Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Bilateral Primary Osteoarthritis Of Knee.
Treatment: Formulary exception for Monovisc (hyaluronan).
The insurer denied the Formulary exception for Monovisc (hyaluronan).
The denial is upheld.

The patient is a female with knee pain. The patient had undergone arthroscopy, microfracture, meniscectomy Right. She had previous injections of Gel. Her left pain was worse than the right. She reported stiffness, swelling and problems with bending. She had received cortisone injections, which were slightly helpful. She had received Monovisc injections to both knees with benefit. She presented for additional cortisone injections and to order "Gel" injections.

The patient's physical examination was significant for the following: effusion and decreased motion to both knees. Her physician then provided bilateral cortisone injections.

No, the health plan should not cover the Formulary exception for Monovisc (hyaluronan).
The scientific literature has proposed use of hyaluronic acid in the management of osteoarthritis to the knee. There are several preparations, but none has been shown to be more efficacious than others. Issues have been made with regard to method of preparation. Some brands are obtained from rooster combs while others are from bacterial fermentation, meaning people with avian or allergic reactions are recommended to use the latter.

In this case, the health plan's preferred alternative is Durolane. Per Durolane's Manufacturer's web site: "DUROLANE is a unique, single-injection hyaluronic acid therapy that provides long-lasting pain relief from knee osteoarthritis, and acts as a supplemental lubricant and shock-absorber for affected joints."

"What makes DUROLANE different is its concentration of hyaluronic acid, which has been carefully stabilized to resist degradation, extending the time DUROLANE stays in the joint and adding to its long-lasting effect."

"Introduced worldwide, DUROLANE has been tested in more clinical studies than any other single-injection hyaluronic therapy on the market. It is proven safe for repeated courses of therapy and provides longer-lasting pain relief versus steroid injections. The hyaluronic acid in DUROLANE is also derived from a nonanimal source to reduce any risk of allergic reaction."

The patient is requesting formulary exception for Monovisc. A search was performed using National Library of Medicine. The key word was Durolane vs. Monovisc. There were no studies showing one product better than the other.

Based upon review of literature, there is no documented reason why the patient could not receive the formulary agent. There were no documented circumstances nor medical condition to prevent its use.

In conclusion, the formulary medication would be expected to be just as effective as the requested Monovisc. As such, the health plan should not cover the formulary exception for Monovisc.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Moderate-Severe Psoriasis Vulgaris.

Treatment: Skyrizi Pen 150 mg/ml (milligram/milliliter) SC (subcutaneous) SOAJ (solution auto injector).

The insurer is denied coverage for Skyrizi Pen 150 mg/ml (milligram/milliliter) SC SOAJ.

The denial is overturned.

The patient has a diagnosis of moderate-severe psoriasis vulgaris. The patient has failed topical therapy as well as systemic biologic therapy with humira, ilumya, stelara, and cosentyx.  The requested medication is Skyrizi.  

The patient has failed topical therapy and requires systemic therapy for control and management of her psoriasis diagnosis. The patient has tried and failed numerous biologics, including humira, ilumya, stelara, and cosentyx.  Skyrizi is Food and Drug Administration (FDA) approved for treatment of psoriasis vulgaris and it is reasonable to attempt this treatment option.  

The joint American Academy of Dermatology (AAD)-National Psoriasis Foundation (NPF) guidelines for psoriasis treatment with biologics states, "An RCT [randomized controlled trial] assigned 166 patients to receive risankizumab subcutaneously (a single 18-mg [milligrams] dose at week 0 or 90-mg or 180-mg doses at weeks 0, 4, and 16) or ustekinumab (45 or 90 mg [depending on body weight] at weeks 0, 4, and 16). At week 12, 77% [percent] of patients receiving risankizumab (the 90-mg and 180- mg groups pooled), as compared with 40% in the ustekinumab-treated group, achieved PASI 90 (P \ .001); in contrast, 45% in the pooled groups treated with 90 mg and 180 mg of risankizumab, as compared with 18% in the ustekinumab-treated group, achieved PASI 100 (2,5)."

In this case, Skyrizi is a reasonable next therapy for the treatment of the patient's disease.  Note that Skyrizi is among the insurer's formulary options. As such, Skyrizi is approved, and the decision is overturned in whole based on the current evidence-based medical literature.

The insurer's denial of Formulary Exception for Skyrizi Pen 150 mg/ml (milligram/milliliter) SC SOAJ is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma Exacerbation.

Treatment: inpatient hospitalization.

The insurer is denied coverage for inpatient hospitalization.

The denial is overturned. 

This male patient has a history of eczema and asthma.

He was noted to have wheezing, prolonged expiration and retractions which did not respond to treatment in the emergency room (ER) with prednisone, continuous albuterol and magnesium sulfate. The decision was made that he would require inpatient pediatric treatment for status asthmaticus. Since there was no inpatient pediatric service at the facility the child was transferred by ambulance to another hospital for admission. In the ER , he had a pulse oximeter reading of 93% (percent) and he was noted to have an increased respiratory rate of 40. His viral respiratory panel was positive for rhinovirus. When his respiratory symptoms did not improve with treatment in the ER, the decision was made to admit him with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 2 hours.  

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. He had been treated in the ER with continuous albuterol, prednisone and magnesium sulfate. Following treatment in the ER he continued to have ongoing respiratory distress with persistent wheezing, prolonged expiration and increased work of breathing. 

It was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with albuterol every 2 hours with a diagnosis of status asthmaticus. He continued to be in respiratory distress with a pulse ox of 93% and was not stable enough to be discharged home.  The admission was medically necessary.

Based on the above, the medical necessity for the inpatient hospitalization is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet, open bite, ectopic eruption, anterior crowding, incisor protrusion and posterior unilateral crossbite.

Treatment D8080 braces and D8670 monthly visit (x [times]12).

The insurer denied coverage for D8080 braces and D8670 monthly visit (x12).

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite, ectopic eruption, anterior crowding, incisor protrusion and posterior unilateral crossbite.  The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index attaining 31 total points. 

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation (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 completes the second portion of the index arriving at 31 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 31 points on the HLD index (6 overjet, 8 open bite, 10 anterior crowding, 3 labiolingual spread, 4 posterior unilateral crossbite) which is above the threshold of 26 points to support orthodontic care.

The clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care. The healthcare 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 D8080 braces and D8670 monthly visit (x12) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary and mandibular spacing, excessive overjet and deep impinging overbite.

Treatment braces (code D8080).

The insurer denied coverage for braces (code D8080).

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular spacing, excessive overjet and deep impinging overbite. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements reaching only 12 points on the HLD index by internal reviewers. 

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, a Handicapping Labiolingual Deviation 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 deep
impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care as on examination of the intraoral clinical images there is evidence of palatal gingival recession due to direct impingement of the teeth on the gingival soft tissues. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

The clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care. The healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for braces (code D8080) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.

Treatment: Inpatient admission.

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This patient presented to the hospital complaining of chest pain, shortness of breath and weakness for several days. Past medical history was significant for hypertension and diabetes mellitus.  Upon arrival to the emergency department (ED), vital signs were stable (blood pressure 142/91 and pulse was 68). Physical examination revealed no significant abnormalities.  12 lead electrocardiogram (ECG) revealed normal sinus rhythm without ST (interval on ECG) segment or T (interval on ECG) wave abnormalities. Serum blood testing demonstrated no elevation in troponin levels (<0.012 ng/ml [nanogram per milliliter]).  Echocardiogram revealed preserved left ventricular ejection fraction without wall motion abnormalities.  Pharmacologic myocardial perfusion study revealed an left ventricular ejection fraction (LVEF) of 51-59% (percent) and possible mild ischemia along the distal anteroseptal/anteroapical region of the left ventricle. The patient was ultimately discharged on medical therapy.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. This patient presented with chest pain and fatigue. His pretest probability of coronary artery disease is intermediate.(Reference 1)  Utilizing the HEART [history, ECG, age, risk factors, troponin] score he was considered low risk for major adverse cardiac events. (Reference 2)  Utilizing the TIMI [Thrombolysis in Myocardial Infarction (TIMI) Score ] risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST (interval on ECG) changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient did not require inpatient hospital admission and could have been treated 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: Upheld

Diagnosis: Diabetes

Treatment inpatient level of care

The insurer denied coverage for inpatient level of care

The denial is upheld

This is a patient who presented with chronic abdominal pain in the right lower quadrant for the last year, intermittent, aching, radiating to the left lower quadrant, no specific alleviating or relieving factors.  She was diagnosed a month prior to presentation with a right ovarian mass that is likely a malignancy and that she would like to have it surgically removed. She also reports fever for the last month. She reported to the emergency department (ED) staff that she had been short of breath and had a dry cough as well. Laboratory testing showed her glucose was 302 and hemoglobin A1c (measure blood glucose) was 12.7. Computed tomography (CT) scan of the abdomen showed a right pelvic mass. She was admitted and received intravenous (IV) fluids and IV antibiotics as well as glucose monitoring and insulin. She was discharged with instructions to follow up with an Oncologic Gynecologist and Endocrinology. 

From the submitted information, it appears that the patient was admitted to optimize her medical condition for possible surgery, specifically, to control her diabetes. This patient was stable, she was not ketoacidotic. The patient's blood sugar could have been easily controlled as an outpatient. Sugar control and diabetic teaching are done routinely as an outpatient. Nutritional counseling does not require admission. 

People with diabetes are usually admitted if they have the following:
1) Life-threatening acute metabolic complications of diabetes.
2)Severe chronic complications of diabetes that require intensive treatment or other severe conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes. 

This patient had none of the above.

Based on the above, admission for glucose control was not medically necessary. The patient could have been followed up closely (daily in the clinic) for monitoring and dose adjustment if needed. This is in accordance with the standard of care and Milliman guidelines. 

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

The inpatient level of care is not considered medically necessary for this patient.

The insurer's denial of coverage for inpatient level of care is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness, unsteady gait.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented to the emergency ward with the complaint of dizziness. At presentation, she was noted to have unsteady gait. Computed tomography (CT) of the brain was negative for acute pathology. The patient was admitted for possible stroke. Subsequent magnetic resonance imaging (MRI) of the brain was negative for stroke.

No, the proposed inpatient hospital admission was not medically necessary.
The patient presented with unsteady gait and dizziness. There were no concerning features at presentation to support stroke. She was admitted and magnetic resonance imaging (MRI) did not show stroke. The duration of symptoms was not consistent with a transient ischemic attack (TIA). The monitoring, diagnostic studies, treatment and neurology consultation could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted canine.
Treatment: D8080 Braces and D8670 Monthly Visits, Pre-service.
The insurer denied the D8080 Braces and D8670 Monthly Visits, Pre-service.
The denial is overturned.

The patient is a male requesting orthodontic benefits. He has a Class II malocclusion, moderate upper and lower crowding, deep bite, excessive overjet and an impacted lower right permanent canine.

Yes, the proposed braces and monthly visits are medically necessary.
The patient has an impacted lower permanent canine which is to be erupted with orthodontic treatment. When there is an impacted anterior permanent tooth, when extraction is not indicated, this is an "automatic qualifier" for benefits according to the handicapping index scale. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: morbid obesity

Treatment: inpatient hospitalization

The insurer is denied coverage for inpatient hospitalization.

The denial is upheld. 

This female patient has a history of bilateral congenital hip dysplasia, morbid obesity, pulmonary embolism (PE) with acute cor pulmonale.

"The Laparoscopic Sleeve Gastrectomy (LSG) has increased in popularity and is currently very "trendy" among laparoscopic surgeons involved in bariatric surgery. As LSG proved to be effective in achieving considerable weight loss in the short-term, it has been proposed by some as a sole bariatric procedure." (Iannelli, et al., 2008)
"The epidemic of obesity in the United States is a major public health issue and more than a third of adults are now considered obese (body mass index > or = 30 kg/m(2)). Surgery for morbid obesity, bariatric surgery, is the most durable treatment for this disease and about 140,000 cases are performed annually. Laparoscopic sleeve gastrectomy (LSG) has been advocated as the first of a 2-stage procedure for the high-risk, super-obese patient." (Moy, et al., 2008)                                                     

There were no pre- operative, intra-operative, or post-operative incidents or complications. The patient remained stable and afebrile throughout. The patient was not dehydrated. There were significant co-morbidities or past medical history. There was no information provided to this reviewer that suggests the need for an acute care facility admission. The justification for admission, as outlined in the appeal letter authored by the facility, spells out the need for observation and release after an overnight observation. There were no acute care needs. Observation was required. Observational status would have been adequate quality medical care.      

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

The carrier's denial of coverage for the inpatient hospitalization is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent (dupilumab) SC injection. 

The insurer denied Dupixent (dupilumab) SC injection. 
The determination is upheld. 

The patient has widespread atopic dermatitis, for which the patient has tried and failed topical augmented betamethasone dipropionate 0.05% ointment, mometasone ointment, tacrolimus 0.03% and 0.1% ointments, 0.025% triamcinolone cream, and 0.1% triamcinolone ointment. However, the patient is still erythrodermic and considerably symptomatic. At issue is the medical necessity of Dupixent. 

The Dupixent (dupilumab) SC injection is not medically necessary for this patient. 

Modern dermatology literature [1-4] supports use of the preferred medications as similarly efficacious to the requested Dupixent, particularly for a patient with a limited history of systemic atopic dermatitis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. This is particularly true for patients of this very young age, for which Dupixent is not FDA-approved for treatment. 

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. This review focuses on the use of systemic treatments in adult AD patients analyzing published literature. (2) Many AD patients respond satisfactorily to topical or systemic treatments, but for those patients who do not respond or have contraindications, new biologic agents appear to be promising therapies. (4) 
Therefore, as per current medical standards of care, Dupixent is not medically necessary for this patient.