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

Skin Disorders
Pharmacy/prescription drugs

Diagnosis: Psoriasis
Treatment: Humira
The insurer denied Humira. 
The health plan's determination is upheld. 

The patient is a female with moderate to severe psoriasis (27% body surface area involvement) manifesting in the shins, thighs, legs, calves, back, arms, chest and abdomen. The patient has tried and failed topical clobetasol, ketoconazole, and triamcinolone.

Humira is not medically necessary.
First-line oral and/or light therapy are time-tested and have been used safely for decades in the treatment of moderate to severe psoriasis. The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, and/or Phototherapy. Therefore, Humira is not medically necessary.
Modern dermatology literature supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Humira, particularly for a patient with little to no history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. The patient's potential for childbearing does not preclude her from utilizing methotrexate, alternative oral medications (such as isotretinoin instead of acitretin if oral retinoids are desired), and/or light therapy, provided there is proper counseling and monitoring as part of this patient's treatment. Therefore, as per current medical standards of care, Humira is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system /gastrointestinal/cholecystitis/inflammation of the gall bladder 
Treatment: Inpatient  hospital stay 
The insurer denied  the inpatient hospital stay  
The denial is upheld in whole 

The patient who presented to the hospital with chronic cholecystitis and a left arm mass. She underwent laparoscopic cholecystectomy and excision of the left shoulder mass (basaloid neoplasm, favor trichoblastoma).
No, the inpatient stay was not medically necessary. This patient  who presented with cholelithiasis/cholecystitis and a left shoulder mass for scheduled cholecystectomy and excision of the left shoulder mass. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. Surgery (laparoscopic cholecystectomy and excision of the left shoulder mass) was performed . The perioperative period was uncomplicated and there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. The patient was discharged from the hospital on the day following surgery after being monitored overnight. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered in the lower level of care setting. A lower level of care level of care would have provided for surgical consultation, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care.
The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. Inpatient stay related to cholecystectomy may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case, none of these indications existed to justify an inpatient level of care. A lower level of care would have satisfied the clinical needs of this patient and would have been consistent with medical standards. The excision of the left shoulder mass did not substantially alter this patient's recovery and did not require inpatient care.
Based on the submitted clinical documentation, an inpatient hospital level of care was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder 
Treatment: Dental/Orthodontic Procedure 

The insurer denied the build up on tooth #15. The denial is upheld.

The patient presented for evaluation and treatment of tooth number (#) 15. Provided for review are previous letters of appeal and denial, a narrative from office staff explaining radiographic opening under the failed restoration #15, radiographic images, one page of American Dental Association (ADA) claim forms, and health plan language.
Previous denials have been on the basis that the tooth has adequate remaining tooth structure to support the crown prosthesis. There are no clinical notes provided describing the resulting amount of tooth structure after removal of decay. There is a narrative provided by an office staff but no official notation from the patient chart signed by the doctor. At issue question is the medical necessity of the planned treatment of buildup (2950) for tooth #15. 

The build up on tooth #15 is not medically necessary. The documentation provided does not support the need for the buildup procedure. The radiographic images provided show that there is adequate tooth structure to support the crown prosthesis and there is not the need for a buildup.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute appendicitis

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services. The denial was reversed.

This patient is a female with a history of Crohn's disease who presented to the emergency department (ED) with complaints of right lower quadrant pain.  Her temperature in the ED was 98.9 F., 99.2 F. The lab results showed white blood cell count (WBC) 19.9 K. Computer tomogram (CT) of the abdomen and pelvis showed acute appendicitis without perforation. Intravenous (IV) Flagyl was administered. The patient was admitted, made nothing by mouth, and treated with IV fluids, IV Ciprofloxacin and IV Flagyl. Gastroenterology was consulted; no acute intervention was needed. The patient's diet was advanced, her WBC improved and she was medically cleared for discharge home with outpatient follow up.

The admission was medically necessary at the acute inpatient level of care. The patient could not have been safely and effectively managed at an Observational level of care or been directly discharged from the emergency department (ED) or ambulatory surgery unit. In this case there was symptomatology for Crohn's disease, elevated WBC, abdominal pain and imaging suggesting acute appendicitis, terminal ileitis and colitis.

Acute abdominal pain often requires urgent investigation and management. This was not the case in this clinical setting. Patients with a suspected surgical abdomen must be managed by an acute care facility where urgent surgical consultation and management are available. Patients should also be managed by an acute care facility where more appropriate nursing care and laboratory and radiology facilities are available. Patients with less acute illnesses may require consultation or referral for further management following a more detailed history and initial assessment. Once the patient is stable, the differential diagnosis can be considered to guide further management and investigation. 

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

Based on the above, the medical necessity for the inpatient hospital services is substantiated. The insurer's denial is reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Epileptic seizures
Treatment: Clobazam Suspension 2.5MG/ML
The insurer denied the Clobazam Suspension 2.5MG/ML.  
The denial is upheld.

The health plan should not cover the proposed treatment with clobazam. 

The patient is a female with Aicardi syndrome, seizures and infantile spasm based on electroencephalogram (EEG) data. 

Current standard of care guidelines do not support the use of clobazam for infants with seizures, including those with infantile spasms (Wilmshurst et al., 2015).  There are no high quality clinical trials to support that this medication is safe or effective for persons under the age of two years for any seizure type.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Epileptic seizures
Treatment: Clobazam Suspension 2.5MG/ML
The insurer denied the Clobazam Suspension 2.5MG/ML.  
The denial is overturned.


The health plan should cover the proposed clobazam.  

The patient is a female with Aicardi syndrome and infantile spasms, and history of hydrocephalus and Dandy Walker malformation status-post ventriculoperitoneal (VP) shunt.  The patient was seen by the physician and it was noted that a few weeks prior the patient had an episode suspicious for seizure with stiffening of her lower extremities, and her levetiracetam dosage was increased at that time.  Outpatient electroencephalogram (EEG) was reviewed at the office visit and the features of the EEG were compatible with Lennox-Gastaut syndrome. The physician further noted that based on the EEG findings, the patient was predisposed for additional seizures as well as subclinical seizures.   Clobazam was prescribed as add-on therapy and the patient was to follow-up with repeat EEG in two to three months. 

The patient has Aicardi syndrome and infantile spasms, with Dandy-Walker malformation and hydrocephalus.  Considering this constellation of neurological conditions, evolution from infantile spasms to Lennox-Gastaut syndrome is expected.  The patient's most recent EEG is indicative of Lennox-Gastaut syndrome.  Clobazam is an appropriate medicine for the patient's case since clobazam is approved by Food and Drug Administration for the management of Lennox-Gastaut syndrome and associated seizures.  Medical literature supports use of clobazam in infantile spasms evolving to Lennox-Gastaut syndrome.  Therefore, the health plan should cover the proposed treatment.

The requested clobazam is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.  

Considering that the patient has EEG compatible with Lennox-Gastaut syndrome, use of clobazam, which is approved for Lennox-Gastaut syndrome by the Food and Drug Administration, is expected to provide results superior to any other treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Epileptic seizures
Treatment: Clobazam Suspension 2.5MG/ML
The insurer denied the Clobazam Suspension 2.5MG/ML.  
The denial is overturned.

The health plan should cover the proposed clobazam.

The patient is an infant with complex medical history including Aicardi syndrome, hydrocephalus with Dandy Walker malformation status post ventriculoperitoneal (VP) shunt placement, infantile spasms status post adrenocorticotropic hormone (ACTH) protocol, and recent electroencephalogram (EEG) demonstrating an active seizure focus with slow spike-wave complexes consistent with Lennox-Gastaut syndrome. The patient was already receiving Keppra for seizure management, but with the new EEG findings, Onfi was added. 

Clobazam is likely to be more beneficial for this infant than any other standard treatment for her complex neurologic condition.

Onfi, or clobazam, is a somewhat atypical benzodiazepine medication approved for use as an adjunctive agent for intractable epilepsy. It is particularly effective as an adjunctive agent for patients with Lennox-Gastaut syndrome, an epileptic encephalopathy characterized by multiple types of seizures along with developmental delay. Onfi is available as a suspension and has less sedating effects than typical benzodiazepines, making it a desirable adjunctive agent. The National Institute for Health and Care Excellence (NICE) has recommended Onfi as an adjunctive treatment for the following types of seizures: focal seizures, generalized tonic-clonic seizures, benign epilepsy with centrotemporal spikes, Panayiotopoulos syndrome, late onset childhood occipital epilepsy, Dravet syndrome, and epilepsy with generalized tonic-clonic seizures only. NICE has recommended Onfi as an option for a number of patients upon referral to tertiary care for seizures, including childhood absence epilepsy. Young children benefit from the liquid formulation. 

In a review of the literature published in 2011, a number of studies were reviewed showing clinical efficacy using clobazam in both infants and children. Three studies included infants under two years of age (the current FDA recommended age cut-off). In one study, the patients ranged from one to seventeen years of age. In another, patients were seven months to twelve years of age. And in a third, patients' ages ranged from 0.1 to 15.1 years of age. There were no adverse effects specifically targeting infants under two years of age documented in any of these studies, and there was no decrease in efficacy.

This particular infant has seizures and encephalopathy in evolution, starting with infantile spasms that responded well to ACTH, now with seizures and EEG findings consistent with Lennox-Gastaut syndrome (LGS). As stated above, clobazam has particular efficacy as an adjunctive agent in the treatment of LGS. Clobazam is likely to be more beneficial for this infant than any other standard treatment for her complex neurologic condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Chiropractic Services 

The treatment of chiropractic services has been denied. The decision is UPHELD in whole. 

The patient is a male teenager, who began chiropractic treatment three years ago for neck and back pain, of unknown origin. The patient was examined and spasm and subluxation, and reduced ranges of motion, were noted, and he was treated with spinal manipulation, ultrasound and mechanical traction. He was seen again two years ago for an exacerbation of neck and upper back pain, and again treated in similar fashion, for six months. He came back for another exacerbation four months later, and again four months later, at which time his visual analog scale (VAS) for neck and back pain was 8/10. He was treated for another year. He again came in for an exacerbation of neck and upper back pain a year ago and was treated for two months. VAS on the first visit was 6-7/10, and 3-6/10 for the subsequent two months. Notes dated early last summer noted spasm, subluxation and reduced cervical ranges of motion. 

The subject under review is the medical necessity for the chiropractic services for the dates of service in question. 

The health plan's determination is upheld in whole. 

No, the chiropractic services were not medically necessary for this patient. The patient was seen for a series of exacerbations of a chronic condition, over the course of several years. The patient was treated for his condition for months without any significant objective evidence of clinical improvement, as noted by ongoing VAS scores which varied little. There was little or no change in diagnoses, no referral to other practitioners for another treatment option, and no change in the treatment protocol even when it was not bringing ongoing objective clinical improvement. There was no documented non-supervised home rehabilitation program, which might have made the patient's chronic exacerbations and bouts of chiropractic treatment less likely to occur, and which would be a primary tool in improving the patient's clinical outcomes. The lack of objective evidence of ongoing clinical improvement denotes a lack of medical necessity in this case.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Rectal Bleeding
Treatment: Inpatient hospital stay. The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a female with past medical history of diabetes mellitus, hypertension, asthma, gastroesophageal reflux disease, alcohol abuse, and cocaine dependence, who presented to the emergency room with concern for rectal versus vaginal versus urethral bleeding that she noted while using the restroom with blood noted on the tissue paper.

The inpatient stay was not medically necessary. This patient presented with concerns for rectal bleeding given guaiac positive stool in the setting of hemodynamic stability and hemoglobin of 12.7 with normotension, without tachycardia, and with hemorrhoids noted on exam. After presentation, she was subsequently noted to have no evidence of further bleeding, with hemoglobin stable. She was not on anti-coagulation, and did not have other concerning signs or symptoms such as altered mental status, concomitant cardiac ischemia, heart failure, or associated abdominal pain. She subsequently underwent a colonoscopy demonstrating hemorrhoids, rectal prolapse, diverticulosis, and non-bleeding polyps. In the setting of a hemodynamic stability, hemoglobin of 12.7 without evidence of ongoing bleeding and without any of the aforementioned higher risk associated conditions (being on anticoagulation, concomitant chest pain, heart failure, etc.), it is unclear why she could not have been safely cared for at a lower level of care with observation services in lieu of needing admission at the inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/Gastrointestinal.
Surgical Services  (All).

Diagnosis: achalasia.
Treatment: peroral endoscopic myotomy (POEM).
The insurer denied the peroral endoscopic myotomy (POEM). The health plan's determination is overturned. 

The peroral endoscopic myotomy (POEM) is likely to be more beneficial than any standard treatment or treatments for the patient's achalasia than any available alternatives.
The American Gastroenterological Association best-practice guideline for peroral endoscopic myotomy states that "if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (Kahrilas, et al). Accordingly, the provider is a POEM expert (Stavropoulos, et al).
The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, stating that POEM is a "a potential attractive option for the treatment of achalasia that offers a minimally invasive endoscopic approach to myotomy with the potential for a durable response to therapy" (ASGE PIVI Committee, et al). Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available (Barbieri, et al; Schlottmann, et al). However, despite comparable efficacy, POEM is significantly less invasive than surgical intervention, resulting in less postoperative pain and a more rapid recovery (Docimo S, et al).
In this patient with severe symptoms including dysphagia, regurgitation, and unintentional weight loss, the use of POEM is supported by current medical literature and guidelines. For these reasons, POEM should be considered likely to be more beneficial than any standard treatment or treatments for the patient's type II achalasia.
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/Gastrointestinal.
Surgical Services  (All).

Diagnosis: achalasia.
Treatment: peroral endoscopic myotomy (POEM).
The insurer denied the peroral endoscopic myotomy (POEM). The health plan's determination is overturned. 

The patient is a male with achalasia. The patient's symptoms have been going on for approximately one year and consist of dysphagia to both solids and liquids. He also experiences regurgitation and due to these symptoms has experienced weight loss. The patient is highly symptomatic. The patient has undergone an upper endoscopy to rule out other causes of dysphagia. A high resolution manometry study revealed findings consistent with Type II achalasia. The patient's provider has recommended endoscopic treatment of achalasia with the peroral endoscopic myotomy (POEM) procedure. 

A landmark study published in 2019 by Werner et al, established POEM as non-inferior to laparoscopic Heller myotomy (LHM), the gold-standard procedure for achalasia. This multicenter, randomized trial, compared POEM with LHM plus Dor's fundoplication in patients with symptomatic achalasia. The primary end point was clinical success, defined as an Eckardt symptom score of 3 or less without the use of additional treatments, at the 2-year follow-up; a non-inferiority margin of -12.5 percentage points was used in the primary analysis. A total of 221 patients were randomly assigned to undergo either POEM (112 patients) or LHM plus Dor's fundoplication (109 patients). Clinical success at the 2-year follow-up was observed in 83.0% of patients in the POEM group and 81.7% of patients in the LHM group (difference, 1.4 percentage points; 95% confidence interval [CI], -8.7 to 11.4; P=0.007 for noninferiority). Serious adverse events occurred in 2.7% of patients in the POEM group and 7.3% of patients in the LHM group. POEM has been shown to be superior to pneumatic dilation, the most common standard treatment for achalasia. A randomized multicenter clinical trial conducted at 6 hospitals including the United States. Adult patients with newly diagnosed achalasia and an Eckardt score greater than 3 who had not undergone previous treatment were included. The primary outcome was treatment success (defined as an Eckardt score <=3 and the absence of severe complications or re-treatment) at the 2-year follow-up. Of the 133 randomized patients, 130 underwent treatment (64 in the POEM group and 66 in the pneumatic dilation group) and 126 (95%) completed the study. The primary outcome of treatment success occurred in 58 of 63 patients (92%) in the POEM group vs 34 of 63 (54%) in the pneumatic dilation group, a difference of 38% ([95% CI, 22%-52%].
Based on the above, the Peroral Endoscopic Myotomy (POEM) is 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: Overturned

Digestive System/Gastrointestinal.
Surgical Services  (All).

Diagnosis: achalasia.
Treatment: peroral endoscopic myotomy (POEM).
The insurer denied the peroral endoscopic myotomy (POEM). The health plan's determination is overturned. 

The patient is a male with a diagnosis of achalasia. The appeal letter  requests authorization for peroral endoscopic myotomy (POEM). The patient has a history of dysphagia and he had a barium swallow that showed delayed emptying of barium into the stomach. Endoscopy showed a narrowing of the distal esophagus. Manometry showed a high resting pressure of the distal esophagus and findings of type 2 achalasia. A progress note describes dysphagia, regurgitation, and weight loss. The various alternative procedures to treat achalasia were discussed with the patient. 

The Peroral Endoscopic Myotomy (POEM) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Current scientific evidence shows that this procedure is considered safe, effective, as compared with standard means for treatment of achalasia. Reliable evidence shows that the consensus of opinion among experts is that safety and effectiveness compared to standard means of treating has been established. Dilation and Botox therapy require repeated procedures with limited durability. Surgical myotomy is associated with morbidity of more blood loss and pain. The literature supports the use of this procedure as safe, effective, with relief of symptoms.