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

Diagnosis: Skin Disorders
Treatment: Pharmacy/Prescription Drug (Stelara)
The health plan denied the requested drug. 
The health plan's determination is upheld.

The patient is a female with moderate to severe psoriasis that includes the hands and feet and trunk. The patient is also diagnosed with pityriasis rubra pilaris. The patient has been on Stelara at a dosing of every 8 weeks. The patient has tried and failed topical Duobrii, Halobetasol, Clobetasol, and Triamcinolone.
The medical necessity of Stelara dosed every 6 weeks is under review for medical necessity.

The health plan's determination of Stelara for a dosing of every 6 weeks is upheld. 

No. Stelara appears to have had insufficient results for this patient at a standard Food and Drug Administration (FDA) dosing of every 12 weeks, or even at 8 weeks, and an alternative medication or combination of treatments (such as Taltz, which is FDA-approved as of the spring of 2020) is a more medically appropriate treatment for this patient at this time. Alternative treatments, either alone or in combination should be considered as a more effective way of treating this patient's particular clinical scenario. Accordingly, the request for coverage of Stelara dosed every 6 weeks for this patient is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Endometrial Hyperplasia.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient hospital stay.  The denial is upheld.


The patient has a diagnosis of endometrial hyperplasia.  She underwent a robotic assisted total hysterectomy, bilateral salpingectomy and sentinel lymph node biopsy.  She was admitted after surgery and discharged the next day.  At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.  Robotic-assisted hysterectomy is an outpatient or ambulatory procedure.  The operation was not complicated and did not require conversion to a laparotomy.  That the patient had stable vital signs after surgery, a nonfocal exam and was able to ambulate, void and tolerate an oral diet and oral medications.  She did not have any acute conditions that would justify medical necessity for inpatient level of care.  Therefore, the requested hospital admission was not medically necessary, since it is not supported by peer-reviewed literature; it is not standard of care, and it is not supported by professional organizations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neuropathic pain. 
Treatment: Temporary Spinal Neurotransmitter (CPT 63650). 

The insurer denied coverage for a Temporary Spinal Neurotransmitter (CPT 63650). 

The denial is upheld. 

This is a female patient with a history of neuropathic pain of the left anterolateral thigh corresponding to the left lateral femoral cutaneous nerve. The patient also has been experiencing right upper extremity radicular pain. The notes state that the patent continues to find benefit of approximately 50 percent reduction in the left thigh pain with methadone. In the past, the patient has tried nortriptyline, duloxetine, and Lyrica, which were poorly tolerated. The Pain Medicine Specialist is requesting approval of Abbot dorsal root ganglion (DRG) stimulation. 

There is no documentation of transcutaneous electrical nerve stimulation (TENS), transdermal medications or intra-thecal medication trials. The patient had a lumbar sympathetic block but obtained no relief of the pain. Based on the review of the medical record, the patient has peripheral neuropathy.  The patient does not meet the Budapest criteria for complex regional pain syndrome (CRPS) and had a negative lumbar sacral sympathetic block. The literature support for dorsal root ganglion (DRG) in peripheral neuropathy is scarce and is limited to small case studies (Falowski et al., 2019; Mol and Roumen, 2018). The long-term effectiveness of this approach has not been documented.  The conventional methods of transdermal analgesics, TENS, and intra-thecal medications are not documented as having been previously trialed. 

The spinal (DRG) neurostimulator is not considered medically reasonable or necessary for this patient. There are evidence-based therapies available that this patient has not trialed. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for a Temporary Spinal Neurotransmitter (CPT 63650) is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis. 
Treatment: Tecfidera. 
The insurer denied Tecfidera. 
The health plan's determination is overturned. 

The patient is a female with a diagnosis of relapsing remitting multiple sclerosis. She complained of a film over the vision in the right greater than left eye occurring intermittently that was more likely to occur with headaches, as well as fatigue and pain that had been more manageable. Tysabri that was restarted and was missed the previous month. She was scheduled for an infusion on that date. She had been diagnosed with multiple sclerosis after developing bilateral foot numbness the year previously and developed optic neuritis and enhancing brain and spinal cord lesions. She was previously treated with Copaxone, Tecfidera, and Tysabri that was interrupted by pregnancy. Continuation of Tecfidera was recommended. 

Tecfidera is medically necessary for this patient. A change to dimethyl fumarate resulted in an adverse reaction, suggesting an adverse reaction not due to the active ingredient of Tecfidera (dimethyl fumarate). It is contrary to neurological standards of care to change the disease-modifying therapy, if the patient is being treated successfully. While there are other multiple sclerosis disease-modifying therapies available for the patient, a change to another medication with a different mechanism of action may result in loss of efficacy and progression of symptoms. As the patient had been successfully maintained on Tecfidera and was switched to dimethyl fumarate with adverse effects, the use of Tecfidera is appropriate and medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Bilateral Chorioretinal Inflammation And Bilateral Panuveitis Of The Eye
Treatment: Intravenous Immunoglobulin (IVIG) Code J1569
The insurer denied the Intravenous Immunoglobulin (IVIG) Code J1569.
The denial is overturned. 

The patient is a female with bilateral chorioretinal inflammation due to non-paraneoplastic autoimmune retinopathy vs. acute zonal occult outer retinopathy (AZOOR). She has positive anti-retinal antibodies tested at the University of Oregon Ocular Immunology Laboratory. Her treating physician is a fellowship trained ocular inflammation specialist who has been following her due to the fact that her vision loss is progressing despite corticosteroid treatment and due to the expected adverse effects of corticosteroids. She has tried Cellcept, azathioprine, Humira, and methotrexate without control of the disease and side effects. She has also tried intraocular corticosteroid injections without improvement. The patient obtained a specialty opinion from a specialist who recommended IVIG (intravenous immunoglobulin) treatment based on the available medical literature. Her insurance company considers IVIG (intravenous immunoglobulin) investigational or experimental for this condition. 

Yes, the health plan should cover the treatment with IVIG (intravenous immunoglobulin) Therapy.

All other reasonable treatment options for this patient have been explored. Treatment of this condition with IVIG (intravenous immunoglobulin) is reasonable given the medical history and the currently available medical literature.

 Yes. The patient has attempted all other reasonable standard treatments. The literature suggests that IVIG (intravenous immunoglobulin) may be more beneficial than any other treatments. Therefore, given these circumstances, the health plan should cover the IVIG (intravenous immunoglobulin) Therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class II, retruded mandible, maxillary and mandibular crowding, deep bite, excessive overjet and impacted right mandibular canine)

Treatment: D8080 braces and D8670 monthly visit x 12

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.

The denial is upheld. 

This is a male patient who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II, retruded mandible, maxillary and mandibular crowding, deep bite, excessive overjet and impacted right mandibular canine. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. This reviewer concurs with the findings of the insurer of attaining 12 points on the HLD index (i.e., 4 points overjet, 5 points overbite, 3 points labiolingual spread).
 
As per review of the medical record and literature, D8080 braces and D8670 monthly visit x 12 is not considered medically necessary for this patient.

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

Based on the above, the medical necessity for D8080 braces and D8670 monthly visit x 12 is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Infection
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient female with history of asthma who had subjective fevers at home with cough and shortness of breath. The patient was found to have pneumonia during the emergency room evaluation. The patient was admitted to acute hospitalization for the management of pneumonia.

The patient was admitted to acute hospitalization for intravenous (IV) antibiotics and intravenous (IV) steroids. The patient's dyspnea slowly improved. The patient was continued on intravenous (IV) antibiotics and IV steroids were tapered. The patient then had worsening hypoxia and required oxygen at 4l NC. Patient was continued on IV antibiotics as well as oral prednisone. The patient was able to tolerate oral diet. Patient's oxygen levels did not drop below 90%. Patient was slowly improving on current antibiotics.  There was not trial and failure of outpatient treatment with oral antibiotics and steroids. Although patient had multi-focal pneumonia, patient's oxygen levels stayed at or above 90% on room air. The acute hospitalization is not medically necessary. 

No, the proposed inpatient admission was not medically necessary.

The patient was admitted to acute hospitalization for intravenous (IV) antibiotics and intravenous (IV) steroids. The patient's dyspnea slowly improved. The patient was continued on intravenous (IV) antibiotics and intravenous (IV) steroids were tapered. The patient has worsening hypoxia and required oxygen at four liters nasal canula (4L NC). The patient was continued on intravenous (IV) antibiotics as well as oral prednisone.  The patient was able to tolerate oral diet. The patient's oxygen levels did not drop below 90%. The patient was slowly improving on the current antibiotics.  There was not trial and failure of outpatient treatment with oral antibiotics and steroids. Although the patient had multi-focal pneumonia, the patient's oxygen levels stayed at or above 90% on room air. The acute hospitalization was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD (gastroesophageal reflux disease).
Treatment: LINX Reflux Management System (43284) and Inpatient Stay.
The insurer denied the LINX Reflux Management System (43284) and Inpatient Stay. The denial is overturned. 

The patient is a man with belching, chest pain, early satiety, globus sensation, heartburn, a hoarse voice and a sore throat.  He was found to have an ulcer at the GE (gastroesophageal) junction on upper endoscopy, elevated esophageal acid exposure on esophageal pH (potential of hydrogen) monitor, and normal motility on esophageal manometry and UGI (upper gastrointestinal series) revealed hiatal hernia.  He was recommended to undergo laparoscopic hiatal hernia repair with LINX.  He has tried Protonix 40 twice a day without benefit. He has tried elevating the head of bed and dietary changes. 

Yes, the health plan should cover the LINX Reflux Management System (43284) and Inpatient Stay.

Yes, the LINX Reflux Management System (43284) and Inpatient Stay is likely to be more beneficial.

This patient suffers from GERD (gastroesophageal reflux disease) causing profound symptoms.    Even with PPI (proton pump inhibitor) there is refluxing gastric contents.   Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF (Laparoscopic Nissen Fundoplication) make it a less than ideal operation.  LINX is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA (Food and Drug Administration).  There is published data on patients who have had the device for 12 years, showing a very low complication rate and a high resolution of GERD (gastroesophageal reflux disease).  This operation commonly requires an inpatient stay to prevent postoperative nausea and vomiting, and to observe for bleeding, therefore the inpatient stay should be approved as well.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trigeminal neuralgia
Treatment: An electrical stimulator for the nerves of the head (trigeminal nerves)
The insurer denied coverage for an electrical stimulator for the nerves of the head (trigeminal nerves).
The denial is upheld.

This is a female with a diagnosis of trigeminal neuralgia. Her pain was in the maxillary branch (V2) and mandibular branch (V3) distribution on the left with numbness in the V2 distribution. She rated her pain at an 8-9/10. A neurosurgeon suggested an electrical stimulator for the pain that had not responded to conservative treatment. She was seen by another neurosurgeon who recommended an intrathecal pump trial or a cervical spinal cord stimulator trial. She was seen by a third neurosurgeon who did not feel that she had trigeminal neuralgia as the medications had not made a difference and she had no imaging suggestive of trigeminal nerve compression. She had 40-50% relief of pain in the V2 but not the V3 distribution after a nerve block. A computed tomography angiography (CTA) of the head noted a tiny linear outpouching that arose near the junction of the left posterior cerebral artery and left posterior communicating artery, unchanged. Magnetic resonance imaging (MRI) of the head noted a tiny focal outpouching at the left P1 posterior communicating artery junction, felt related to small aneurysm. A brain MRI noted no pathological enhancement, mass or compression that involved either trigeminal nerve. A computerized tomography (CT) of the maxillofacial bones stated status post extraction of third maxillary molar tooth; no etiology for the reported symptoms was identified.

The procedure for the patient's condition is not supported by the literature. Studies are limited by relatively few patients studied and limited duration of follow-up. The electrical stimulator is not considered medically necessary for this patient. It is not clear that the patient has trigeminal neuralgia at V2 and V3. There are differences of opinion among providers if she has trigeminal neuralgia as she has not responded to medications. Her studies do not show any pathology of the trigeminal nerves. She did have 40-50% improvement with a nerve block in the V2 distribution only. There is a history of personality changes, memory loss and anxiety. No psychological evaluation is provided.  The documentation provided does not support the need for the requested surgery and it is thus not medically necessary.

There is little evidence regarding the long-term efficacy of peripheral nerve stimulation therapy in managing chronic pain. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an electrical stimulator for the nerves of the head (trigeminal nerves) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Benign prostatic hyperplasia.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a history of hypertension, arrhythmia, benign prostatic hyperplasia (BPH) and bladder outlet obstruction, who presented for an elective procedure.  He underwent a cystoscopy and transurethral resection of the prostate under general anesthesia.  Postoperatively, he was admitted to the hospital and inpatient status.  He was managed with continuous bladder irrigation.  He had an uneventful hospital course and was discharged home the next day.  At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.

A majority of patients who undergo transurethral resection of prostate can be discharged within 24 hours of the procedure.  The procedure was an elective scheduled procedure.  The patient did not have any significant risk factors, which increase the risk of post-operative complications.  His postoperative course was essentially normal without any significant complications or issues with pain control.  Care could have been provided safely and effectively at a lower level of care, which is the generally accepted standard and the most appropriate treatment option.  Admission status may be changed anytime during the stay, if the patient requires continuing services and monitoring and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

Skin disorder. 
Home Health Care

Diagnosis: Decubitus Sacral Ulcer. 
Treatment: Personal Care Worker (PCW) Service.  
The insurer denied Increase in Personal Care Worker (PCW) Service to 7 Days per Week, 12 Hours per Day, Mutually with Spouse in Total 24 Hours, Split Shift Continuous Care by More Than One Person. The health plan's determination is overturned. 

The patient is a female with past medical history of dementia, depression, decubitus sacral ulcer, urinary incontinence, stool incontinence, osteoarthritis, coronary artery disease, congestive heart failure, cerebrovascular accident (CVA), hypertension, hyperlipidemia, and gastroesophageal reflux disease (GERD) who had been assigned PCW (personal care worker) services mutual with spouse 24 hours/day, live-in. There was a request to increase PCW services mutual with spouse to 24 hours, split-shift. The patient requires supervision day and night due to constant anxiety, difficulty sleeping, and her physical and mental decline. The primary care physician (PCP) also noted the patient is bed bound, is unable to re-position herself in bed, and current home care services are no longer sufficient for her needs. Proper repositioning in bed every 2-3 hours day/night with proper incontinence care day/night to prevent skin complications was recommended by the patient's PCP. 

The increase in Personal Care Worker (PCW) Service to 7 Days per Week, 12 Hours per Day, Mutually with Spouse in Total 24 Hours, Split Shift Continuous Care by More Than One Person is medically necessary. The patient's PCP documented progression of patient's chronic medical problems as well as documented need for turning and repositioning every 2-3 hours due to stool and urinary incontinence in the setting of previous sacral ulcer. The increase in PCW services hours is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) tasks, specifically bed mobility, personal hygiene, toileting and transfer toilet in the overnight hours. The patient has unscheduled and unpredictable care needs in the overnight hours (toileting/diaper care/repositioning). The patient's care needs would not allow a PCW to obtain greater than 5 hours of uninterrupted sleep. 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 her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine.
Treatment: Sumatriptan/Naproxen Sodium 85-500MG Tab.

The insurer denied Sumatriptan/Naproxen Sodium 85-500MG Tab. The determination is upheld.

The patient has a listed diagnosis of migraine. The type of migraine is not specified. The limited documentation that was provided reports a monthly headache, severe, with photophobia, and avoidance of physical activity. Over the counter ibuprofen is reported as having failed. Sumatriptan/Naproxen (Treximet) was requested. At issue is the medical necessity of Sumatriptan/Naproxen Sodium.

The Sumatriptan/Naproxen Sodium is not medically necessary. There is no evidence that the patient failed standard of care triptans.

The requested Sumatriptan/Naproxen Sodium is neither the standard of care for headaches, nor a first line therapy. The current standard of care for the acute treatment of migraines includes 5-HT (hydroxytryptamine receptor) agents, which have a better established long-term efficacy and safety profile. There is insufficient evidence to support the superiority of the requested agent over such options. The formulary medications of Sumatripatin, Naproxen (prescribed as separate agents and used concurrently), Rizatriptan, Zolmitriptan, Naritriptan are Food and Drug Administration (FDA) approved and proven agents in the treatment of acute migraine attacks.