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

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied dental procedure of Partial dentures, root canal, and crowns. 
The denial was upheld. 
 
This is a male patient who has a history of rectal cancer, status/post (s/p) chemotherapy. He is scheduled for upper and lower partial dentures, root canal treatment for #23 and crowns for #26, #27, #28 and #30 because the prognosis of the remaining teeth is not good. 

At issue is the medical necessity of Plate replacing some upper and lower teeth (Partial dentures), cleaning inside roots of tooth (Root Canal) for tooth #23, tooth colored cap (Crown) for teeth #'s 26, 27 and 28 and metal cap (Crown) for tooth #30. 

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

The requested health service/treatment of Plate replacing some upper and lower teeth (Partial dentures), cleaning inside roots of tooth (Root Canal) for tooth #23, tooth colored cap (Crown) for teeth #'s 26, 27 and 28 and metal cap (Crown) for tooth #30 is not medically necessary for this patient. 

The notes state that the patient has a collapsed bite, and the vertical dimension must be opened, and partial dentures will be submitted for. There is not enough clinical documentation to determine if the treatment is medically necessary and appropriate. There is not a complete examination and treatment plan. In order to determine the appropriateness for treatment, a thorough examination and treatment plan is typically documented. The Panorex shows almost all the teeth have had root canal treatment and there are multiple non-restorable teeth. There is no documentation showing the pocket depths of the remaining teeth. #23 has extensive caries and a periapical lesion. Generally, the determining factors would be the periodontal examination and whether or not this tooth could be removed and replaced with a partial denture. In addition, the examination does not state which teeth are to be the abutment teeth. The notes do not contain this documentation or treatment plan. 

Therefore, the treatment of Plate replacing some upper and lower teeth (Partial dentures), cleaning inside roots of tooth (Root Canal) for tooth #23, tooth colored cap (Crown) for teeth #'s 26, 27 and 28 and metal cap (Crown) for tooth #30 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Myelogenous Leukemia
Treatment: Prevymis
The insurer denied the Prevymis.
The determination is overturned.

This is a patient who is cytomegalovirus positive (CMV+) with a treatment-related acute myelogenous leukemia. The patient has a translocation [t] (16;16) abnormality. She has undergone induction with cytarabine and achieved a compete response (CR). She underwent a haplocord stem cell transplant. The donor was CMV+. Treatment with Prevymis (letermovir) has been recommended and is under review.

In this scenario, CMV-prophylaxis is reasonable and appropriate based on support in the literature as the patient is high risk based on the seropositive donor. The authors of UpToDate state "When we give prophylactic therapy, we favor letermovir." Letermovir has considerably less toxicity than alternatives and it is recommended in the peer-reviewed literature. It is Food and Drug Administration (FDA) approved for this indication and it is being used in a fashion consistent with its label. The plan states that a therapy can be approved if consistent with the FDA product labeling. The labeling for this indication states "Prevymis is a CMV deoxyribonucleic acid (DNA) terminase complex inhibitor indicated for prophylaxis of cytomegalovirus (CMV) infection and disease in adult CMV-seropositive recipients [R+] of an allogeneic hematopoietic stem cell transplant (HSCT)." This clinical scenario is consistent with the label. Further, with regard to comparison to the agents Valganciclovir tablets or Ganciclovir intravenous solution noted in the final adverse determination (FAD), the authors of UpToDate state letermovir "is a potential alternative that has considerably less toxicity."

For these reasons, medical necessity has been established for this service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polyarticular Juvenile Idiopathic Arthritis. 
Treatment: Humira 40mg, Pre-service. 

The insurer denied the Humira 40mg, Pre-service. 

The denial is overturned. 

This case involves a female with a history polyarticular juvenile idiopathic arthritis.  The patient has tried and failed multiple different medications for her disease including meloxicam, nabumetone, celecoxib, and intra-articular steroid joint injections.  Despite this, she continues to have active disease.  In addition, the patient has elevated transaminase levels and a positive hepatitis immunoglobulin M (IgM) antibody, excluding the use of conventional disease modifying anti-rheumatic drug (DMARD) agents such as methotrexate or leflunomide due to risk of worsening liver disease.  The board certified treating pediatric rheumatologist in this case is asking to start adalimumab therapy 40 milligrams every other week to treat her polyarticular juvenile idiopathic arthritis (pJIA). 

Yes, the proposed treatment with adalimumab therapy is medically necessary for this patient. 

Adalimumab is an Food and Drug Administration (FDA) approved therapy for treatment of polyarticular juvenile idiopathic arthritis.  It has been studied in multiple phase III clinical trials and been shown to be safe and effective in patients with polyarticular juvenile idiopathic arthritis (pJIA).  Additionally, it is listed as treatment options for polyarticular juvenile idiopathic arthritis (pJIA) in both the American College of Rheumatology treatment recommendations and the Childhood Arthritis and Rheumatology Research Alliance consensus treatment plans for this disease.  It is considered standard of care in the pediatric rheumatology community to use adalimumab in patients with polyarticular juvenile idiopathic arthriti (pJIA). 

The reason for denial for this patient was that patient had not yet tried a conventional disease-modifying anti-rheumatic drug (DMARD) such as methotrexate.  This patient has pre-existing liver disease, documented in the patient's clinic notes and labs showing an elevated alanine aminotransferase (ALT) level and a positive hepatitis A immunoglobulin M (IgM).  This patient should not be treated with a disease-modifying anti-rheumatic drug (DMARD) such as methotrexate due to the possibility of worsening liver disease.  Therefore, the patient should be allowed to start a Food and Drug Administration (FDA) approved drug for polyarticular juvenile idiopathic arthritis (pJIA) such as adalimumab.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder-braces
Treatment: Braces and office visits
The insurer denied Braces and office visits.
The determination is overturned.

The patient has crossbites of anterior teeth number (#) 7 and 10. She presented with a skeletal Class III malocclusion with severe crowding in the maxilla and the mandible. Tooth # 13 is completely blocked out to the lingual. She is treatment planned for of 30-36 months of orthodontics with extraction of four premolars to address the crowding and crossbite, but the treatment was denied due to a lack of medical necessity.
At issue is the medical necessity of braces and office visits.

This patient presented with anterior crossbites on teeth 7 and 10, as well as severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) It appears the lower anterior teeth are migrating labially in the arch. If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic recurrent multifocal osteomyelitis (CRMO) and spondyloarthropathy
Treatment: Enbrel 25 milligram (mg)
The insurer denied coverage for Enbrel 25 milligram (mg).
The denial is overturned.

The patient is a male with a medical history of chronic recurrent multifocal osteomyelitis (CRMO) and spondyloarthropathy. The patient has been followed by a specialty hospital for many years. Previous treatment has included oral corticosteroids, bisphosphonates, methotrexate and Enbrel. He has done well on Enbrel. Continuation of Enbrel 50 mg/week is requested. A recent cut in dose has led to a flare requiring prednisone. 

The patient's father is appealing. In his appeal letters, he states that the patient has been treated with his current dose of Enbrel 50 mg every 7 days for several years. The insurer has previously approved his current regimen. The patient's physicians are widely respected in their field and have published research on the patient's conditions. Attempts to lower the patient's dosage have been unsuccessful and have led to worsening of his symptoms.

The health care plan did not act reasonably, with sound medical judgment or in the best interest of the patient. This reviewer disagrees with the plan's assessment.

This reviewer cannot find documentation that the insurer's denial is based on the medication not being Food and Drug Administration (FDA)-approved for CRMO. But this reviewer would note that it is a rare disorder, and multi-treatment failures like this patient are even rarer. There are no FDA-approved treatments for CRMO. As noted in www.uptodate.com chapter "Chronic nonbacterial osteomyelitis (CNO)/CRMO" anti- tumor necrosis factor (TNF) medications have a prominent role in the treatment of this disorder. The patient has been on and failed the suggested alternatives. 

It appears the denial is for more than 4 vials of 25 mg Enbrel/month, resulting in a dose of 25 mg/week. The patient has been on 50 mg/week for several years with good control of disease and is flaring on 25 mg/week. He should continue on 50 mg/week either with 2 x 25 mg vials/week or one 50 mg dose/week using the prefilled syringe (PFS) or Sureclick forms. 

The insurer's denial of coverage for Enbrel 25 milligram (mg) vial is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcoholic cirrhosis. 

Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient who has a history of alcoholic cirrhosis, essential hypertension, and morbid obesity. He was brought to the Emergency Department (ED) by Emergency Medical Services (EMS) for evaluation of increasing weakness and confusion.  

The patient had alcoholic cirrhosis and presented with weakness and confusion.  He was not compliant with his Lactulose.  He was afebrile and the vital signs were stable.  On admission he was noted to be alert and oriented.  The ammonia level was 129.  The electrocardiogram (EKG) showed a junctional rhythm.  Magnesium replacement was given.  The elevated ammonia level was treated with Lactulose.

Based on Milliman Care Guidelines (MCG) Clinical indications for admission for Liver Disease Complications include having hepatic encephalopathy that persists despite observation care.  This patient had hepatic encephalopathy, but he showed improvement when the Lactulose was re-started.  He also did not have hemodynamic instability, persistent tachypnea, infected ascites, hepatorenal syndrome, severe vomiting, or an inability to maintain oral hydration after observation care.

The assessment at the time of admission was that the patient would benefit from an observation period overnight.  He required being re-started on the Lactulose but this could have been done with observation care.  His mental status improved.  The magnesium replacement could also have been done with observation status.  He did not meet MCG criteria for an acute inpatient admission based on MCG criteria for Liver Disease Complications.  The health plan acted reasonably with sound medical judgment. 

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

Diagnosis: renal stone

Treatment: percutaneous nephrolithotomy (PCNL).

The insurer is denied coverage for percutaneous nephrolithotomy (PCNL).

The denial is overturned. 

This female patient has a history of hypertension (HTN), obesity, recurrent urinary tract infection (UTI), and renal stones.  The patient presented to the hospital for planned left percutaneous nephrolithotomy (PCNL) procedure.  The procedure was uncomplicated.  The patient had a 4 cm renal stone.  The patient's postoperative course was complicated by fevers, leukocytosis.  The patient was given intravenous (IV) antibiotics, IV fluids, the stent remained in place.  All cultures were negative, pain was well controlled.  Diet was advanced, and the patient ambulated.  Foley was removed.  The patient was discharged to complete 7 day course of Cefdinir.

They noted an uncomplicated procedure and postoperative elevated leukocytosis/fever.  While in some cases percutaneous nephrolithotomy (PCNL) can be an outpatient procedure, this patient had post-operative low-grade fever, chills, abdominal pain, and loose stools.  She required intravenous (IV) antibiotics for several days postoperative while the evaluation was in process.  Cultures, Covid, and clostridium difficile tests were all eventually negative.
Per MCG Health 24th Edition:

1)	Urologic Surgery or Procedure GRG - the patient fails to meet GRC discharge parameter within 24 hours postoperative
2)	Nephrostomy, Percutaneous - the patient fails to meet ORG because parameters within 24 hours postoperative.

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 the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Other/Irreversible Pulpits.
Treatment: Dental/Orthodontic Procedure-root canals .
The health plan denied the requested dental treatment plan as not medically necessary. 
The health plan's determination is overturned.

The patient is a male who presents for evaluation and treatment of teeth #2 and 3. Provided for review are previous letters of appeal and denial, a narrative from the patient's son, full mouth radiographic images, health history forms, two pages of claim forms, data collection forms, and a referral form for teeth #2 and 3 to receive root canal therapy. In question is the medical necessity of the treatment of (0330) endodontic treatment on teeth #2 and 3.
At issue is the medical necessity of the requested dental treatment plan.

I overturn in whole, the health plan's determination of medical necessity.

Yes, based on the documentation provided, the requested service/treatment of root canal for teeth # 2 and 3 is medically necessary for the patient.
As the patient has irreversible pulpits on both #2 and 3, in any situation where the patient has the diagnosis of irreversible pulpits, as long as the tooth is restorable, there is the requirement to treat the pulpitis through removal of the infected nerve, artery, vein, as well as the canal tooth structure, irrigate with sodium hypochlorite, and fill with gutta percha medicament as this is the only therapy that will treat the diagnosed pathology. This is a root canal. If the therapy is not done, the pulpal infection can spread to the surrounding bone, which can lead to the presence of abscess, with an array of sequential systemic sequela. Hence, based on the diagnosis of irreversible pulpits alone, the therapy of root canal therapy is indicated for both #2 and 3. Hence the treatment of (0330) root canal therapy for #2 and 3 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immunologic Disorders/ Lupus
Treatment: Inpatient Hospital

The health plan denied the requested inpatient stay as not medically necessary. The health plan's determination is overturned.

This is a case of a female admitted for a diagnosis of a Lupus flair. The patient had chief complaint of bilateral arm pain. She was also found have left-sided pleural effusion and was evaluated by cardio-thoracic surgery with no intervention recommended. Vital signs demonstrated temperature of 36.1C, a blood pressure of 134/80 millimeters of mercury (mmHg), a pulse of 82 beats per minute (bpm), a respiratory rate of 17/minute and an oxygen saturation of 99%. Physical exam showed no altered mental status or acute distress. Lungs were clear bilaterally. The patient was recommended to have additional rheumatology evaluation because of the pleural effusion and history of Lupus. The patient was seen by rheumatology and started on a steroid taper and Cellcept. The patient was planned to have pleurodesis on an outpatient basis when the steroid taper was completed. 
At issue is the medical necessity of the inpatient stay.

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

Yes, the medical necessity of admission has been established.
According to Up-to-date, 2021:
"Flares: Definition - The clinical course of systemic lupus erythematosus (SLE) is variable and may be characterized by unpredictable disease flares and remissions. There is no consensus on what constitutes a disease flare, but most definitions have incorporated a combination of results from serologic measures and disease activity indices. Flares are generally categorized by severity, with moderate or severe flares being the most clinically significant. Most clinicians agree that a moderate or severe flare refers to a measurable increase in disease activity that is clinically meaningful enough to result in a change in therapy. A challenge in clinical practice is to stratify patients at risk for disease flares. We use serologic measures of disease activity in the context of the clinical presentation and organ domain involvement to evaluate for a disease flare. (See 'Laboratory evaluation' above.)

The patient in this case had a lupus flair evaluated by rheumatology which required treatment with steroids in addition to immunosuppressive therapy with Mycophenolate placing her in a severe flare category. She also had recurrent pleural effusion causing hypoxia which require treatment with supplemental oxygen. Therefore, the medical necessity of admission has been established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spondylosis.

Treatment: pain injections 64493, 64494, and 64495.

The insurer is denied coverage for pain injections 64493, 64494, and 64495.  The denial is overturned. 

According to the documentation submitted, this patient has a history of spondylosis, degenerative disc disease, and lumbar radiculopathy.  The patient had a laminectomy at level L4-5.  She has been taking Etodolac, Gabapentin, and Advil.  As per an office visit note from Elite Pain and Sports Medicine she had complaints of chronic, worsening back pain that is worse when standing or walking and better when sitting down. She has received paravertebral facet joint injections.

In an office visit note from Elite Pain and Sports Medicine, she had complaints of chronic, worsening back pain that is worse when standing or walking and better when sitting down.  She has radiation to the left lateral thigh.  She has failed physical therapy and a home exercise program of 12 weeks duration.  

She has had lumbar epidural steroid injection and lumbar facet block at L4-5, L5-S1 with reported 80% relief and improvement with activities of daily living.  

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 the pain injections 64493, 64494, and 64495 is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis.
Treatment: Dupixent at a dose of 300 milligrams (mg) per week.
The insurer denied coverage for Dupixent at a dose of 300 milligrams (mg) per week.  The denial is overturned. 

According to the documentation submitted, this is the case of a female patient with a past medical history of atopic dermatitis.  According to the appeal letter written by Physician Assistant, the patient has severe dermatitis and has been on Dupixent with some relief, but not complete relief of symptoms.  The letter states that prior to Dupixent, the patient had tried and failed clobetasol, Enstilar, Eucrisa, mometasone, and phototherapy.  The letter states that the patient is being increased to weekly dosing of Dupixent.

Based on the current peer-reviewed literature, Dupixent weekly is medically necessary.  The patient has tried and failed biweekly Dupixent.  There are no other systemic therapies approved for use in atopic dermatitis.  In 2019, Thibodeaux et al. published "A review of dupilumab in the treatment of atopic diseases." in which they demonstrated that weekly dosing of Dupixent had significant efficacy.(1)  Beck et al. also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to 3 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis."(2)  Therefore, it is appropriate, based on the patient's clinical findings and refractory disease, to approve weekly Dupixent in 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 coverage for Dupixent at a dose of 300 milligrams (mg) per week is overturned.  The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Moderate, Persistent Asthma. 
Treatment: Formulary exception for Dulera. 
The insurer denied the Formulary exception for Dulera. 
The denial is upheld. 

The patient is a female. She has moderate-severe persistent asthma. She is requesting approval for Dulera, which was denied for off-formulary. 

No, the health plan should not cover the Formulary exception for Dulera. 

The formulary alternatives, specifically Advair HFA (hydrofluoroalkane-134a) and Advair Diskus, have not been shown to be inferior to the requested off-formulary drug. There is no evidence that the patient has tried the formulary alternatives, specifically Advair, or has shown adverse effects to the formulary alternatives.  The clinical notes only indicate prior trials with Symbicort and Breo. 

Therefore, given the above, the health plan should not cover the formulary exception for Dulera.