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

Diagnosis:  Osteoporosis.
Treatment:  Forteo.

The insurer denied the Forteo.  The denial is overturned. 

This is a female diagnosed with osteoporosis.  This request is for Forteo. 

As reported her history extends back many years when she was started on Fosamax for osteoporosis.  She had to stop Fosamax because of gastrointestinal ulcers.  She was placed on Aredia therapy by another provider for two years, but she did not improve. 

She had transiliac bone biopsy, which showed microarchitectural deterioration consistent with advanced osteoporosis. 

The patient started on Forteo; during the second year, her bone density was impressively good at 9.2 % at lumbar spine, and 4.4 % at hip region.  She received Forteo for two years.  

Two years later she started Actonel, but had complications with gastrointestinal issues.  She had osteonecrosis of the jaw.  After three months, Actonel was restarted. 

Three years later the patient started Prolia every six months; she received ten doses over six years.  Her T-score at the lumber spine was -2.2; total hip was -2.9; femoral neck was -2.2; distal forearm was -3.2. 

The patient again developed osteonecrosis of the jaw. 

She required a debridement of exposed area of necrotic bone in the right posterior mandible that was directly attributed to her antiresorptive.  Antiresorptive therapy is contraindicated according to her doctor.  Her T-score was <-3.5. 

Yes, Forteo is effective for the treatment of osteoporosis and is a first line therapy for women with severe osteoporosis or prior fractures [2-16].  Forteo is indicated and FDA approved for the treatment of women with osteoporosis who are at high risk of fracture[17].  "These include women with a history of osteoporotic fracture, or who have multiple risk factors for fracture, or who have failed or are intolerant to previous osteoporosis therapy, based upon physician assessment." 

The patient has declining bone mineral density and is at high risk of fracture.  She was treated with Forteo for two years in prior years.  She has osteonecrosis of the jaw making all antiresorptive agents contraindicated, including bisphosphonates, Prolia and Evenity.  As there are no other good options, the benefit outweighs the risk of treatment.  The treatment is expected to be beneficial for the patient, and is, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute deep vein thrombosis (DVT) of the right lower extremity. 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 

The denial is upheld. 

This is a female patient with a past medical history significant for immunocompromised status, hypertension, hyperlipidemia, hypothyroidism, and pre-diabetes who presented to the Emergency Department (ED) with complaints of right lower extremity pain for 3 weeks. The patient's vital signs on ED presentation included: temperature 98.6, blood pressure 121/79, pulse 66, respiratory rate 18, and oxygen saturation 99% on room air. The patient's laboratory results included the following: white blood cell (WBC) count 4.13, Hemoglobin 13.0, Hematocrit 38.5, Creatinine 0.72, and Glucose 92. The patient was started on anti-coagulation with Lovenox. The patient's bilateral lower extremity Doppler confirmed a deep vein thrombosis (DVT) in the right popliteal, right posterior tibial and right peroneal veins. The patient's computed tomography angiography (CTA) of the chest was negative for pulmonary embolism. She was admitted to the Medical Surgical unit with an acute DVT of the right lower extremity. The patient remained afebrile and hemodynamically stable. She was discharged on day 2 of admission to continue on oral Eliquis as an outpatient. 

According to documentation, the patient presented with a lower extremity DVT. Otherwise, the patient remained hemodynamically stable with no complications of DVT. Literature review supports that outpatient treatment is safe and effective using low-molecular-weight heparin and an oral anticoagulant. Hospitalization is generally required for patients with massive DVT, with symptomatic pulmonary embolism, at high-risk of anticoagulant bleeding, or with major comorbidity. In this case, the patient did not fulfill criteria for acute hospitalization; the patient met criteria for observation level of care. Thus, the inpatient admission was not medically necessary for this patient. 

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

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

Diagnosis: Cystic fibrosis. 
Treatment: Trikafta. 

The insurer denied coverage for Trikafta. 

The denial is upheld. 

This is a female patient with a medical history of cystic fibrosis (CF). The patient has the genotype W1282X/3849 +10Kb. As per the patient's medical doctor (MD), the patient gets frequent chest infections needing intravenous (IV) antibiotics twice a year and also intermittent courses of oral antibiotics. The patient has had multiple courses of broad spectrum antibiotics and also received posaconazole for Mucor infection. The patient has also had Burkholderia cepacia pneumonia and also in sputum culture/sensitivity (C/S). The patient has chronic bronchiectasis, CF with gastrointestinal (GI) manifestations and Mucor and multidrug-resistant (MDR) Burkholderia infection. 

As per the patient's medical record, the patient has been on maximal medical management with nebulized bronchodilators, antibiotics, Pulmozyme, hypertonic saline, nebulized antibiotics (i.e., aztreonam, tobramycin and ceftazidime), and nasal steroids.  The patient is also using the Vest therapy. The patient's pulmonary function test (PFT) indicated: forced vital capacity (FVC) 2.84 (80%), forced expiratory volume (FEV1) 1.61 (52 %), and FEV1/FVC ratio 57%; it was an obstructive ventilatory pattern. The last sputum was negative for Mucor. The patient complained of some chest pain after exercise. 

The patient's provider is requesting approval for Trikafta (Triple therapy with Elexacaftor, Tezacaftor and Ivacaftor) for this patient to prevent deterioration in her condition and delay need for lung transplantation. 

The medical literature was reviewed and the patient's Health Insurance Plan guidelines were also reviewed for this case. This patient does not have the F 508 del mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Based on current literature and studies, Trikafta is indicated only in patients with CF who have at least one gene with this mutation. This drug has not been studied in patients with the mutation that this patient has, which is W1282X/3849 +10Kb. 

Based on the above Trikafta is not considered medically necessary for this patient. 

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

The carrier's denial of coverage for Trikafta should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headaches
Treatment: Nurtec
The insurer denied coverage for Nurtec.
The denial is overturned.

This is a female patient with a history of episodic headaches that are both tension and predominantly migraine type. The patient was seen by a neurologist with a chief complaint of headaches. The patient reported that her headaches can be unilateral or bilateral, and she has trialed over-the-counter (OTC) anti-inflammatory medications without relief. The documentation indicates that that the patient has tried triptan medications in the past but they were without efficacy and intolerable due to side-effects.  As per the patient's physical exam, the patient was alert and oriented with no sensory or motor deficits. The physician states that the patient does not need preventive treatment given the frequency of her migraines. The patient was recommended to utilize indomethacin. An addendum does indicate that the patient has had intolerance or failure of response to Fiorinal, Naproxen, and Cafergot. Thus, the patient's treating physician wishes to proceed with therapy with Nurtec. At issue is the medical necessity for Nurtec. 

As per the patient's medical record, the patient has failed therapy with several abortive approaches in the past including Fiorinal, Naproxen, and Cafergot. As per UpToDate, Nurtec received Food and Drug Administration (FDA) approval for the treatment of acute migraine in adults. The literature review supports that in clinical trials, Nurtec has shown to be effective in the abortive treatment of severe migraine headaches, deriving clinical benefit within two hours of administration. Therefore, considering this patient's trial and failure to insurer's formulary drugs and intolerance to triptan medications, the use of Nurtec medication is considered medically necessary for this patient's case. 

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

The carrier's denial of coverage for Nurtec should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Iritis.
Treatment:  BromSite 0.075% Ophthalmic Solution.

The insurer denied coverage for BromSite 0.075% Ophthalmic Solution.  The denial is upheld. 

This is a male patient with a history of chronic iritis in the right eye.  The patient's visual acuities are 20/40 in the right eye (OD) and 20/20 in the left eye (OS).  The patient has diagnoses of posterior capsular opacification OD, dry eye and status post retinal detachment repair OD.  The patient's treating physician noted that BromSite is used to treat chronic iritis in the right eye, and BromSite will be used to stabilize and alleviate the patient's symptoms due to iritis.  The physician also noted that the patient has used Ketorolac 0.5% in the past with no success and is currently using Bromfenac, but the patient states this does not seem to be as effective as BromSite.  It was noted that the patient has used BromSite in the past with great success.

Based on the review of the patient's medical record and literature, the requested medication, BromSite (bromfenac) 0.075% ophthalmic solution is not considered medically necessary for this patient.  The patient has not tried available formulary alternatives (i.e., flurbiprofen), or has not demonstrated contraindications to use of alternatives.  The literature does not support that BromSite is superior in efficacy or tolerability compared to other topical nonsteroidal anti-inflammatory drug (NSAID)-based ophthalmic drops.

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

Based on the above, the medical necessity for BromSite 0.075% Ophthalmic Solution is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Skyrizi 150 dose inj 
The health plan denied Skyrizi 150 dose inj.
The determination is upheld.


The patient has severe psoriasis (10% body surface area involvement) across her face, scalp, groin, and vaginal region. The patient has tried and failed topical betamethasone, Taclonex, triamcinolone, clobetasol, and ketoconazole. At issue is the medical necessity of Skyrizi.

The patient has no documented treatment failure with, or true medical contraindication to, plan-preferred oral/systemic therapies such as either Methotrexate or Acitretin. Light therapy is inappropriate for the face and groin. The patient has no documented treatment failure with, or true medical contraindication to standard, first-line systemic therapies such as either Methotrexate or Acitretin. Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Skyrizi, particularly for a patient with a limited or non-existent history of systemic psoriasis therapy previously utilized, and recommends use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Skyrizi is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental caries. 
Treatment: Orthodontic treatment (braces) (D8080). 
The insurer denied coverage for orthodontic treatment (braces) (D8080). 
The denial is upheld. 

This is a male child with a history of dental caries who presented for an orthodontic care evaluation. Upon examination, it was determined that the patient's tooth number 3 was non-maintainable and that tooth was extracted. The treating oral surgeon recommended orthodontic care to close the patient's edentulous space in the tooth number 3 area in order to avoid the need for an implant in that site in the near future. The insurer denied coverage for orthodontic treatment (braces) (D8080). The orthodontist completed the Handicapping Labio-Lingual Deviation (HLD) index, attaining 9 total points to support orthodontic care. 

The patient exhibits a malocclusion; however, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid Program) modeled after Handicapping Labiolingual Deviation Index. 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 9 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 9 points on the Handicapping Labio-Lingual Deviation (HLD) index (3 points overjet, 4 points overbite, 2 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Furthermore, the patient does not present with skeletofacial deformity or craniofacial abnormality that would qualify the insurer's criteria for orthodontic care. The patient thus does not meet either the New York State criteria or the insurer's criteria for orthodontic treatment (braces). 

Orthodontic treatment (braces) (D8080) is not considered medically necessary for this patient. 

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

The carrier's denial of coverage for orthodontic treatment (braces) (D8080) should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung Cancer
Treatment: Increase Personal Care Assistance Services (PCA), 7 Hours Per Day, 7 Days Per Week, A Total Of 49 Hours Per Week
The insurer denied the Increase Personal Care Assistance Services (PCA), 7 Hours Per Day, 7 Days Per Week, A Total Of 49 Hours Per Week. 
The denial is overturned. 

The patient is a male with a history of recently diagnosed lung cancer requiring chemotherapy for active treatment. Due to impairments related to this condition, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review requested for potential approval of 49 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 49 hours per week Personal Assistance Services is deemed medically necessary.  

This is a male with a history of recently diagnosed lung cancer requiring chemotherapy for active treatment. Due to impairments related to this condition, he requires assistance for completion of the majority of his activities of daily living (ADLs). Review of the medical records indicates that patient's lung cancer was only recently diagnosed via bronchoscopy and surgical pathology and hence will require aggressive treatment with chemotherapy. For these reasons, the patient's functionality and ability to perform ADLs (activities of daily living) will obviously be impacted/further impaired. Hence, the currently approved plan of 22 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 49 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis (AD)

Treatment: Dupixent

The insurer denied coverage for Dupixent.

The denial is overturned. 

This is a female patient with a history of atopic dermatitis (AD) and asthma. The patient has failed topical steroids and phototherapy. The patient has scaly, erythematous, eczematous plaques on legs, arms, back and abdomen; 25% of her body surface area (BSA) is noted to be affected. The provider is requesting Dupixent for this patient's treatment. Dupixent is approved by the Food and Drug Administration (FDA) for the treatment of moderate to severe atopic dermatitis (AD) in patients over the age of 6. Standard treatment options for patients with atopic dermatitis (AD) include a regimen of topical steroids as well as topical calcineurin inhibitors. After topical agents fail, standard practice is to pursue systemic therapy such as phototherapy. 

Per Prezzano and Beck (2017), "Many patients with mild to moderate atopic dermatitis (AD) are managed by identifying and avoiding allergens and irritants, ensuring skin moisturization, and graded use of topical corticosteroids and/or calcineurin inhibitors. There is little consensus on the next step. Most systemic therapies are "off label" in the United States and include phototherapy, cyclosporine, mycophenolic acid precursors, azathioprine, and methotrexate. The decision to use these therapies should be based on efficacy and safety readouts from well designed, long-term trials."

According to Del Rosso (2019), "Atopic dermatitis (AD) is a chronic disorder that requires thorough patient education and a therapeutic management strategy designed to control flares, decrease recurrences, and reduce pruritus. In cases that cannot be controlled by proper skin care and barrier repair, topical therapy, and avoidance of triggers, systemic therapy is often required to control flares and maintain remission. It is important for clinicians to avoid becoming overly dependent on the intermittent use of systemic corticosteroid therapy to control flares, without incorporating other treatment options that might more optimally control AD over time..."

Based on the review of the medical record and the particular issues germane to this patient, Dupixent is medically necessary for this patient.   

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

The carrier's denial of Dupixent is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Home Health Care. 
The insurer denied increase in CDPAP hours to 70 per week. The plan's determination is overturned in whole.

The patient is a female with past medical history of atrial fibrillation, coronary artery disease, cerebrovascular accident (CVA), gout, hypertension, macular degeneration with legal blindness, valvular heart disease, recurrent pneumonia, incontinence of bowel and bladder, hypothyroidism, anxiety, and depression who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 5 hours/day x 5 days/week to total 25 hour/week based on assessment tool. The patient subsequently had Covid-19 infection with aspiration and viral pneumonia with congestive heart failure (CHF). There was a request to increase CDPAP service hours and the patient had a universal assessment tool performed via telephone noting the patient to be total assistance with tasks of meal preparation and ordinary housework while maximum assistance with tasks of managing finances, managing medication, stairs, shopping, and transportation. The patient was assessed at extensive assistance with task of bathing, dressing lower body, walking, locomotion, and transfer toilet while limited assistance with tasks of personal hygiene, dressing upper body, toilet use, and eating. She was independent with bed mobility. The patient was hospitalized with pneumonia and ventricular tachycardia with discharge summary noting discharge to home with home health aide services.

The health plan's determination is overturned in whole. 

The patient had need for PCA/CDPAP services prior to a decline in functional status following three hospitalizations. At a more recent assessment it was noted the patient's daughter, who was informal helper, was unable to continue caring activities due to her own health. The patient therefore needed further assistance from CDPAP in the hours where informal helper had been available. The patient has unscheduled and unpredictable care needs over a span of time, with noted need for assistance with personal hygiene, walking, locomotion, transfer toilet and toilet use. PCA/CDPAP services are not solely for safety and supervision but to assist the patient in safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home. Based on the documentation provided increase in CDPAP hours to 70 hours/week is medically supported and necessary.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Skilled Nursing Facility

Diagnosis: intracranial hemorrhage
Treatment: Skilled Nursing Facility Continued Stay 
The health plan denied the Skilled Nursing Facility Continued Stay. The health plan's determination is upheld. 

The patient is a male with a diagnoses significant for intracranial hemorrhage, concussion, hypertension and traumatic brain injury. At question is the skilled nursing facility continued stay.

The Skilled Nursing Facility Continued Stay is not medically necessary for this patient.
As of the date in question, the patient was independent with bed mobility, independent with sit to stand transfers, ambulated greater than 500' while making "multiple turns with independence. No loss of balance or instability." He was also medically stable and ready for discharge to a lower level of care. Also, documentation continued to note that patient was independent with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, donning/doffing footwear, bed mobility, toilet transfers, transfers, money management, community re-entry, laundry, hot meal prep, moving and carrying. The patient was also ambulating 150' without assistive device independently and balance was described as good. Physical therapy (PT), specifically, described cognitive status as "AO (alert/oriented) x 4 and follows multi-step commands consistently." Lastly, medically the patient was stable with normal vitals, normal BMP and not on any IV medication.
Therefore, the continued stay was not medically necessary and the patient's needs could have been met at a lower level of care.