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

Diagnosis: Gum Infection
Treatment: Cleaning of tooth roots (deep cleaning) for the four corners of mouth
The insurer denied the Cleaning of tooth roots (deep cleaning) for the four corners of mouth.
The denial is upheld.

The patient is a male. The request is for dental benefits for periodontal scaling and root planing (deep cleaning) for four quadrants of the mouth.

Per the Provider's consultation, "patient presents with active gum disease with bone loss, 2-6mm [millimeters] pockets and moderate calculus."

The health plan denied the claim because there was no bone loss or calculus deposits evident on the x-rays. The Provider appealed, because their assessment concluded active gum disease.

No, the requested health service of periodontal scaling and root planing (deep cleaning) is not medically necessary.
The main indication for periodontal scaling and root planing (deep cleaning) is bone loss and epithelial attachment loss. This bone loss must be evident on the x-rays, along with visible calculus deposits on the root of the teeth. These are not evident or supported on the x-rays submitted for review.

Therefore, the requested service is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgement and in the best interest of the patient.
Because periodontal scaling and root planing (deep cleaning) is a therapeutic procedure and not a prophylactic one, bone loss and visible calculus deposits must be present on the root to warrant this procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: gastroesophageal reflux disease.

Treatment: gastric bypass for treatment of acid reflux and hospital admission for several camera procedures for the gallbladder, one to look at the stomach, and another for repair of a stomach hernia.

The insurer is denied coverage for gastric bypass for treatment of acid reflux and hospital admission for several camera procedures for the gallbladder, one to look at the stomach, and another for repair of a stomach hernia.

The denial is upheld. 

This female patient has a history of obesity and gastroesophageal reflux disease (GERD) with esophagitis.

Based upon the records provided and Milliman Care Guidelines (MCG) guidelines, the patient does not meet the criteria and indications for bariatric surgery and does not meet the criteria to have a gastric bypass done for treatment of the GERD. The patient has a BMI (Body Mass Index) of 36 and there are no records to show that she has a 
comorbidity requiring a gastric bypass, nor any records to show that she has met the criteria for bariatric surgery. Gastric bypass is done for GERD in patients who have had previous sleeve and not as a primary procedure such as in this case. More importantly they do note that alternatives to procedure include: Long-term medical therapy (e.g., proton pump inhibitor, histamine-2 receptor antagonist, baclofen, lifestyle modifications, elevates head of the bed); Laparoscopic hiatal hernia repair; Laparoscopic fundoplication; Gastric bypass surgery in patient with morbid obesity.  Thus, gastric bypass is indicated when it is being used to treat a patient with morbid obesity. But to do that the patient has to meet the indications for morbid obesity and this patient has not met them.

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 gastric bypass for treatment of acid reflux and hospital admission for several camera procedures for the gallbladder, one to look at the stomach, and another for repair of a stomach hernia is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic Adenoid Cystic Carcinoma

Treatment continued hospital admission

The insurer denied coverage for continued hospital admission

The denial is upheld

The patient was admitted for the management of lower extremity weakness, dysphagia due to mucositis and oral candidiasis. He has an underlying diagnosis of metastatic adenoid cystic carcinoma. He received radiation therapy to S (sacral) 2 to S3 and subsequent radiation therapy to S1 to S3, without complication. He was eventually transferred to a rehabilitation facility. The patient completed his radiation treatment without complication. The clinical records document the clinical team's consensus treatment plan to transfer the patient to a rehabilitation facility after completion of the radiation treatment. Subsequent medical progress notes document was "awaiting placement" to a rehabilitation facility. During this time, the physical and occupational therapists also recommended inpatient rehabilitation. Efforts were undertaken by the case management team to transfer the patient to a rehabilitation facility with reported limited success until his eventual transfer. However, the clinical records clearly document that the patient was medically stable, clinically appropriate for inpatient rehabilitation and no longer required the acute care services. 

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

From a physical medicine and rehabilitation perspective, continued hospital admission was not medically necessary. Based on the above, the medical necessity for the continued hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient presented to the hospital for an elective catheter ablation of atrial fibrillation. Relevant past medical history includes persistent atrial fibrillation with past hybrid ablation with left atrial appendage clip, hypertension, non-ischemic cardiomyopathy with reduced left ventricular ejection fraction and hypothyroidism. During an electrophysiologic (EP) study the left atrium was mapped and electrical connections were present in all of the pulmonary veins.  There were no perioperative complications. The patient was observed overnight and discharged the following day on amiodarone and oral anticoagulant therapy.

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

This patient presented to the hospital for an elective electrophysiolgic study and ablation. According to hospital records, the ablation was successfully performed without complication.  Observation following ablation was unremarkable and no post operative issues were noted.  The patient was discharged home the following day.  In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation for atrial fibrillation (AF), more than 80% (percent) of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity (Reference 1). Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. (Reference 2) The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Ciliary dyskinesia (PCD), asthma, chronic cough, bronchiectasis, and Kartagener's syndrome

Treatment Pulmozyme

The insurer denied coverage for Pulmozyme

The denial is modified

The patient has a history of primary ciliary dyskinesia (PCD), mild persistent asthma, chronic cough, chronic sinusitis, multiple nasal polyps, and Kartagener's syndrome. The patient presented Pediatric Pulmonology, for a follow-up visit. He has bronchiectasis and despite daily intensive airway clearance regimen with albuterol and a chest vest he has a persistent cough. Pediatric Pulmonology states that the patient will significantly benefit from the use of Pulmozyme to break down neutrophils deoxyribonucleic acid (DNA) and decrease viscosity of secretion facilitating its removal from the lower airway. In addition, the doctor has performed a bronchoscopy which demonstrated the presence of purulent airway secretions which grew out bacteria. The BAL (bronchoalveolar lavage) specimen demonstrated the presence of a high white blood count in the airway secretions.

The patient has Kartagener's syndrome with situs inversus, ciliary dyskinesis and bronchiectasis. He has been on daily airway clearance with persistent respiratory symptoms and a cough. His bronchoscopy specimen has elevated neutrophils and bacteria present. 

It would be appropriate for Pediatric Pulmonology to prescribe pulmozyme for a 3 month period to monitor for the effectiveness of this treatment to control the patient's symptoms. PCD is a progressive disease and if pulmozyme is found to be effective in controlling his daily cough and purulent sputum it would be an effective addition to his daily therapy for long term use to prevent worsening of bronchiectasis over time.

Although clinical studies have not been performed in an adequate study in patients with PCD to document the benefit for this diagnosis, there are multiple case reports and data indicating frequent clinical use of this therapy prescribed by physicians at PCD Foundation care centers Several case reports of DNase in PCD suggest possible benefit when used for both short and long-term periods

Since this patient with PCD has ongoing symptoms and bronchoscopic evidence of infection and inflammation, it would be appropriate for Pediatric Pulmonology to prescribe this medication for a 3 month trial period to monitor for improvement in patient's lung function, sputum culture and clinical symptoms. If there is improvement during this trial period then Pediatric Pulmonology can document this improvement and submit this data to the insurer in order to determine the appropriateness of ongoing treatment with this daily inhaled medication.

The health plan did not act reasonably in the best interest of the patient.

Based on the above, the medical necessity for the Pulmozyme for primary ciliary dyskinesia (PCD), asthma, chronic cough, bronchiectasis, and Kartagener's syndrome is substantiated. The insurer's denial is modified to allow a 3 month trial of pulmozyme to determine efficacy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess, Right Thigh. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

The patient had no significant past medical history other than recent incision and drainage by Dermatology who presented to the emergency department with complaints of right upper thigh abscess. Vitals on presentation included: Temperature 100.9 Fahrenheit, Blood Pressure 140/87, Pulse 115, Respiratory Rate 18, oxygen (O2) saturations 100% (percent) on Room Air. Laboratory results included the following: white blood cell count (WBC)13.4, hemoglobin (HGB)-14.7, hematocrit (HCT)-42.5, creatinine-1.0, glucose-176. The patient was admitted and started on intravenous antibiotics (cefazolin, vancomycin, ceftriaxone, and clindamycin) for a right thigh cellulitis. Computed tomography (CT) scan of the leg was consistent with cellulitis without fluid collection. All cultures remained negative. The patient remained afebrile, hemodynamically stable, and clinically improved. He was discharged on oral antibiotics to continue management as an outpatient. 

According to documentation, the patient presented with a right thigh infection following an unsuccessful I&D procedure as an outpatient. He was febrile (100 Fahrenheit), tachycardic (HR-115) with laboratory results showing elevated WBC (13.4). Based on these abnormal findings including failure of outpatient management, patient met criteria for hospital admission for administration of intravenous antibiotic and other diagnostic testing. 

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

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Severe Headaches
Treatment: Emgality Pen 120mg/ml Pen Injector
The insurer denied the Emgality Pen 120mg/ml Pen Injector.
The denial is overturned.

The patient is a female with reported diagnosis of migraine without aura. A note indicates she uses rizatriptan for acute therapy. She reports using Emgality, and that it is very helpful. The records reflect failure of celexa, ajovy, gabapentin. The headaches are associated with symptoms of nausea, photophobia and phonophobia and were occurring nearly every day. Since starting Emgality, the headaches are reported to be stabilized and the headaches begin breaking through if she becomes overdue for dosage.

Yes, the health plan should cover the requested Emgality.
The patient has demonstrated positive response in regard to her headache condition with the noted treatment of Emgality. The records reflect poor response or intolerance to other standard treatments for migraines in adolescents. Reasonable further alternatives are limited and did not have any demonstrated greater efficacy or safety.

There are limited treatments for migraine headaches that have been studied in adolescents. The records reflect those agents having been used, and the patient continues to have headaches that would affect function. The use of CGRP (calcitonin gene-related peptide) antibody therapy has published data for adolescents that has been published in peer-reviewed fashion and demonstrate benefit.

The records reflect the patient is clinically benefiting from this treatment. Given the alternative of not using this treatment would result in the patient experiencing increased headache, and as such increased suffering and effect on function, as well as increased utilization of medical services, it is this reviewer's medical opinion in this case that the patient be supported for continued use of this treatment.

Yes, the requested Emgality is more beneficial. The records reflect trial of other standard treatments for migraine headache in adolescents and reports poor response or reaction.
There are limited treatments for migraine headaches that have been studied in adolescents. The records reflect those agents having been used, and the patient continues to have headaches that would affect function. The use of CGRP (calcitonin gene-related peptide) antibody therapy has published data for adolescents that has been published in peer-reviewed fashion and demonstrate benefit. The records reflect the patient is clinically benefiting from this treatment. Given the alternative of not using this treatment would result in the patient experiencing increased headache, and as such increased suffering and effect on function as well as increased utilization of medical services, it is this reviewer's medical opinion in this case that the patient be supported for continued use of this treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Severe Headaches
Treatment: Emgality Pen 120mg/ml Pen Injector
The insurer denied the Emgality Pen 120mg/ml Pen Injector.
The denial is upheld.

The patient is a female with migraine headache disorder. She has been treated with Ajovy, citalopram and gabapentin for migraine prevention. The provider is requesting Emgality.

This request was denied coverage by the health plan, as she is under the age limit and therefore, does not have an FDA (United States Food and Drug Administration) indication for use.

No, the health plan should not cover the treatment with Emgality.
The patient has not tried and failed any first-line oral migraine prevention agents (Schwedt). There is no documented reason she cannot be treated with first-line oral migraine preventive agents. There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Emgality relative to first-line oral migraine preventive agents. Moreover, there are no high quality clinical-trials or standard-of-care guidelines to support efficacy or the routine use of CGRP (calcitonin gene-related peptide) inhibitors in persons under the age of 18. The clinical trial leading to the FDA (United States Food and Drug Administration) approval of Emgality did not include persons under the age of 18 (Detke et al.).

No, the requested Emgality is not more beneficial than any standard treatment for the insured's condition or disease.
There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Emgality relative to first-line oral migraine preventive agents.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Alopecia Areata. 
Treatment: Xeljanz 5 mg tablet. 

The insurer dened the Xeljanz 5 mg tablet. 
The determination is upheld. 

The patient has a diagnosis of alopecia areata. He is currently taking Xeljanz. He is doing well on Xeljanz. On physical examination, his scalp is noted to have full regrowth. His eyebrows and eyelashes have normal growth. The medication under review is Xeljanz 5 mg tablet. 

There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Xeljanz for this patient's condition as an accepted standard of practice in the United States prior to the standard of care alternatives. There is no documentation the patient has exhausted all topical options, and that it would therefore be medically necessary to start systemic treatment with Xeljanz, which would carry a higher side effect profile. There is no documentation provided that the patient has tried and failed topical immunotherapy, such as Diphenylcyclopropenone (DPCP). Chiang et al writes their 2015 study findings: that for DPCP "treatment success, defined as 50% terminal hair regrowth, was reached in 71% of alopecia totalis patients and in 56% of alopecia universalis patients" (1). Moreover, there is no documentation that the patient has tried and failed topical squaric acid. Topical squaric acid dibutylester is a sensitizing agent which is also used for the treatment of alopecia areata, and has been shown to be effective in several studies (2). Based on the documentation provided, the patient has not tried and failed all topical therapies available. 
According to the dermatology literature, the standard of care medicines methotrexate and oral corticosteroids (OC) are effective treatments for the management of alopecia areata (3-5). Within the peer-reviewed literature, Anuset et al 2016 writes "MTX combined with low- to moderate-dose OC may be an efficient and well-tolerated treatment for severe AA." Thus, methotrexate and corticosteroids are an effective first-line treatment for the management of severe alopecia (4). Additionally, according to Phan et al "Methotrexate for alopecia areata: A systematic review and meta-analysis," published in the Journal of the American Academy of Dermatology early 2019, "Methotrexate has reasonable effectiveness in patients with severe AA...Combination treatment results in a higher complete response rate than methotrexate stand-alone treatment...Methotrexate is an effective monotherapy or adjunct therapy in combination with corticosteroids in the treatment of severe AA" (5). The conventional agents are appropriate agents for the treatment of the patient's alopecia. Standard of care medications should be tried and failed prior to initiating Xeljanz. After review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Xeljanz prior to the standard of care alternatives such as methotrexate in combination with oral corticosteroids, and the topical medications aforementioned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Alopecia Areata. 
Treatment: Xeljanz 5 mg tablet. 

The insurer dened the Xeljanz 5 mg tablet. 
The determination is upheld. 

The patient has severe alopecia areata, and has had full regrowth of his hair while on Xeljanz. The patient had previously lost all of his scalp, facial, and body hair before starting Xeljanz. The patient has previously tried and failed oral, topical, and intralesional steroids prior to Xeljanz. 

At issue is whether the Xeljanz is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

No. The Xeljanz is not likely to be more beneficial than any standard treatment (s). The requested medication merits further study before being presumed acceptable for widespread clinical use. At this time, the long-term safety of this medication is not as confirmed as short-term efficacy in the use of Xeljanz for this condition. 
Alopecia areata is notoriously difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, contact allergen treatment and related therapies have all resulted in variable and unsatisfactory outcomes, and self-resolution is often the only choice a patient has (along with hairpieces) for severe cases. However, while Xeljanz has some promising preliminary results in open-label studies (5, 6), the overall literature and reviews on alopecia areata (1-4) mention Xeljanz only as not yet proven in the risks outweighing the benefits. Xeljanz was denied Food and Drug Administration (FDA) approval for use in psoriasis, in large part for safety reasons, and is not without a significant risk of side effects. 

At this time, Xeljanz is only Food and Drug Administration (FDA)-approved for rheumatoid arthritis patients who have failed methotrexate, for juvenile idiopathic arthritis, for psoriatic arthritis, and for ulcerative colitis--all four conditions have indications whereby the safety risks of not using treatment are significantly greater than treatment itself. Xeljanz has been recommended to be used with lower dosing in rheumatoid arthritis patients because of concerns about excessive blood clotting.
The same cannot be said for Xeljanz in the treatment of alopecia areata, where physical/functional impairment and overall health impacts are minimal to nonexistent--despite the social/psychological impacts that can occur in some patients. The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of alopecia areata, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with a specific dosing of Xeljanz. 

Therefore, as per the evidence-based literature, Xeljanz is not likely to be more beneficial than standard treatments for this patient's clinical condition.