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

Diagnosis: Dental Problems-Brace. 
Treatment: Dental or Orthodontic Procedure. 
The insurer denied insertion of braces and adjustment of braces. 
The denial is upheld.

The patient in question is a male with a Class I occlusion with 6 millimeter (mm) overbite and 3mm overjet. He has minor crowing. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion. Treatment was denied by the health plan as not medically necessary.

The health plan's determination is upheld. 

There is no medical reason to correct his malocclusion with braces.
The patient has minor crowding. 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 contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient.
While the patient has minor crowding, there is no anterior or posterior crossbite. 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's overjet is slightly more than ideal but his overjet would not affect oral health related quality of life unless it was greater than 6 mm.[3] If his teeth were aligned it would provide a minor esthetic 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: Upheld

Diagnosis: Respiratory System-antitrypsin deficiency.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Prolastin-C for medical necessity. 
The denial was upheld in whole.

This patient is a female who is being evaluated for alpha 1 antitrypsin deficiency and the need for augmentation therapy. Testing revealed a Z allele (MZ) phenotype with an alpha-1 level of 85 milligrams (mg)/deciliter (dL). She currently smokes and has taken Anoro in the past to help with her symptoms. Pulmonary function testing (PFT) revealed a forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) ratio of 66% and an FEV1 of 2.39 liter (L) (75% predicted). A computed tomography (CT) scan of the chest was done which showed no interstitial or alveolar infiltration and no bullous disease or bronchiectasis.
At issue is the medical necessity of Prolastin-C solution 1000 milligrams (mg)/20 milliliter (ml).

The health plan's determination of medically necessity is upheld in whole.

The requested health service/treatment of Prolastin-C Solution 1000mg/20ml is not medically necessary for this patient.
This patient does have obstruction based on PFTs with a FEV1/FVC ratio of 66%. However, the alpha-1 antitrypsin level was 85 mg/dL, which is above the minimum threshold to be protective for emphysema due to alpha-1 antitrypsin deficiency as noted by the American Thoracic Society, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) initiative, and European Respiratory Society. There is no supporting documentation stating that this patient was in an acute inflammatory state during her measurement and there is no documentation of a lower level when not in an inflammatory state. This patient is not appropriate to be treated with augmentation therapy given her level of 85 mg/dL is higher than the threshold for augmentation, per the American Thoracic Society and the GOLD initiative. As such, augmentation therapy in this patient is not clinically indicated or medically necessary.
Therefore, the Prolastin-C Solution 1000mg/20ml is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Hernia
Physical Therapy

The patient is a male status/post (s/p) left sports hernia repair. The patient was prescribed physical therapy in 2018 and began receiving physical therapy (PT) following the hernia repair.
The health plan has denied coverage for the PT (CPT 97110) stating it was not medically necessary.

The health plan's determination is overturned. The requested PT was medically necessary. It is generally accepted standard of care to have physical therapy following sports hernia repair including the exercises as noted on the daily flowsheet. These exercises were being taught to the patient and performed for the purpose of regaining strength, range of motion, flexibility and endurance training. In addition, records noted that the patient was improving and making gains which further supports continued physical therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epilepsy
Treatment: Epidiolex
The insurer denied the Epidiolex.
The determination is upheld.

This is a patient with epilepsy. He has used the following medications for treatment of seizures: Keppra, Trileptal, and Dilantin. The patient has also recently used Lamictal but felt that it caused cognitive side effects. The office notes indicate that the patient is only interested in treatment with cannabidiol (CBD). Epidiolex is requested. The medical necessity of Epidiolexis the subject of this review.
The Epidiolex is not medically necessary for the patient. The patient has focal epilepsy. He has tried Keppra, Dilantin, Trileptal, and Lamictal. He discontinued treatment with these drugs either due to inefficacy or side effects. Treatment with Epidiolex is requested. The provider states that there are no other viable treatment options. However, this is not that case as the patient has not tried and failed a number of standard anticonvulsants, some of which are routinely used for refractory treatment of epilepsy. As such, Epidiolex is not the only remaining treatment option. Epidiolex has been examined for treatment of refractory seizures in prospective and open-label studies; however, controlled trials are lacking. The provider specifically documents in her office note that she discussed "the use of Epidiolex and the lack of evidence for treatment partial seizures". As such, the requested drug is not medically necessary as other standard anticonvulsants exist, there are a lack of controlled trials (as confirmed by the provider), and documents indicate the request is out of patient preference for a CBD product.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder surgery. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This case describes a female patient with a complaint of right shoulder pain. She failed conservative management of a torn rotator cuff and elected to undergo right shoulder arthroscopy with rotator cuff repair, acromioplasty and biceps tenodesis. The patient complained of chest tightness after the operation. She was kept in the hospital on telemetry monitoring and had serial blood draws done for troponin levels. The troponin levels were found to be normal. The patient remained in the hospital until she was deemed stable for discharge to a rehab facility. 

The inpatient hospital admission was not medically necessary for this patient. 
The surgery performed for this patient was consistent with the recommendations of the current, peer-reviewed literature as documented by Rossi and colleagues in the Orthopedic Journal of Sports Medicine and by Dang and associates in the Sports Medicine Arthroscopic Review. 

The provided records document that this patient experienced chest pain and tightness following general anesthesia administered during an elective right shoulder arthroscopy. The patient was monitored on a telemetry floor to assess her cardiac rhythm. She also underwent serial blood draws for troponin levels which were found to be within normal limits. Based on the lab values and documentation in the records, the patient could have been safely cared for at a lower level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Migraines (w/o aura)
Treatment: Formulary exception for Ubrelvy (ubrogepant)
The insurer denied the Formulary exception for Ubrelvy (ubrogepant)
The denial is overturned.

The patient is a female with migraine headache disorder. She has tried and failed rizatriptan, frovatriptan, zolmitriptan, naratriptan, and sumatriptan for abortive therapy. Her provider is requesting Ubrelvy.

Yes, the health plan should cover the formulary exception for Ubrelvy.
The provider has indicated in an appeal letter that the patient has tried and failed five preferred formulary triptans (Thorlund et al.). This is sufficient to conclude that she is unlikely to response to this class of medications, and further trials would likely be futile. Ubrelvy is FDA (United States Food and Drug Administration)-indicated for the patient's condition (Dodick et al.) and a trial in this clinical context would be considered standard of care and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and treatment visits for medical necessity. 
The denial was upheld. 

The patient is a male with Skeletal Class I occlusion. He has mild mandibular crowding, mild overjet, and a mild overbite with anterior crossbite at teeth #7 and #26. Tooth #7 is a peg lateral. The patient has treatment planned for braces and periodic treatment visits over an estimated time of 36 months.
At issue is the medical necessity of Braces and periodic treatment visits.

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

The requested health service/treatment of Braces and periodic treatment visits is not medically necessary for this patient.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 10 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9-millimeter (mm) or greater and an underbite of 3.5 mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary under generally accepted standards of care. The malocclusion in question does not meet the criteria to be classified as handicapping per the HLD index, and therefore, treatment would not be considered medically necessary.
Thus, according to the generally accepted standards of care, braces and periodic treatment visits are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man who presented to the hospital. He had a history of lung cancer status post radiation and he presented with a chief complaint of shortness of breath, chest tightness and chills to the bilateral hands. He also reported that the room was spinning and that he felt dizziness. He denied nausea, vomiting, and headache. Vital signs showed temperature 36.8 Celsius, heart rate 122, oxygen saturation 97%, and blood pressure 132 / 73. On physical exam, heart was regular and rapid, breath sounds were normal, and the abdomen was soft and nontender. Cranial nerves were intact. An electrocardiogram (EKG) showed sinus tachycardia. Chest computed tomography (CT) angiography was negative for pulmonary embolus but showed postoperative changes of the right lung consistent with the patient's known history of malignancy. In addition, there was a possible left sided pneumonia. Labs showed white blood cell count (WBC) 6.4, hemoglobin 11.2, platelets 214, troponin negative, sodium 140, potassium 3.4, creatinine 1.23, glucose 157, calcium 8.7, magnesium 2.1, and troponin negative. The patient was admitted for community acquired pneumonia. 

The inpatient hospital level of care was not medically necessary. The patient had tachycardia but was otherwise hemodynamically stable and did not require respiratory support/mechanical ventilation, nor was there evidence of sepsis or severe pneumonia. In addition, there was no evidence of multi organ dysfunction such as acute kidney injury or encephalopathy in the setting of infection. Overall, the patient did require care, but it could have been safely and effectively provided at a lower level.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Infectious Disease/Hepatitis
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug, Mavyret as non formulary. 
The health plan's determination is upheld. 

The patient is a male with hepatitis C, genotype 2. The viral load is 153,000. Fibrosis is F1-2 (concentration of prothrombin fragment). Mavyret was prescribed.

At issue is the medical necessity of the requested prescription medication, Mavyret.

The health plan's determination is upheld, in whole.

No. Harvoni is not Food and Drug Administration (FDA) approved for hepatitis C genotype 2. However, Vosevi and Epclusa are FDA approved for the treatment of hepatitis C genotype 2. The patient has not failed or been intolerant to and has no contraindication to either of these agents. The formulary drugs will not be ineffective, have not been ineffective, would be as effective as the nonformulary drug, and would not have adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shoulder pain.
Treatment: Joint surgery.
The insurer denied the Joint surgery.
The denial is overturned.

The patient is a male with a painful shoulder. He had episodes of instability, and he underwent surgery. He underwent a right labral repair.

Yes, the Joint surgery was medically necessary.

The records showed consistency of subjective complaints, positive physical findings, and correlative imaging for the diagnosis of shoulder instability. The man reported problems with his shoulder going out of place. He had pains and inability to play sports (soccer). His shoulder would come out with minimal force. This would limit his activities. He was found to have +(positive) Obrien, + drawer and laxity to other joints. He was found to have a labral tear on MR (magnetic resonance) arthrogram.

The patient's pathology was identified. He reportedly had received conservative treatment, which did not provide benefit. The next step should be surgery.

Based upon review of all documentation, the criteria for surgery were met, i.e., + Drawer, Obrien and instability testing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission. 
The denial is upheld. 

This is a male patient who presented to the Emergency Department (ED) complaining of dizziness as well as nausea and abdominal pain. The patient's past medical history includes prostate cancer as well as chronic kidney disease, hypothyroidism, hypertension, and cerebral palsy. The submitted documentation indicated the patient presented from home after waking up with dizziness. He had gone to get some food, felt dizzy and sat down for 5 min and noted the whole room spinning. He also had complaints of vomiting and mild lower abdominal pain. He indicated he initially sat down after he felt dizzy and began to vomit after he got back to bed. The patient was examined; however, it is noted in the ED they were unable to perform orthostatic blood pressures given complaints of dizziness. The physical examination revealed a pulse of 69 beats per minute (bpm) with a blood pressure 168/80. Oxygen (O2) saturation was 99%. The patient did undergo laboratory and diagnostic studies revealing aspartate aminotransferase (AST) of 9 with venous blood partial pressure of oxygen (PO2) of 48. Venous blood O2 saturation was 80.2 and venous blood hemoglobin was 16.5. 

The documentation indicated the patient was recommended for admission. A computed tomography (CT) scan of the abdomen was undertaken showing no free intraperitoneal air or evidence of bowel obstruction. There were 2 separate soft tissue density masses of the left mid and lower poles of the kidney concerning for malignancy. He was recommended to continue with treatment with orthostatic vitals and follow-up with additional studies such as an echocardiogram. A CT scan of the head revealed a focal area of ill-defined low-attenuation to the right frontal lobe periventricular white matter which was nonspecific; however, may be secondary to a subacute infarct. Brain magnetic resonance imaging (MRI) scan was negative for acute stroke. The patient continued with additional treatment and multiple consultations. Neurology evaluated the patient; it was noted the patient was unlikely to have had an acute ischemic stroke, but a transient ischemic attack (TIA) could not be excluded. 

According to the provided documentation the patient remained hospitalized until his symptoms fully resolved with minimal intervention. He was treated with meclizine for his dizziness. The documentation does not detail any significant abnormalities that would warrant the requested hospital stay. The patient could have been treated at a lower level of care.  

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Chronic pain
Issue under review:  Neurostimulator implantation surgery

Determination:
The health plan should not cover the Neurostimulator implantation surgery.

The patient is an adult female with a history chronic pain following a thoracic disc herniation and subsequent decompression and fusion at T12-L1 with resultant myelopathy and subsequent chronic pain.  The patient has failed numerous conservative treatments in the form of physical therapy medications injections.  

The patient has a complicated pain history with thoracic decompression fusion and subsequent myelopathy and radiculopathy.  The patient has been treated with injections medications and physical therapy.  The requested DRG stimulation is unlikely to be of greater utility than traditional spinal cord stimulation.  According to the attached documentation, the patient was referred specifically for dorsal root ganglion stimulation at an outside center than where she typically follows, due to them not offering this procedure.  However dorsal root ganglion stimulation (DRG Stimulation) has not been shown to be more effective for post laminectomy syndrome, chronic radiculopathy and chronic low back pain in the literature.  In fact it has been shown to be superior to traditional spinal cord stimulation in a few conditions, specifically complex regional pain syndrome.  There is some evidence that it is superior already in conditions such as Pelvic Pain, Pudendal Neuralgia, Amputee Pain, Post Hernia Pain, Post Mastectomy Pain, Post Herpetic Neuralgia.  However these are not the conditions being treated this patient.  

Given the above, and the lack of failure of traditional spinal cord stimulation, the requested dorsal root ganglion stimulation is not medically appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Chronic pain
Issue under review:  Neurostimulator implantation surgery

Determination:
The health plan should cover the Neurostimulator implantation surgery.

The patient is an adult female.  The patient has left distal thigh and proximal calf area severe pain with burning and numb qualities.  She has a history of decompressive surgery at the level.  She has tried and failed multiple medications, including opioids and anti-neuropathic agents.  Exam noted allodynia on exam.  There was right foot dystonia and touch evoked paresthesia.  The patient had evidence of myelopathy from lower thoracic cord with severe pain and ongoing activity limitation.  There is stenosis above her fusion.

The patient was psychologically cleared for the proposed treatment.

The patient is female.  The request is for a dorsal root ganglion stimulator.  

The patient has left distal thigh and proximal calf area severe pain with burning and numb qualities.  She has a history of decompressive surgery at the level.  She has tried and failed multiple medications, including opioids and anti-neuropathic agents.  Exam noted allodynia on exam.  There was right foot dystonia and touch evoked paresthesias.  The patient had evidence of myelopathy from lower thoracic cord with severe pain and ongoing activity limitation.  There is stenosis above her fusion.

In this case, the patient has failed other conservative treatment for a period of six months or longer.  The patient had previous lumbar-thoracic level surgery and has residual stenosis on the spine canal.  As a result, the patient is a poor candidate for epidural spinal cord stimulation that would be first line therapy for the neuropathic pain condition/ failed back pain syndrome she is experiencing.  The patient has also been psychologically cleared.  Dorsal root ganglion stimulation (DRG) is the supported treatment as alternative given the locality of the pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Occlusion.
Treatment: braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is upheld. 

The patient in question is a male with a Class I, crowded occlusion with a deep bite. The orthodontist states he has an anterior crossbite with gingival attachment loss on tooth 22. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion.

Braces and Monthly Visit x 12 are not medically necessary for this patient. 

There is no medical reason to correct his crowding with braces. The patient does have slightly retroclined maxillary incisors and a deep bite. However, that alone is not a medical necessity to treat. There are many ways to correct patients with a deep bite and retroclined incisors, and there is strong evidence that one treatment is not better than another. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. 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. The patient's overjet is slightly more than ideal but his overjet would not affect oral health related quality of life unless it was greater than 6mm. If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.