. There is no anterior crossbite evident. Also, in order to qualify with an anterior crossbite, there must be clinical attachment loss and recession of the gingival margin. There is no clinical attachment loss and recession of the gingival margin evident on the photographs.

This reviewer calculated the HLD to be 5. That is, 4 points for an open bite and 1 point for the labiolingual spread. Since the HLD score is below 26, the guidelines for braces are not met.

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

The insurer's denial of coverage for braces (comprehensive orthodontic treatment) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease (CAD). 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who presented to the hospital for elective percutaneous intervention for a chronic total occlusion (CTO) of his left circumflex coronary artery. This had been attempted earlier but was unsuccessful due to vessel dissection. The patient's medical history was remarkable for coronary artery disease, coronary artery bypass graft surgery, hypertension, hyperlipidemia and moderate aortic stenosis. The patient's hemoglobin prior to the procedure was 11.4. An attempt at opening the left circumflex CTO via the anterograde approach was unsuccessful and again resulted in vessel dissection, which was non-occlusive. A sheath was then placed in the contralateral femoral artery and the vessel was accessed via the saphenous vein graft. Drug-eluting stents were successfully placed in the proximal and mid left circumflex artery. Post-procedure, there was significant oozing from both femoral arterial puncture sites. The patient's hemoglobin was 8.6. He was transfused with two units of packed red blood cells. A computed tomography (CT) scan showed no evidence of a retroperitoneal bleed. The patient remained stable overnight and was discharged. 

The inpatient stay was not medically necessary. This patient underwent percutaneous intervention (PCI) for a chronic total occlusion of his left circumflex coronary artery. He had significant oozing from both femoral arterial puncture sites and had a significant drop in his hemoglobin. However, he experienced no symptoms with this and remained hemodynamically stable. While he required red blood cell transfusion, no surgical intervention was required. Per 2009 expert consensus document from the Society for Cardiovascular Angiography and Interventions, admission under extended observation greater than (>24 hours) status is recommended for patients who undergo elective PCI and have vascular complications requiring transfusion, but not requiring surgery. Per the 2018 update to this document, admission under observation status (rather than same day discharge) after elective PCI is appropriate for hemodynamically stable patients with complications such as fluid or electrolyte imbalance, ongoing pain, bleeding, ischemia, or dysrhythmia after the procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia areata

Treatment: Xeljanz extended release (XR)

The insurer denied coverage for Xeljanz XR.

The denial is upheld. 

This is a female patient with a past medical history of alopecia areata. The patient was seen at a Dermatology office visit for worsening alopecia areata. The Dermatologist is requesting coverage of Xeljanz extended release (XR) for the patient.

Xeljanz XR is not medically necessary for the patient's condition, alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, 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 and Xeljanz XR. It is noted that the Food and Drug Administration (FDA) released a statement in early 2019 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 two times per day. (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, diphenylcyclopropenone (DPCP), and anthralin. (9-10) Based on the information provided, the health care plan acted reasonably in denying the coverage for Xeljanz XR.  

The insurer's denial of coverage for Xeljanz XR is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia universalis. 
Treatment: Jakafi (ruxolitinib).

The insurer denied coverage for Jakafi (ruxolitinib).  The denial is overturned. 

This is a female patient who has a diagnosis of alopecia universalis.  She has failed therapy with numerous topical steroids, oral pulse prednisone, intralesional Kenalog (ILK), minoxidil, Diphencyprone applications, and Bimatoprost.  The patient, according to documentation provided by the patient's mother, has been on continuous therapy with Jakafi.  The patient has been followed by her Dermatologist and is not noted to have had complications or side effects associated with Jakafi treatment.  The patient's condition, alopecia universalis, has been controlled adequately with the combination of Jakafi and ILK treatments.  

Based on the provided medical records and associated documentation, the patient is currently stable with her current regimen.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. It would be medically inappropriate to deny coverage for a stable therapy of many years.  As a result, the denial is overturned and the use of Jakafi is medically necessary for use in the treatment of the patient's condition.

The insurer's denial of coverage for Jakafi (ruxolitinib) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Home Health Care (24 hours per day live).
The insurer denied 24 hours per day live in medically necessary. 
The denial is overturned.

The patient is a male with past medical history of osteoarthritis, coronary artery disease, deep vein thrombosis (DVT), hypertension, hyperlipidemia, prostate cancer, asthma, gastroesophageal reflux disease (GERD), glaucoma, urinary incontinence who had been assigned personal care assistance (PCA) services 6 hours/day x 5 days/week and 5 hours/day x 1 day/week to total 35 hours/week based on assessment tool performed on assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and shopping while maximum assistance with managing finances. The patient was assessed at extensive assistance with phone use, stairs, and transportation while limited assistance with tasks of managing medication and bathing. With tasks of dressing lower body, transfer toilet, and toilet use the patient was assessed as supervision only and independent with tasks of personal hygiene, dressing upper body, walking, locomotion, bed mobility, and eating. 

The requested services are medically necessary for the patient. The patient has recent diagnosis of pancreatic cancer with current treatment with chemotherapy with documented decline in physical functioning with fatigue, weight change, extremity weakness and unbalanced gait. The patient's condition has worsened since his assessment. The patient also has progressive illness of osteoarthritis. The patient used a wheelchair for ambulation. The patient lives alone without informal help. Based on the assessment the patient requires at least limited assistance with all activities of daily living (ADLs)/Instrumental activities of daily living (IADLs) except for eating. The patient therefore has unpredictable and unscheduled care needs over a continuum of time. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The plan assumed the patient's daughter would be able to provide care outside of the hours of PCA services and the patient's daughter is unable to provide care 16 hours/day. The patient's medical oncologist has documented in the reading letters the medical necessity for increased PCA services. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA home health care (HHC)-Level 2 Personal Care Services increase to 24 hours per day live in is medically necessary for this patient.  Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.