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

Diagnosis: Open bite
Treatment: D8080 Braces and D8670 Monthly Visit, Pre-service
The insurer denied the D8080 Braces and D8670 Monthly Visit, Pre-service.
The denial is overturned.

The patient is a female.  The request is for dental benefits for orthodontic treatment (braces) and monthly visits.  Per the records, the patient presents with an anterior open bite of 1.5 millimeters (mm), overjet of 4 millimeters, and Handicapping Labio-Lingual Deviation (HLD) Index of 26.

Exam and orthodontic records were created.  The Health Plan denied the claim because it did not reach their criteria of 26 on Handicapping Labio-Lingual Deviation (HLD) Index.  The provider's appeal is based on the clinical findings and the scoring of the provider's Handicapping Labio-Lingual Deviation (HLD) Index.

Yes, the proposed treatment of orthodontic therapy (braces) and monthly visit are medically necessary.

The patient's photos and x-rays exhibit the presence of an open bite.  An open bite can cause difficulty with chewing, speech, and mouth breathing.

The complications that can arise from non treatment of an open bite as it relates to speech, chewing, and mouth breathing will have long-term far reaching consequences for the patient.  The patient can develop a lisp, ineffective chewing that can lead to poor digestion, and mouth breathing that can lead to dry mouth and hence increased risk of caries (tooth decay).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 Braces, D8670 Monthly Visit x 4, Pre-service
The insurer denied the D8080 Braces, D8670 Monthly Visit x 4, Pre-service
The denial is upheld. 

The patient is a female with Class I malocclusion. The request is for braces and monthly visits.

No, the braces and monthly visits are not medically necessary.
The patient has slight crowding in her upper and lower dental arches, not enough to cause a "handicapping malocclusion." She does not reach the threshold of 26 for treatment as required by the handicapping index scale.

Therefore, given the above, the braces and monthly visits are not medically necessary.

The patient does not have a handicapping malocclusion.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lipodystrophy
Treatment: 17999 Unlisted procedure (skin mucous membrane and subcutaneous tissue, six units); pre-service
The insurer denied the 17999 Unlisted procedure (skin mucous membrane and subcutaneous tissue, six units); pre-service
The denial is upheld.

The patient is a male with a history of human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART). He has HAART-induced lipodystrophy and Sculptra injections are requested. The condition appeared a couple of decades ago when he started therapy and has been getting worse. The patient is bothered by the appearance of it.

No, the proposed treatment is not medically necessary.
The term human immunodeficiency virus (HIV)-associated lipodystrophy typically refers to changes in fat distribution that are often associated with metabolic abnormalities, including dyslipidemia and insulin resistance. Specifically, patients with lipoatrophy have loss of subcutaneous fat, most noticeably in the limbs, face, and/or buttocks areas. Patients with fat accumulation have gain of visceral fat in the abdomen and may have dorsocervical fat pad enlargement (buffalo hump) and breast enlargement.  Patients may present with lipoatrophy, fat accumulation, or a combination of the two.  Buccal lipoatrophy is a known side effect of antiretroviral therapy. It does not produce physical functional impairment; however, there are multiple reasons to consider treating human immunodeficiency virus (HIV)-associated lipodystrophy, as there are several potential benefits beyond pure cosmesis.  Patients are often distressed by the physical changes in their appearance, especially if they develop facial lipoatrophy. These morphologic abnormalities can have a significant impact on self-esteem.  The presence of lipodystrophy raises concern, for some patients, that their human immunodeficiency virus (HIV) status will be obvious to others.  Lipodystrophy, or fear of developing it, may impact adherence to antiretroviral therapy (ART) or the willingness to initiate such therapy.

This patient expressed concern about the aesthetic appearance and did not raise any issues with self-esteem, distress, or impact on adherence to his anti-retroviral therapy. Therefore, Sculptra injections are not considered medically necessary.

In this case, the injections are considered cosmetic.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Parkinson's Disease.
Treatment: Formulary exception for Rytary CAP 95MG, Pre-service
The insurer denied the Formulary exception for Rytary CAP 95MG, Pre-service
The denial is upheld. 

The patient is a male with Parkinson's disease (PD).  The provider indicated that he has had side effects and no improvement with carbidopa/levodopa treatment. He is currently treated with Rytary. He has also tried and failed selegiline.

No, the health plan should not cover the Formulary exception for Rytary.
In this patient's case, it is not clear what formulation and dose of carbidopa/levodopa has been tried and failed (viz. immediate release or controlled release). There are no high-quality clinical trials demonstrating that Rytary is superior or should be use preferentially to carbidopa/levodopa CR (controlled release) or IR (immediate release) or to dopamine agonists (e.g. ropinirole, pramipexole). There is no evidence that these medications would be ineffective here or that these agents are more likely to have adverse effects relative to Rytary.

Therefore, given the above, the health plan should not cover the formulary exception for Rytary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and Office Visits
The insurer denied the braces and office visits.
The determination is overturned.

The patient has an anterior crossbite on tooth 10. She presents with a skeletal Class II subdivision left malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 30-36 months of orthodontics with extraction of teeth numbers 5, 12, 21 and 28 to address the crowding and crossbite. The treatment was denied due to a lack of medical necessity. At issue is the medical necessity of the requested braces and office visits.

This patient presents with an anterior crossbite on tooth 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. [1, 2, 3] If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. Orthodontic treatment is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Coronary Artery Disease/CAD
Treatment: Skilled Nursing Facility/Long Term Care 
The health plan denied the requested long term facility care as not medically necessary. 
The health plan's determination is upheld.

The patient is a male who resides at an extended care facility. The patient has a medical history of hypertension with atherosclerotic heart disease, psoriasis, chronic left knee problem, history of substance abuse, left femur distal condylar fracture with patellar dislocation and stasis dermatitis of both legs.

At issue is the medical necessity of continued long term custodial care.

This reviewer upholds, in whole, the health plan's determination of medical necessity.

No, the requested health service/treatment of long-term care is not medically necessary for this patient. The patient is a male with a medical history of hypertension with atherosclerotic heart disease, psoriasis, chronic left knee problem, history of substance abuse, left femur distal condylar fracture with patellar dislocation and stasis dermatitis of both legs. Long term facility care is not medically necessary for this patient. Review of all documentation noted that he ambulated with a slow, but steady gait. He had no difficulty swallowing. His weight was stable. His vitals were stable. He is continent of both bowel and bladder. While he does need some assistance with bathing, upper body dressing and lower body dressing, it was described as limited, and showering was described as supervision. There was documentation, not dated, noting periods of agitation and care resistance but none of the documentation supported this report and there were no medications to support an impacting psychiatric diagnosis. Furthermore, an assessment noted that his memory was alright. The patient is able to ambulate independently, feed self, is continent of both bowel and bladder and only requires some limited assistance for bathing, upper body dressing and lower body dressing. Additionally, his vitals are stable, and documentation does not support any needs that require 24-hour custodial care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility.
Treatment: Infertility medication: Cycle of Injectable Medication (gonadotropins).

The insurer denied infertility medication: Cycle of Injectable Medication (gonadotropins).  The health plan's determination is overturned. 

The patient is a female undergoing ovulation induction for infertility. The current treatment plan is to utilize gonadotropins to induce follicular recruitment. At issue is the medical necessity of Infertility Medications: Cycle of Injectable Medication.

The requested Infertility Medications: Cycle of Injectable Medication (gonadotropins) is medically necessary for this patient, as she has failed both letrozole and clomiphene therapy.

In the case of a fertility patient who does not ovulate on a regular basis, standard of care is to start with oral ovulation induction agents, such as clomiphene or letrozole. Most reproductive endocrinologists would attempt ovulation induction with at least one of these agents. This patient has tried both of these agents and did not have successful follicular recruitment. In the presence of lack of follicular development with oral agents, it is standard of care within the field of reproductive endocrinology and infertility to then use injectable gonadotropins as was used in this patient. Under appropriate surveillance, gonadotropins can be very successful in follicular recruitment that was otherwise resistant to oral medications with good chances of pregnancy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility due to anovulation.
Treatment: Infertility services (injectable medications [gonadotropins]), Pre-service.

The insurer denied the Infertility services (injectable medications [gonadotropins]), Pre-service.  The denial is overturned. 

The patient is a female with a diagnosis of infertility due to anovulation.  The patient underwent four cycles of ovarian stimulation with clomiphene citrate.  However, she did not conceive. She conceived on her first cycle of low-dose gonadotropin stimulation. She returned for further pregnancy. She underwent ovarian stimulation with letrozole and Clomid however she did not respond.  She then proceeded with low-dose gonadotropin stimulation and did achieve a pregnancy which ended in a miscarriage.  The patient and provider are requesting coverage for gonadotropins.

Yes, the proposed treatment is medically necessary.

The treatment is medically necessary.  Gonadotropins are Food and Drug Administration (FDA) approved for this patient's condition.  This patient has anovulation that did not respond to oral stimulating agents. The next step is to proceed to the use of gonadotropins.  This patient conceived twice previously on a gonadotropin protocol; going back to using Clomid or letrozole is not clinically appropriate.  The aim of any treatment is the final result, in this case, getting pregnant. Using a medication that did not work in the past is counterintuitive.

This patient has a diagnosis of anovulation.  She conceived previously twice with the use of low-dose gonadotropin stimulation of her ovaries.  The next step is to use the same treatment that was successful in the past.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment is testing for serum antibodies to Remicade
The insurer denied coverage for the testing for serum antibodies to Remicade
The denial is overturned

The patient has ulcerative colitis. He was being treated with infliximab, methotrexate, and prednisone. He had an increase of diarrhea and cramping. The infliximab levels was 1.9. He did not have antibodies.

Clinical Gastroenterology and Hepatology article titled "Appropriate Therapeutic Drug Monitoring of Biologic Agents for Patients with Inflammatory Bowel Disease" concluded that there was a consensus achieved towards the utility of therapeutric drug monitoring, particularly for anti-TNF [Tumor Necrosis Factor] therapies.

Inflammatory Bowel Disease article titled "Proactive In Drug Monitoring is Superior to Conventional Management in Inflammatory Bowel Disease" concluded that proactive therapeutic drug monitoring has higher mucosal healing rates and is associated with fewer surgeries than conventional non-therapeutic drug monitoring management.

This patient has ulcerative colitis and therapeutic drug monitoring has been shown to improve health outcomes. 

The healthcare plan did not act with sound medical judgement therapeutic drug levels including measurement of serum antibodies is medically necessary.

The insurer's denial of coverage for the testing for serum antibodies to Remicade is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is the case of a male patient with a history of 2 weeks of cough and wheezing. The cough was initially only present at night but then was present both day and night. On the day prior to admission, he began complaining of chest tightness and feeling out of breath when speaking. He also complained of shortness of breath (SOB) when climbing one flight of stairs. He was also coughing up sputum. Since his cough was persisting and his respiratory symptoms were getting worse his mother brought him to the Emergency Room (ER) for evaluation. In the ER he was noted to have increased work of breathing and respiratory distress with abdominal retractions. He was tachypneic and on physical exam he was noted to have bilateral wheezing with prolonged expiration and retractions. Testing for respiratory syncytial virus (RSV), influenza and Covid-19 virus was negative. He was treated with three inhalations of Combivent, a bolus of intravenous (IV) normal saline, magnesium sulfate and 2 doses of dexamethasone. When his wheezing and increased work of breathing did not improve with treatment in the ER the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours.

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The patient was treated appropriately in the ER for an acute episode of wheezing and difficulty breathing. The child had no previous history of asthma. When he did not respond to treatment in the ER it was appropriate to have him admitted to the hospital with a diagnosis of status asthmaticus. He was not stable enough to be safely discharged since he required albuterol every 2 hours.

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

The Inpatient Hospital Admission is considered medically necessary for this patient.

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

Diagnosis: Right Flank Pain.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is a patient with no significant past medical history. The patient presented to emergency department (ED) for evaluation of right flank pain and hematuria. The patient was previously treated in ED for right flank pain, was found to have right hydronephrosis, and was started on Flomax and pain medication. She was discharged with nephrolithiasis, hypokalemia, intolerable pain/ nausea/vomiting and dehydration. The patient was again treated in ED and subsequently admitted with concern for obstructive uropathy and pain control. Urology was consulted, the patient's symptoms improved, and she was discharged home. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. They felt that the treatment in the ED was sufficient to manage the patient's condition. 

The appeal on behalf of the hospital is noted and read in detail. The prior computed tomography (CT) revealed mild-minimal right hydronephrosis due to a 5 millimeter (mm) right distal ureteral calculus. The patient had a bedside renal ultrasound in ED which was negative for hydronephrosis. She was initially felt ready to be discharged from the ED but was found to be vomiting in the ED bathroom; she was then admitted. The patient improved quickly on intravenous fluids, pain medication and Flomax, and she was stable for discharge. 

Per MCG Health 25 Renal Colic and Kidney Stones guidelines, this patient fails to meet clinical indications for admission to inpatient care. The patient did have vomiting, but there was no severe underlying cause or complications (bilious, coffee and bloody) and vomiting did not resolve with appropriate antiemetic treatment. 

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

The inpatient hospital admission was not considered medically necessary for this patient.

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

Diagnosis: Hypercholesterolemia and Atherosclerotic Cardiovascular Disease.
Treatment: Praluent (alirocumab) 75 mg/mL (milligrams per milliliter) SC (subcutaneous) SOAJ (solution auto-injector).
The insurer denied coverage for Praluent (alirocumab) 75 mg/mL SC SOAJ.
The denial is overturned.

This is the case of an adult female with a history of hypertension, prediabetes and hyperlipidemia. She was diagnosed with primary severe hyperlipidemia with low density lipoprotein (LDL) cholesterol levels of 200 milligram/deciliter (mg/dL). The patient developed myalgias on high dose statin therapy and was hospitalized for rhabdomyolysis. She is on Zetia and maximally-tolerated statin therapy; her total cholesterol remains elevated (215 mg/dL) and her LDL cholesterol remains elevated (124 mg/dL). A carotid duplex revealed mild to moderate atherosclerotic plaque in both right and left internal carotid arteries. Her physician is requesting treatment with Praluent for hypercholesterolemia and atherosclerotic cardiovascular disease (ASCVD). 

Current American Heart Association (AHA) and American College of Cardiology (ACC) guidelines clearly note that in patients with ASCVD and statin-associated muscle symptoms or recurrent muscle symptoms (despite appropriate re-challenge), randomized trial-proven non statin therapy should be considered (1). AHA/ACC guidelines also recommend the use of PCSK9 (class of drugs that lower LDL) inhibitors in patients with atherosclerotic coronary disease and LDL levels greater than 70 mg/dL in patients intolerant to statin therapy (1). Evolucumab was demonstrated to reduce major adverse cardiovascular events by 15% (percent) in the FOURIER (skilled in math, physics... randomized clinical trial (2).

Medical records clearly indicate that this patient suffered from statin-induced myositis on multiple agents (rosuvastatin and atorvastatin). Given these findings, Alirocumab (Praluent) therapy is the current standard of care according to recent guideline statements (1,3) and is medically necessary treatment for the patient's condition.

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

The insurer's denial of coverage for Praluent (alirocumab) 75 milligrams per milliliter (mg/mL) SC SOAJ for the treatment of hypercholesterolemia and atherosclerotic cardiovascular disease is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 Diabetes. 
Treatment: Invokamet XR, Pre-service. 

The insurer denied the Invokamet XR (extended release). 
The denial is overturned. 

This is a male with type 2 diabetes. He has tried and failed Synjardy, due to stomach pain, and Xigduo, due to hyperglycemia. He is stable on Invokamet. Request for continuation of Invokamet is under review. The prior request for Invokamet was denied as the patient has not had a trial of Synjardy XR (extended release) and Xigduo XR (extended release). The attending physician is appealing this determination. 

Yes, the health plan should cover the proposed treatment. 

This patient has type 2 diabetes. He is stable on Invokamet. He has tried and failed Synjardy and Xigduo. Given he has tried and failed Synjardy, he can be expected to fail Synjardy XR (extended release). Given he has tried and failed Xigduo, he can be expected to fail Xigduo XR (extended release). Without Invokamet, this patient will be at risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the health plan should cover the proposed Invokamet. The recommend duration of treatment is 12 months.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: suspected posterior circulation stroke.
Treatment: inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is upheld. 

This male patient has a history of diabetes, cerebrovascular accident (CVA), hypertension, hyperlipidemia, deep vein thrombosis (DVT), chronic obstructive pulmonary disease (COPD), seizure disorder, alcohol use, and tobacco abuse.

Given that the patient was neurologically and hemodynamically stable with non-focal neurological exam and non-acute brain imaging as well as clinical symptoms suggestive of likely benign positional vertigo rather than acute ischemic stroke, inpatient level of care was not medically necessary, as the patient could have been evaluated for stroke versus benign paroxysmal positional vertigo (BPPV) on the observation level of care.

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 the inpatient hospital admission is upheld.  The medical necessity is not substantiated.