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

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Pharmacy/Prescription Drugs 
The insurer denied OxyContin. 
The denial is overturned. 

The patient is a female with a history of chronic low back pain. She was treated under the care of her provider for chronic low back pain. She was treated with Percocet in the past as well as MS (morphine sulfate) Contin, which did not provide pain relief. She has appropriate pain control with OxyContin 15 milligrams (mg) twice daily. She does undergo regular urine drug testing.

At issue is the medical necessity of OxyContin 15 mg OR T12A.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of OxyContin 15 mg OR T12A is medically necessary for this patient.

OxyContin should be individually titrated to a dose that provides adequate analgesia and minimizes adverse reactions. The physician must continually reevaluate patients receiving OxyContin to assess the maintenance of pain control and the relative incidence of adverse reactions, as well as monitoring for the development of addiction, abuse, or misuse. Frequent communication is important among the prescriber, other members of the healthcare team, the patient, and the caregiver/family during periods of changing analgesic requirements, including initial titration. During chronic therapy, patients should be periodically reassessed for the continued need for the use of opioid analgesics. Because there are differences in patient tolerance, pain relief and metabolism, there are no definitive parameters for the appropriate dosage of this medication. It is also widely known and generally accepted that opiate analgesic medication does not have a "ceiling effect," therefore the appropriate dose will depend on the presented variables. In this case, the patient has failed multiple other treatments. She has kept regular follow up appointments with her prescribing physician and undergoes regular urine drug testing. The treatment is appropriate.

Therefore, the requested health service/treatment of OxyContin 15 mg OR T12A is medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: dental problems
Treatment: Outpatient Dental Surgery 
The insurer denied Outpatient Dental Surgery. The health plan's determination is overturned. 

The patient is a female who presents for evaluation and treatment of multiple teeth for treatment of pulpal therapy, direct and indirect restorations including stainless steel crowns, and full mouth debridement. In question is the medical necessity of outpatient dental care under general anesthesia.

The outpatient dental surgery is medically necessary for this patient.
From the documentation provided, the clinical exam showed the patient to be uncooperative for examination, fearful, uncooperative, emotional, and was not able to complete radiographic examination. The patient does not weigh enough to allow for multiple injections of local anesthetic to allow for treatment of the entire mouth and cannot sit for simple procedures let alone pulpal therapy and stainless steel crowns. Considering the medical limitation of the patient and age, it is medically necessary to deliver the treatment in an outpatient setting under general anesthesia to allow for the appropriate treatment to move forward. The treatment of outpatient dental surgery under general anesthesia is thus medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He had abdominal pain and was hospitalized.

A brief summary of the hospital stay follows:

Day one, per the ED (emergency department) note and admission H&P (history and physical), he was seen in ED (emergency department) for abdominal pain; no other symptoms; normal labs; CT (computed tomography) scan result was inconclusive with possible acute appendicitis. Surgery requested admission for serial abdominal exam. The patient was made NPO (nothing by mouth) and given IV (intravenous) fluids.

On day two, per the discharge summary, the patient's diet was advanced as tolerated, and then he was discharged home.

No, the Inpatient admission was not medically necessary.
As documented in ED (emergency department) note and admission H&P (history and physical), this patient had acute abdominal pain for one day. The patient did not have fever, vomiting or diarrhea. Labs were normal. Abdominal CT (computed tomography) scan did not show any significant changes and was equivocal for appendicitis. The surgery consult requested to admit the patient for monitoring of symptoms and serial abdominal exam. After admission, the patient did not have much pain and was able to tolerate regular diet.

There was no documentation for any hemodynamic instability, severe abdominal pain, peritoneal signs, suspected toxic colon, intestinal perforation, inability to maintain hydration, or electrolyte abnormalities. Thus, the requested inpatient care was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The health plan's clinical indications for inpatient admission are consistent with current clinical standards of medical practice. The health plan acted reasonably.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Plaque Psoriasis. 
Treatment: Formulary exception for Taltz. 
The insurer denied the Formulary exception for Taltz. 
The denial is upheld. 

The patient is a female with psoriasis, over 60% body surface area (BSA), treated with topical steroids, topical calcineurin inhibitors, Tremfya, Stelara, and Ilumya.  The provider is requesting Taltz. 

No, the health plan should not cover the proposed formulary exception for Taltz. 

The health plan requires a trial and failure of all formulary medications: 
1) topical steroids 
2) calcipotriene 
3) methotrexate, cyclosporine, acitretin 
4) Humira, Otezla, Stelara, Skyrizi, Tremfya, Enbrel, Cosentyx, and Cimzia. 

The formulary biologics would be effective for the patient and are likely to be as effective as Taltz, and are no more likely to have adverse effects than Taltz. Methotrexate and other systemic immunosuppressants are likely to be ineffective and carry a greater risk of adverse events than the biologic medications.  Therefore, Cosentyx or other formulary biologics are appropriate for this patient and Taltz should not be covered.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hypertension (HTN), migraine headaches, seizures and hypothyroid.

Treatment PCW (personal care worker) service for 7 days per week, 24 hours per day, live in, 91 hour per week.

The insurer denied coverage for PCW service for 7 days per week, 24 hours per day, live in, 91 hour per week.

The denial is modified .

This is a patient with chronic medical problems including hypertension (HTN), migraine headaches, seizures and hypothyroid.  She currently has PCW services, 4.5 hours/day at 7 days/week.  She is requesting an increase of 24 hours/day at 7 days/week: totaling 91 hour per week.

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance for meal preparation, housework and shopping.  She requires limited assistance for personal hygiene, toilet use and walking.  Upper and lower body dressing requires extensive assistance.  She is continent of bowel and "occasionally incontinent" of bladder.  The patient's cognitive status is "minimally impaired."  The clinical records and assessments do not support the patient having functional and cognitive deficits to support the medical necessity of the requested personal care worker (PCW) services for 7 days per week, 24hours/day: totaling 91 hour per week.  However, an increase of PCW services 7 days/week for 8 hours/day will allow the patient to continue to safely live at home.    

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

From a physical medicine and rehabilitation perspective, an increase of PCW services 7 days/week, for 8 hours/day is clinically appropriate and medically necessary.  

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

The insurer's denial of coverage for personal care worker (PCW) service for 7 days per week, 24 hours per day, live in, 91 hour per week is modified. Medical Necessity is substantiated for an increase of PCW services to 8 hours/day, 7 days/week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo

Treatment: tofacitinib compound

The insurer denied coverage for tofacitinib compound

The denial is overturned.

The patient has a history of breast cancer and diagnosis of vitiligo.  The patient has failed therapy with tacrolimus, topical steroid, triamcinolone as well excimer light therapy.  The requested medication is topical compounded tofacitinib cream.  

Based on the submitted documentation, topical tofacitinib cream is medically necessary for the treatment of the patient's condition.  The patient has failed standard topical therapies, which would include topical steroids as well as non-steroidal option-tacrolimus ointment.  Vitiligo is an autoimmune disease and requires appropriate therapy.  The use of topical anti-inflammatory agents is within the standard of care prior to proceeding to systemic therapies with associated increased risks.  The use of topical tofacitinib under the supervision of the Dermatologist is medically necessary. 

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

Based on the above, the medical necessity for the Tofacitinib Compound is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female.  She presented to the hospital at 36 weeks gestation with contractions every 10 minutes.  Her pregnancy was complicated by a prior loss at 20 weeks consistent with cervical insufficiency, and she had a cerclage placed earlier in pregnancy, which had been removed the day prior to admission.

There was no evidence of ruptured membranes.  On exam, the patient's cervix was dilated 4 centimeters and 100% effaced, and contractions were noted to be irregular.  Fetal assessment was normal with 8/8 biophysical and reactive nonstress test.  She was treated with hydration, Benadryl, and morphine.  The contractions resolved, and she was discharged home on hospital day # (number) 1.

Coverage for the hospitalization was denied by the health plan due to lack of documentation of ruptured membranes, significant maternal disease requiring inpatient treatment, complications of tocolytic therapy, or monitoring requirements beyond observation care time frame.  The health plan cites MCG (Milliman care guidelines) 24th edition Preterm Labor ORG:M-287 (ISC).  The facility contends that the admission was medically necessary because it would have been unsafe to provide care other than as acute inpatient, and cites MCG (Milliman care guidelines) 25th edition Preterm Labor M-287 (ISC) need for continued fetal monitoring that requires inpatient care.

No, the inpatient admission was not medically necessary.

The patient did not meet criteria for the diagnosis of preterm labor, defined as change of cervical exam demonstrating progressive effacement or dilation of the cervix.  Additionally, at 36 weeks there is no demonstrable benefit from tocolytic therapy, the intervention that would be applied if preterm labor were to be appropriately diagnosed, because the gestational age is beyond 34 weeks.  The standard approach to patients presenting with uterine contractions near term beyond 34 weeks with intact membranes would be observation as an outpatient for cervical change, and if not present, discharge to await true labor.  Therefore, the admission was not medically necessary.

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

The admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient in this case is a female who presented to the emergency department with a two week history of abdominal pain, flank pain and back pain.  Evaluation in the emergency department revealed right lower extremity deep vein thrombosis (DVT) and right lower lobe pulmonary emboli were identified.  At the time of initial evaluation she was not hypoxic and also had no hemodynamic instability.  She was admitted to the hospital and started on Lovenox.  

It was noted that the patient had been taking doxycycline prior to admission due to concern for possible pneumonia.   She was not started on intravenous antibiotics at the time of admission.  She was noted to have significant fatigue at the time of admission and during her hospital stay.  She was transitioned from Lovenox to Xarelto and was to be discharged.  However, it was decided before she was sent home that she would be discharged to inpatient rehab and therefore she was not discharged officially until a few days later.

No, the inpatient admission was not medically necessary.
This patient was diagnosed with pulmonary embolism and deep vein thrombosis (DVT) and was treated with anticoagulation.  She was hemodynamically stable at the time of hospitalization and remained so during her hospital stay.  She was not hypoxic.  Also, based on review of records, she did not have massive or sub-massive pulmonary embolism and there was no documented evidence of right heart strain.  She did complain of significant fatigue, but given lack of hemodynamic instability, hypoxia, active infection requiring intravenous antibiotics or any other acute condition causing instability, she did not require acute care inpatient hospitalization.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee end stage osteoarthritis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female with right knee end stage osteoarthritis. She was admitted to hospital and underwent an elective total knee arthroplasty. She had problems with ambulation after the procedure. Her admission status was changed to inpatient secondary to her inability to reach PT (physical therapy) goals.

No, the Inpatient admission was not medically necessary.
The records show a non-complicated course after total knee arthroplasty. The patient's vital signs were stable. There was no evidence of bleeding or infection. There were no other medical problems to required care. The patient was able to tolerate oral pain medications.

The physical therapy records showed ability to walk 50 and 75 feet with walker on post-operative day #1. The patient also requested to go home on that date.

There were no medical problems to warrant the inpatient admission. Care could have been provided at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs - Dupixent
The insurer denied Dupixent pen. The denial is upheld.

The patient is a male with atopic dermatitis. Body surface area affected is 40%. He has tried and failed triamcinolone cream and hydrocortisone. He has also failed prednisone and Eucrisa. His medication list lists tacrolimus 0.1% ointment, however there is no reference to it in the medical records. It is not clear when it was prescribed, if and how often the patient has used the tacrolimus, and the patient's response. The medication under review is the medical necessity for Dupixent pen 300 milligrams (mg)/2 milliliter (ml) pen injector.

The requested health treatment of Dupixent pen 300mg/2ml pen injector is not medically necessary for this patient. There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the preferred therapies, which have been shown to be effective for atopic dermatitis.
Based on the evidence-based literature, the Dupixent 300 mg/2 ml pen is not medically necessary. There are no comparative, controlled studies showing that Dupixent has a superior efficacy or safety profile to all of the formulary alternatives.
According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan, such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis (1, 2).
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults" (3).
It is noted that the patient has tried and failed topical steroids. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The preferred agents, such as tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient based on the evidence-based literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pseudo pocketing

Treatment cleaning of tooth roots (deep cleaning) of whole mouth

The insurer denied coverage for cleaning of tooth roots (deep cleaning) of whole mouth

The denial is upheld

Based on the submitted documentation which includes copies of periodontal charting, and full mouth series radiographs and insurer correspondence, it appears that this patient presented for evaluation for dental services and periodontal therapy. The dentist reported periodontal chartings indicating 2-5 mm (millimeter) generalized periodontal pocketing with focal 6 mm depth readings. The recommended treatment was scaling root planning in all four maxillary and mandibular quadrants. The insurer has denied the service as the information provided does not show evidence of moderate to severe periodontal disease or other clinical or radiographic criteria to justify the services and therefore does not meet clinical criteria to support scaling and root planning.  The patient is appealing.

Upon review of the submitted documentation, both the radiographs and periodontal probing depths, there is minimal if any loss of alveolar bone height affecting these teeth. There is no evidence of radiographic calculus. The increased pocket depth likely represent pseudo pocketing due to superficial calculus accumulation and/or poor hygiene.  There is minimal significant periodontal probing with no periodontal probing over 6mm depth. And there is no documentation of any bleeding on probing. The insurer has correctly applied the clinical criteria in denying scaling and root planning services.

Uphold denial of coverage for cleaning of tooth roots (deep cleaning) of whole mouth as not medically necessary as the clinical and radiographic docun1entation does not support or substantiate scaling and root planning services.

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.  Cleaning of tooth roots (deep cleaning) of whole mouth is not considered medically necessary for this patient.

Based on the above, the medical necessity for the cleaning of tooth roots (deep cleaning) of whole mouth is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical Disc Herniation
Treatment: Facet joint injections

The insurer denied coverage for facet joint injections.
The denial is upheld .

This patient has had neck pain for several months and reported greater than 80% (percent) improvement from an epidural steroid injection but continued to have axial neck pain. The patient has tried conservative measures for 2 months and her current pain level is 8/10. Results of magnetic resonance imaging (MRI) of the neck showed a left paracentral disc herniation at cervical (C) 5-6 and at C6-C7 resulting in moderate central canal stenosis and severe left foraminal stenosis. A diagnostic cervical medial branch block of bilateral C4/5, C5/6, C6/7 facet joints is requested.

The patient has clear disc pathology which has not been adequately addressed.  The pain physician wants to perform further diagnostic tests in the face of an extruded disc.  No surgical consultation has been obtained.

In the cervical spine, Bogduk and Aprill (1) assessed the prevalence of discogenic pain and zygapophysial facet joint pain. They showed that discs alone were symptomatic in only 20% of the sample. However, in 41% of the patients, both a symptomatic disc and symptomatic zygapophysial joints were identified. 

Here you have a symptomatic disc, no facet arthropathy on MRI and extruded disc material. 

In the section on cervical disc herniation, guidelines make no mention of the need for diagnostic blocks (2).

The axial pain the patient is experiencing is probably related to the extruded disc. It is not medically reasonable or necessary to perform diagnostic blocks when an obvious pain generator has been identified.

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

Based on the above, the medical necessity for facet joint injections is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic sinusitis. 
Treatment: Ambulatory Surgery (31259). 

The insurer denied the Ambulatory Surgery (31259). 
The denial is overturned. 

The patient is a male with chronic sinusitis who has failed prior antibiotic therapy, irrigation and topical steroids.  The patient has radiographic evidence of sphenoid, ethmoid, maxillary and frontal sinus disease. 

Yes, the proposed treatment is medically necessary. 

There is computed tomography (CT) evidence of mucosal thickening in bilateral sinus cavities indicative of chronic sinusitis. There is therefore indication for the right sided ethmoid and sphenoid surgery in addition to the approved codes. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

It is most beneficial to address all the affected sinuses in one operative procedure as the attending physician (AP) notes in his letters of appeal.