Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gout
Treatment: Kineret
The insurer denied: Kineret
The denial is: Upheld

The patient is a male with a history of gout in the setting of leukemia. The patient was experiencing polyarticular pain. The patient was diagnosed with gout approximately 3 years ago by his primary care physician (PCP) after having episodes of monoarticular pain, including at the base of his toes, ankles, and elbows. These episodes initially occurred every 2 months until he started on prophylactic allopurinol. Allopurinol helped reduce the frequency but was never adjusted upwards of 300 milligrams (mg). He has never had confirmatory joint aspiration.

Anakinra is a medication that has been found to be effective in treating gout flares in cases where the first-line therapies are not a suitable option. It is especially beneficial when the patient is intolerant or when there is a contraindication to the first-line therapies. However, it is not the best choice for gout flare prophylaxis due to its short biologic half-life, which requires daily subcutaneous administration. Anakinra, an interleukin 1 (IL-1) receptor antagonist protein, is used only in gout patients with frequent and/or documented gout flares, in whom other available treatments have failed, are contraindicated, or in whom "rebound flares" occur even when glucocorticoid treatment is appropriately tapered. This patient has not been optimized on standard therapy like allopurinol after maximum tolerated dose.

This patient is being prescribed Kineret for chronic gout. The notes document that his symptoms have resolved. He has never been on allopurinol with up titration in doses which can be upwards of 300 milligrams (mg) to 900 milligrams (mg). Also, he can be retried on Prednisone if he were to have a flare or can get intra articular joint injection. He has received anakinra successfully in the past for acute flare not for chronic gout.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite
Treatment: Braces
The insurer denied: Braces
The denial is: Upheld

The patient in question is a male with a Class I occlusion with 5 millimeter (mm) overbite and 6 mm overjet. He has minor maxillary spacing and minor mandibular crowing. He is treatment planned for orthodontics to correct his malocclusion. The subject under review is the medical necessity for the treatment of braces.

The health plan's determination is upheld.

There is no medical reason to correct his malocclusion with braces.
He has minor crowding, but no teeth are impacted. His overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are not contacting the palate in occlusion. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior or posterior crossbites present.
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.1 This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion.2 The patient has a 5mm overjet, but this amount of overjet does not affect oral health related quality of life.3 If his teeth were aligned it would provide an esthesic 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: Overturned

Diagnosis: Orthopedic/ Musculoskeletal - torticollis.
Treatment: Pharmacy/Prescription Drugs - Botox.
The health plan denied the requested Pharmacy/Prescription Drugs - Botox as not medically necessary. 
The health plan's determination is overturned.

The patient is a male diagnosed with torticollis, untreated in his home country until 2 years ago when he had a workup and approximately 40 physical therapy sessions to address this. His treating rehabilitation doctor and plastic surgeon requested botulinum toxin (Botox) injections to his neck, sternocleidomastoid (SCM), and upper trapezius to assist and improve range of motion of the SCM and combine with SCM release.
At issue is the medical necessity of the requested health service/treatment of Botox.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Botox is medically necessary for this patient. It is well documented in literature that after failure of physical therapy, it is standard of care to try botulinum toxin (Botox) injections to address congenital muscular torticollis (CMT). It is further supported in the literature that untreated CMT cases even into adulthood can benefit from botulinum toxin injections to the SCM. It is further supported in the literature that use of botulinum toxin injections prior to plastic surgery can improve outcomes and decrease the risk of post-op contracture. Therefore, the requested health service/treatment of Botox is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Motorcycle accident/left knee fracture.
Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who was involved in a motorcycle accident in which he placed his left foot and leg down on the ground to prevent the motorcycle from falling over. He was brought to the emergency department where plain radiographs confirmed a bi-condylar tibial plateau fracture of the left knee. The patient was admitted for further care. An external fixator was placed on the left leg for stabilization of the fracture and to allow the soft tissue swelling to subside. The patient was brought back to the operating room for removal of the external fixator and partial open reduction and internal fixation of a portion of the tibial plateau fracture. The patient was returned to the operative suite for lateral meniscus repair and fixation of the anterolateral portion of the tibial plateau fracture. The patient was subsequently discharged home . The patient's health plan denied coverage of the inpatient hospital admission with a determination that it was not medically necessary. At issue in this case is the medical necessity of the inpatient hospital admission.

The requested health service/treatment of inpatient hospital stay is not medically necessary for this patient. The provided medical records do not document the medical necessity for this healthy, patient to remain the hospital for his entire treatment course. The records state that there was low suspicion for compartment syndrome, and despite some initial soft tissue swelling, there were no associated nerve or blood vessel injuries to his left leg that would necessitate a 16-day inpatient hospital admission. The staged approach to fixation of this patient's left tibia plateau fracture was consistent with the recommendations of the current, peer-reviewed orthopedic literature as documented by Ryu and colleagues in Knee Surgery and Related Research in 2018 and by Cho and associates. The medical necessity of the inpatient hospital admission is not established based upon the provided documentation and the recommendations of the peer-reviewed literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied the Wegovy.
The determination is overturned.

The patient has a history of obesity and is requesting continuation of coverage for semaglutide injections (Wegovy). According to information provided in the Prior Authorization request, the patient's baseline starting weight was 174 pounds and her present weight on treatment was 141 pounds. The plan's criteria for the continuation of semaglutide (Wegovy) include at least a 5 percent reduction from baseline body weight and the maintenance of the initial 5 percent reduction. At issue is the medical necessity of Wegovy.
The requested health service/treatment of Wegovy was medically necessary for this patient. In this case, the patient has lost 33 pounds, which is a 19% reduction. Therefore, the patient meets the criteria for continuing Wegovy. Wegovy is now considered to be one of the most effective and safe treatments for obesity. It is considered the standard of care in obese and/or overweight patients with weight-related comorbidities who have not reached weight loss goals with behavioral modification.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis
Treatment: Xeljanz
The insurer denied Xeljanz.
The health plan's determination is upheld.

The patient is a female who has moderately severe ulcerative colitis and previously tried and failed 5-aminosalicylic acid (5-ASA) agents, steroids, and an anti-tumor necrosis factor (TNF) agent (adalimumab), as well as an anti-integrin agent (vedolizumab). She was started on Xeljanz, but she continued to have symptoms of active ulcerative colitis. The medical records indicate that the patient was switched to Rinvoq (upadacitinib).
At issue is whether continued Xeljanz is medically necessary to treat her moderately severe ulcerative colitis.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Xeljanz is not medically necessary for this patient.
There is no role for Xeljanz in a patient who has been already switched to Rinvoq, which is also a Janus kinase (JAK) inhibitor.
Ulcerative colitis (UC) is a chronic disease of the gastrointestinal (GI) tract that is characterized by mucosal inflammation in the colon. Mesalamine (mesalazine) is a 5-ASA compound that is the first-line treatment for patients with mild-to-moderate UC. Anti-TNF therapy should be initiated in patients with acute severe refractory to corticosteroids ulcerative colitis and in patients with moderate-to-severe ulcerative colitis who are not responsive to conventional treatment with aminosalicylates, corticosteroids and immune modulators.
In patients with moderately to severely active ulcerative colitis, tofacitinib was more effective as induction and maintenance therapy than placebo. However, the patient has been already switched to Rinvoq which is also a JAK inhibitor. Hence it is not medically necessary to use Xeljanz to treat this patient's ulcerative colitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Vomiting
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a teenage male. He had abdominal pain and vomiting. He was hospitalized for 2 days. The health plan denied coverage of the inpatient admission as not medically necessary. The reason for appeal is that the patient had increased symptoms and required inpatient care for cannabis hyperemesis syndrome.
Brief summary of the hospital stay:
Day #1: Seen in the ED (emergency department) again for increasing vomiting and abdominal pain and was seen in ED (emergency department) twice in the last week. The patient was diagnosed with cannabis hyperemesis syndrome. The plan was for admission for IV (intravenous) fluids and monitoring for symptoms.
On day #2: The patient was comfortable and in no acute distress; there was no more vomiting on the floor. The plan was to start clears and advance as tolerated.
The next day the patient tolerated a regular diet, and he was discharged to home.

The Inpatient Hospital Admission was not medically necessary.

Supportive care, including IV (intravenous) fluids, is the mainstay of therapy for children with cannabinoid hyperemesis syndrome, and patients can be managed at observational level of care (1-2). As documented in clinical notes and summarized above, this patient had increasing vomiting and abdominal pain due to cannabis hyperemesis syndrome. During hospital stay, the patient received IV (intravenous) fluids and oral intakes. The patient stopped vomiting after admission and tolerated PO (oral) intake. There was no documentation of any other acute events, such as high fever, respiratory distress and cardiovascular instability. Thus, the acute inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe anterior overjet. 
Treatment: D8080 Braces, D8670 Monthly Visits x 8. 

The insurer denied: D8080 Braces, D8670 Monthly Visits x 8. 
The denial is overturned. 

The patient is an adolescent female. The request is for orthodontic benefits with follow-up visits. She has a Class I malocclusion with severe anterior overjet. The health plan's prior denial of coverage of the request was due to Salzmann index score of less than 26.

The requested braces and visits are medically necessary. 

The patient has a severe anterior overjet. This means that her upper front teeth are way out in front of her lower teeth. First, this is a situation where these upper teeth are more prone to trauma and/or fracturing, because of their position. Secondly, there is no "incisal guidance" for this patient. Normally, an individual's lower front teeth glide along the backs of the upper front teeth when chewing. Since there is no contact between the upper front and lower front teeth in this case, the patient's teeth will traumatically bang into one another during the chewing cycle since there is no 
connection between these teeth. Over time, the teeth will fracture and/or loosen. Orthodontic treatment (with follow up visits) is needed to correct this. This case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left knee anterior cruciate ligament insufficiency.
Treatment: Inpatient hospital stay.

The insurer denied coverage for inpatient hospital stay.  The denial is overturned.

This is the case of a patient with a history of gastroesophageal reflux disease, obesity, sleep apnea and hypertension. The patient was indicated for surgery with diagnoses of left knee anterior cruciate ligament insufficiency, bucket-handle medial meniscus tear, lateral meniscus tear and grade 3 chondromalacia of medial femoral condyle. The patient underwent left anterior cruciate ligament reconstruction using Achilles tendon allograft. Due to oxygen desaturation during surgery, tachycardia and anticoagulation therapy, the patient was admitted to inpatient. The patient had Lovenox and physical therapy. When stable the patient was discharged.

The patient was at high risk for complications. The patient was reported to have a previous history of venous disease with Deep Vein Thrombosis (DVT). The patient had an elevated Body Mass Index (BMI) and other medical comorbidity. The post-surgical course was complicated. The patient required intense monitoring and additional diagnostic studies to rule out a clot. The patient was still diaphoretic on postoperative day #1. The patient required subspecialty consultations for further evaluation. The patient would not be able to be discharged with the above. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This adult male was hospitalized for chest pain. He presented to the hospital emergency department for evaluation of chest pain with dyspnea on exertion (DOE). His past medical history is pertinent for hypertension (HTN), diabetes mellitus (DM) and tobacco abuse. The patient's vital signs were stable. His blood pressure was initially elevated to 170/96. Oxygen saturation (O2 sat) was 99% on room air.  His electrocardiogram (EKG) showed sinus rhythm and no acute changes. There were no arrhythmias or elevated troponin documented. Chest x-ray was negative. 

The patient was treated for hypertensive urgency with oral antihypertensives. By the next day, the patient's blood pressure was 146/87. Non-stress test (NST) was equivocal for inferior ischemia. The patient's ejection fraction (EF) was 77% by transthoracic echocardiogram (TTE). It was decided that the patient did not need cardiac catheterization. The claim for the acute inpatient hospitalization was denied; this is an appeal that the requested acute inpatient hospital stay was medically necessary for this patient. 

The proposed inpatient admission was not medically necessary. 

Based on the peer reviewed medical literature, including the Milliman Care Guidelines for Chest Pain and Hypertension, there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission were not met, including chest pain with hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome (ACS), chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care the patient received for uncomplicated chest pain and hypertensive urgency, including non-stress test (NST) like in this case, is routinely provided safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal 
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is overturned

This adult male patient was admitted to this inpatient hospital due to alcohol withdrawal symptoms including elevated heart rate of 108, tremors, diaphoresis, anxiety, agitation, and headache, and hyponatremia with a low sodium of 125, increased lactate and anion gap, elevated D-dimer, and chest pain. He reportedly was given Valium 10 mg (milligrams) intravenously (IV) for acute withdrawal in the emergency department (ED) and an additional IV Diazepam for alcohol withdrawal. He reportedly had a Clinical Institute Withdrawal Assessment (CIWA) score of 14 on admission and also a CIWA of 11. He reportedly was drinking up to 6 drinks per day.  His creatine kinase (CK) was very high at 3,347 which was consistent with rhabdomyolysis. He reportedly improved when his CIWA was 0 and sodium was 136. 
  
The medical records provided specific evidence to support that he required this level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also reports that patients using large amounts of alcohol or benzodiazepines are at a higher risk of having delirium tremens 3-4 days after cessation of use. It also states that patients with comorbid medical conditions complicating that management of withdrawal are candidates for inpatient hospital treatment. 

In this case, this patient had active alcohol withdrawal symptoms including elevated heart rate of 108, tremors, diaphoresis, anxiety, agitation, and headache and on admission had a CIWA of 14 and had IV Diazepam 10 mg in the ED for detoxification treatment for alcohol withdrawal. He also reportedly had significant comorbid medical conditions including hyponatremia with a low sodium of 125, increased lactate and anion gap, elevated D-dimer, and chest pain and had a cardiac work up and continuous cardiac rhythm monitoring with telemetry as well as nephrology consultation who recommended fluid restrictions. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital admission services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse, Fever. 
Treatment: Inpatient Hospital Stay. 

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

The patient has a past medical history of intranasal oxycodone dependence, Xanax dependence and attention deficit disorder (ADD). The patient was on maintenance Suboxone and in recovery for five years. However, the patient presented to the emergency room (ER) with a request for detoxification (Detox), he had relapsed and had been using 60-80 milligrams (mg) of oxycodone and 4-5 milligrams (mg) of Xanax daily for a few days prior. The patient admitted to feeling feverish and feeling sick. 

The patient's urine toxicology screen showed benzodiazepines. The patient's chest x-ray (CXR) showed no acute pulmonary disease. The admitting diagnoses were benzodiazepine dependence with withdrawal, opioid dependence with withdrawal, and fever secondary to sepsis of unknown etiology. While hospitalized, the patient had blood cultures taken and received intravenous (IV) Vancomycin and Cefepime, Multivitamins, Thiamine and Folic acid. The patient's plan of care included the Clinical Institute Withdrawal Assessment (CIWA) protocol and Methadone protocol. 

The patient's Clinical Institute Withdrawal Assessment (CIWA) score was 4 with complaints of headache. The physical exam was stable, and the patient was without tremors. The patient received a social work (SW) consult for discharge planning and to discuss available substance abuse treatment centers. Blood culture results remained negative, vital signs were stable, and the patient's physical and psychological exam were normal. The patient was stable for discharge to a rehab and was subsequently discharged. At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of the inpatient stay was not medically necessary. In the emergency room (ER), the patient was febrile but not altered, had no arrhythmia, no hemodynamic instability, no significant tremors, no neurological deficits. The patient did have an elevated temperature but had a normal white blood cell count (WBC), negative chest x-ray (CXR), normal lactic acid levels and no obvious source of infection. The patient received broad spectrum antibiotics and a withdrawal protocol. The following day, the patient was awake, alert, and oriented (AAO) with a normal neurologic and psychiatric exam, all of which remained stable until discharge. Records do not show any reason the patient could not be safely managed at a lower level of care, such as a rehabilitation facility for the purpose of detoxification.