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

Diagnosis: Chronic thoracic back pain.
Treatment: Injections (64490 x 2 and 64491 x 2). 

The insurer denied coverage for Injections (64490 x 2 and 64491 x 2).  The denial is upheld. 

This is a male patient who has chronic thoracic back pain.  He has a thoracic vertebra (T)-9 compression fracture and T12 burst fracture demonstrated on magnetic resonance imaging (MRI).  He is taking Diclofenac for pain.  He had a first set of diagnostic facet blocks bilaterally T11-T12 and T12- L1 [lumbar vertebra-1] which produced 80% pain relief.  The request is for a second diagnostic set and then if greater than 80%, the physician plans to perform thoracic radiofrequency ablation (RFA).

The American Society of Interventional Pain Physicians (ASIPP) Clinical Practice Guidelines (1) state for diagnostic facet blocks:

"Thoracic Spine:  1) The level of evidence is II with moderate strength of recommendation, 2) Three relevant diagnostic accuracy studies, with controlled comparative local anesthetic blocks, with concordant pain relief, with a criterion standard of >= 80% were included, and 3) 	The prevalence varied from 34% to 48%, whereas false-positive rates varied from 42% to 58%."

However, for RFA of the thoracic facets (1) "The level of evidence is III with weak to moderate strength of recommendation with emerging evidence for thoracic radiofrequency ablation with inclusion of one relevant randomized controlled trial and 3 observational studies." 

Unfortunately, while the diagnostic block may identify the location of the pain generator, the use of RFA on thoracic medial branches is not evidence-based.  A review of thoracic facet pain concluded: "Radiofrequency neurotomy and thoracic medial branch blocks are normally used to treat facetogenic pain originating in the thoracic spine.  Although demonstrating promise, larger, robustly designed trials are needed to further elucidate the appropriate treatment of this disorder."

The patient has not had any trials of intra-thecal medication therapy.

There are other evidence based therapies available, and while diagnostic blocks are medically reasonable and necessary, RFA of the thoracic medial branch nerves is considered not medically necessary or reasonable. The health plan acted appropriately.

The insurer's denial of coverage for the Precertification Request for Injections (64490 x 2 and 64491 x 2) is upheld. The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine without aura.
Treatment: Formulary Exception for Ubrelvy. 

The insurer denied coverage for the Formulary Exception for Ubrelvy.  The denial is upheld. 

This is a female patient with a history of migraine without aura.  The patient was initially provided a sample of Ubrelvy, and the treating physician detailed the medication has been therapeutic for the patient.  The patient has had a trial of the required number of formulary alternatives according to the physician. The patient utilized rizatriptan, which did not help her headache.

The documentation provided for the review noted that the patient had nausea and vomiting as a response to rizatriptan, which is not considered an allergy. She would be able to try other Triptans such as almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan injection, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, Zembrace-SymTouch, and Zomig nasal spray. 

Additionally, Nurtec orally disintegrating tablets (ODT) is not a Triptan, which should also be tried without fear, and the requested Ubrelvy is in the same class as Nurtec. Therefore, the requested drug would not be more effective than Nurtec.

The insurer's denial of coverage for the Formulary Exception for Ubrelvy is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins of the pelvis.
Treatment: Ovarian Vein Embolization.

The insurer denied the Ovarian Vein Embolization. The health plan's determination is overturned. 

The patient is a female patient with varicose veins of the pelvis for well over 6 months related to symptomatic retroperitoneal and vulvar venous malformations, more concerning post-partum. Imaging by magnetic resonance imaging (MRI) confirms the findings as does a later Ultrasound with Doppler, which noted prominent varicose pelvic veins. The current treatment plan is Ovarian Vein Embolization. This is the subject of this review.

Ovarian Vein Embolization is medically necessary for this patient.

The Ovarian Vein Embolization has been proven to be safe and effective for the diagnosis given of symptomatic retroperitoneal and vulvar venous malformations. The patient in question has confirmed abnormalities of her pelvic veins.

Pelvic venous incompetence can be a terribly disabling diagnosis and a medical problem that should not be ignored but rather requires a meaningful treatment attempt.

To treat the patient's condition by performance of this minimally invasive approach, mainly venous embolization, will lessen her varicosities and improve her symptoms. There is medical necessity for this proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Infusion Therapy. 
The insurer denied infusion therapy of Hyqvia 2.5-200 INJ for medical necessity. 
The denial was upheld. 

This patient is a female with Autoimmune Gastrointestinal Dysmotility. She had aseptic meningitis with intravenous immunoglobulin (IVIG). She has failed dicyclomine. She had a normal endoscopy. Her celiac serology was positive. Her physician is requesting for Hyqvia 2.5-200 injectable (INJ).
At issue is the medical necessity of Hyqvia 2.5-200 INJ.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Hyqvia 2.5-200 INJ is not medically necessary for this patient.
The use of immune globulin in Autoimmune Gastrointestinal Dysmotility is not supported by the medical literature. There are no robust studies which have shown this to be effective in this condition.
Flanagan et al. conducted a small study of twenty-three subjects evaluated  for suspected AGID fulfilled the following criteria: (1) prominent symptoms of gastrointestinal dysmotility with abnormalities on scintigraphy-manometry; (2) serological evidence or personal/family history of autoimmune disease; (3) treated by immunotherapy on a trial basis. Response was defined subjectively and objectively. Post-immunotherapy, 17 had improvement, both symptomatic and scintigraphic. Nine responders had scintigraphic evidence of improvement. The majority of responders had improvement in autonomic testing. However, this was a very small study.
Therefore, the Hyqvia 2.5-200 INJ is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Dental problems
Dental/Orthodontic Procedure

Diagnosis: Class I Occlusion
Treatment: Braces
The insurer denied braces. The health plan's determination is upheld.

The patient in question is a female with a Class I occlusion with deep overbite and 4-millimeter (mm) overjet. She has minor crowding. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion.

The Insertion of Braces and Adjustment of Braces is not medically necessary for this patient.
While the patient has minor crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 mm. If her teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain.
Treatment: Lumbar or Sacral Epidural Steroid Injection. 

The insurer denied Lumbar or Sacral Epidural Steroid Injection.  The health plan's determination is upheld.

This is a female patient diagnosed with low back pain. The patient was seen for follow-up visit with complaints of a two year history of back pain ranging from 5-8/10. She has used Advil, Tylenol and Flexeril without significant relief. Physical examination revealed mild tenderness over the bilateral lumbar paraspinal tissue. There was more prominent tenderness over the midline osseous elements of the lumbar region at about L5(lumbar spine) level. There was limited lumbar range of motion. Sensory exam was intact in the bilateral lower extremities. Motor strength was intact throughout the bilateral lower extremities. Reflexes were 2+(plus) and equal in the bilateral lower extremities. Slump test was negative for radicular symptoms bilaterally. The provider states that the patient has pain that is likely discogenic in nature rather than facet mediated. It was recommended she perform some exercises, and it was noted they would plan bilateral S1(sacral base) transforaminal epidural steroid injection.

Lumbar or Sacral Epidural Steroid Injection is not medically necessary for this patient. Records provided indicate the patient has chronic back pain. There are no radicular symptoms radiating into the lower extremities and there are no physical examination findings of radiculopathy on examination such as diminished motor strength, sensation, or reflexes in a specific distribution. The patient's neurological examination was noted to be normal and slump test was negative bilaterally for radicular symptoms. There were no corroborative findings on magnetic resonance imaging (MRI) showing disc herniation, clinically significant stenosis or nerve root impingement at any level. The provider states that they feel the patient's pain is discogenic in nature rather than facet mediated, and they feel that these injections are appropriate for discogenic pain. However, epidural steroid injections are only supported for the treatment of radiculopathy, and the patient does not have radiculopathy.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Ilumya. 

The insurer denied coverage for Ilumya. 

The denial is upheld. 

This is a male patient with a history of psoriasis. The patient is noted to have tried and failed Otezla, Topicort, prednisone and Duobril. Clinical notes are submitted for review. The patient's Dermatologist is requesting approval for Ilumya injections for the patient. 

Ilumya is not medically necessary for the patient's condition, Psoriasis Vulgaris.  There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Ilumya for this patient's condition above reasonable alternatives as an accepted standard of practice in the United States (U.S.) over existing alternatives. 

There are no comparative, controlled head-to-head studies showing that Ilumya has a superior efficacy or safety profile to all the formulary alternatives such as phototherapy, methotrexate, or Humira.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient. (1,2,6)  Within the peer-reviewed literature, Racz et al. writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (3).  Mehta et al. writes, "Ultraviolet (UV) B phototherapy is most appropriate for patients with >10 % affected body surface area who have not responded to topical treatments...NB-UVB [Narrow-band ultraviolet B] effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile." (4) 

Additionally, West et al. conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. (5) They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve PASI75 [75% reduction in Psoriasis Area and Severity Index] at primary endpoint. Thus, methotrexate is an effective first-line treatment for the management of psoriasis. (5) 

Lanna et al. (7) discuss the safety and efficacy of Humira in the treatment of psoriasis vulgaris. As such, numerous formulary options exist in the treatment of the patient's condition. The formulary medications are not significantly more likely to cause adverse reactions compared to available formulary alternatives. There are no head-to-head studies which conclusively show that Ilumya would provide a greater safety or efficacy than formulary alternatives. The provided medical notes do not provide any evidence of an absolute contraindication for the use of these available. The formulary drug is not likely to produce a more clinically beneficial outcome.

The Formulary Exception denial for Ilumya is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Heart Disease. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He presented as outpatient with dyspnea on exertion. His PMH (past medical history) was significant for HTN (hypertension) and HLP (hyperlipidemia). Outpatient treatment included ASA (aspirin), statin, diuretic, and beta blocker. Chest CT (computed tomography) scan showed Calcium score of 348 and coronary stenosis. 

The patient was admitted for a cardiac catheterization, and he underwent successful, uncomplicated PCI (percutaneous coronary intervention). He was transferred to telemetry unit for monitoring. He was discharged the next morning. 

No, the Inpatient admission was not medically necessary. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results, It is highlighted in the orders for care. This was an elective admission with a stable patient. 

In this case, all care and treatment could have been safely provided in an outpatient setting. 

The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. 

Community practice and references have shown that post PCI (percutaneous coronary intervention) care is safe in an outpatient setting, and often same day discharge occurs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vogt-Koyanagi-Harada Syndrome and panuveitis

Treatment: pre-service request for the medication Acthar

The insurer denied coverage for pre-service request for the medication Acthar

The denial is overturned

The patient has a diagnosis of Vogt-Koyanagi-Harada (VKH) syndrome in both eyes. Visual acuities were count fingers in the right eye, and 20/80 (pinhole to 20/40) in the left eye.  Exam showed trace cell and flare in both eyes (OU), posterior synechiae in the right eye (OD), 1+ posterior sub capsular cataract OU, serous retinal detachments OU, improving papilledema OU and subretinal neovascularization OD.

Diagnosis of VKH syndrome noted, and that patient is taking Prednisone 10mg three times a day and Humira injections every two weeks.  It was noted that Prednisone was causing significant side effects and would require steroid-sparing medication.  Acthar gel was recommended.

In a letter from the patient's doctor, it was noted that the patient has been on steroids for a few years and that Prednisone is not providing an optimal response.  She is experiencing side effects from Prednisone.  The physician noted that Acthar gel is FDA-approved for panuveitis.

Authorization noted that the patient has been on oral prednisone which is causing significant side effects.  It was noted that the patient requires a steroid sparing medication, Humira is not providing an adequate response and additional therapy is required.

Repository corticotropin was approved by the FDA in 1952 for the treatment of various inflammatory conditions, including ocular inflammation/uveitis.  Acthar Gel (repository corticotropin injection) is FDA- approved for various acute and chronic inflammatory ophthalmic conditions, including uveitis.  In specific cases such as this where the patient has developed multiple drug intolerances or ineffectiveness to corticosteroids and immunomodulators (which are conventional treatments currently recommended by the American Uveitis Society and other authorities in the field), Acthar gel is medically necessary.

The patient has significant panuveitis due to VKH syndrome and has tried and failed oral steroid (Prednisone) and steroid immunomodulatory therapy (Humira).  Because the patient has failed sparing immunosuppressive therapy and steroid therapy, Acthar is medically necessary. Conventional treatment for patients with uveitis often requires steroids and immunomodulatory therapy.  The patient has tried these standard treatments, including steroids and Humira.  The patient's disease is not well-controlled despite these therapies.  Because of this, Acthar Gel is one of the limited remaining options for the treatment of this patient's condition to prevent permanent vision loss. 

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

The insurer's denial of coverage for the Pre-Service Request for Acthar to Treat Panuveitis is overturned.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: major depressive disorder and generalized anxiety disorder

Treatment: mental health residential treatment level of care

The insurer is denied coverage for mental heath residential treatment level of care.

The denial is overturned. 

This female patient has a history of depressive symptoms and anxiety symptoms and severe suicidality including suicide attempt by hanging with a sheet. She reportedly had depressed mood, decreased speech, overthinking, social fears, worrying, and anxious mood. She reportedly had diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder. She reportedly took Lithium, Buspirone, Wellbutrin, Trazodone, attended group, individual, and family therapy. 

This patient was considered a high risk patient due to her past suicide attempts, continued depressive and anxiety symptoms, self-injurious behavior while in this setting during the denial period and limited coping skills. She required a significant time in this inpatient therapeutic residential treatment setting to try to learn better coping skills, improve insight and decision making, better control emotions, and sustain gains and further progress so that when finally discharged from 24 hour treatment she could have the best chance of not regressing or making other suicide attempts.
This was a high risk patient who required a long time in a therapeutic residential setting. She even had a reported self-injury attempt by cutting self with scissors on her wrist on during the denial period so she was not considered safe for discharge. She required at least this inpatient mental health residential treatment as she was discharged. This was a high risk patient with psychiatric issues interfering with her functioning and she required a long period of time in a 24 hour therapeutic mental health residential treatment. The previous decision should be reversed and approve continued mental health residential treatment as she was discharged.
	
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for mental health residential treatment level of care is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: severe bacterial infection

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This male patient has a history of hyperbilirubinemia requiring phototherapy. He presented to the emergency room (ER) with complaints of a fever, nasal congestion, decreased intake, and decreased output. Temperature was 102.2 F. Labs revealed leukopenia with neutropenia. The physical examination revealed mild pharyngeal erythema, no petechiae, and no exudates. A chest x-ray (CXR) revealed findings that were suspicious for bronchiolitis or atypical viral pneumonia. The patient was given 120 milligrams (mg) of rectal Tylenol and intramuscular (IM) Ceftriaxone. The infant was bagged. There was a suspicion for a severe bacterial infection (SBI.) He was admitted on for further care. Vital signs were monitored as per protocol.  3-4 ounces (oz) of formula was given every 3-4 hours (Q3-4H.) Ceftriaxone was given once a day (QD.) Intake and output was monitored. Tylenol was given as needed (PRN) for fever. Blood cultures were negative. By the time of discharge the infant remained stable for more than 24 hours and vitals were stable. He was discharged on with instructions to follow up with the primary care physician (PCP) within 2-3 days of discharge.   

A chest x-ray revealed findings that were "suspicious for bronchiolitis or atypical viral pneumonia". About 1 hour after arrival complete blood count (CBC) showed borderline leucopenia of 4,900 with an absolute neutrophil count (ANC) of 1000, and low platelets 58,000. About 2 hours later CBC showed leucopenia 3,600 with an ANC of 1000 again, but platelets normal at 276,000. C-reactive protein (CRP) was normal. All other lab parameters were within normal limits.  The stated justification for admission is suspicion for a severe bacterial infection (SBI.) However, he did not meet criteria for SBI because he was not in the high-risk age range nor was toxic appearing.  (Sherman and Sood) 
He did not have thrombocytopenia. The first low count was likely a lab artifact. He had borderline leukopenia and borderline neutropenia, which can be attributed to his viral infection, and was not an indication for antibiotic therapy. His band count was 6%, which can be seen in a viral infection.

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.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Advanced Imaging. 
The insurer denied MRI. 
The denial is overturned.

The patient is a female with acute traumatic dislocation of left patella. The treating provider requested a magnetic resonance imaging (MRI) to evaluate for osteochondral injury and need for urgent surgical intervention. The subject under review is the medical necessity for the MRI.

The health plan's determination is overturned in whole. 

The MRI is medically necessary for this patient. The patient is skeletally immature, and the literature suggests that the incidence of osteochondral fracture/injury in patients with acute patella dislocation approaches 40% (30-50%) and is frequently not detected by plain radiographs alone, supporting the need for MRI in patients such as the one in this case with patella dislocation. Osteochondral injury was identified on the MRI that was obtained.