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

Diagnosis: Dental Problems. 
Treatment: Dental /Orthodontic Procedure. 
The insurer denied braces and monthly visits x12. 
The denial is overturned in whole.

The patient is a female with a Class III malocclusion, moderate spacing of the upper and lower arches and anterior crossbite of teeth #7-#10. She is treatment planned for 36 months of orthodontics to correct her malocclusion which was denied by her health plan on the basis that treatment is not medically necessary.

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

The requested treatment of braces and monthly visits x12 is medically necessary for this patient. This patient presents with an anterior crossbite, significant spacing, and a skeletal jaw imbalance. 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) These problems are much more time consuming to correct than the patient's current orthodontic problem.

The patient has significant maxillary anterior spacing with teeth #7-#10 in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. (4)

Braces and monthly visits are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the inpatient hospital stay. 
The determination is upheld. 

The patient was brought to the emergency department (ED) just after midnight for multiple episodes of non-bloody vomiting without diarrhea. His urine output had been normal and he was taking Pedialyte orally. At triage, his temperature (T) was 37.6 degrees rectal, heart rate (HR) 143, respiratory rate (RR) 40, and oxygen saturation (O2 Sat) 97% on room air. Shortly after arrival in the ED, he began to have watery diarrhea. The ED physician exam documented a well hydrated patient in no distress with moist mucus membranes and a normal gastrointestinal (GI) exam. The stool was sent for studies, which demonstrated a norovirus infection. The electrolytes were normal except for a bicarbonate of 16 and a blood urea nitrogen (BUN) of 29. He was given two intravenous (IV) fluid boluses and Zofran. He vomited milk after a by mouth (PO) challenge. The ED physician documented that the patient had no episodes of vomiting in the ED, was still having a lot of vomiting and not tolerating PO, and looked "very dehydrated." He was admitted to the pediatric unit for further IV fluid. On admission, the pediatric attending physician noted that his vital signs were normal and that the baby appeared well nourished, sleeping comfortably in no distress, with moist mucus membranes, and capillary refill less than two seconds. The pediatric resident note states that "upon arrival to the floor, the patient was tolerating Pedialyte." Vital signs remained normal throughout the admission. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. The patient was brought to the ED with a gastroenteritis that turned out to be norovirus. He was brought to the ED very early in the illness, just four hours after he began vomiting, and he did not have diarrhea until he arrived at the ED. His vital signs were always normal. The physical exam in the ED documented normal hydration. The patient was provided Zofran for vomiting and had no further vomiting in the ED. The patient was provided two IV boluses in the ED. He was said to have vomited milk on a PO challenge in the ED, but on arrival to the pediatric floor, it was noted he was taking Pedialyte orally and the physical exam again showed normal hydration-moist mucus membranes and normal capillary refill. These exams stand in contrast to the one comment from the admitting ED physician that he appeared "very dehydrated." He did have a mildly decreased bicarbonate and mildly increased BUN, indicating that he may have been somewhat "dry." But, to whatever extent he had a mild dehydration, his fluid was fully replenished in the ED with the two fluid boluses and he was taking oral Pedialyte. He did not require an inpatient level of care; further care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Pharmacy/Prescription Drugs (Skyrizi).
The health plan denied the request for Skyrizi. 
The health plan's determination is upheld.

The patient is a female with moderate to severe psoriasis (90% body surface area involvement) of the arms, legs, chest, back, and scalp. The patient has tried and failed topical therapies (such as 2.5% Hydrocortisone, Triamcinolone, Clobetasol, and Tacrolimus) and laser/light therapies, as well as intralesional Kenalog, for years.
The health plan coverage of Skyrizi is under review for medical necessity.

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

No. Skyrizi is being requested for coverage based on convenience rather than true medical necessity. First-line therapies that are reasonable, safe with monitoring, time-tested, and standard of care for patients who are starting systemic therapy for psoriasis have not been used. Accordingly, the health plan has acted in a reasonable manner, with both sound medical judgment and in the best interest of the patient.
The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate or Cyclosporine. Consistent with current medical literature [2-5], the requested Skyrizi is not medically necessary for coverage.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Musculoskeletal/Orthopedic. 
Treatment:  Home Health Care (increase in personal care services from 56 hours to 84 hours per week). 

The insurer denied the Home Health Care (increase in personal care services from 56 hours to 84 hours per week).  The denial is overturned.

The patient is a female with past medical history significant for multiple sclerosis, coronary artery disease, hypertension, depression, anxiety disorder, incontinence, gait abnormality, osteoarthritis, hyperlipidemia.  The patient lives in a private residence with her son.

The patient was receiving 56 hours per week of personal care services and is requesting an increase to 84 hours per week.  This was denied by the plan due to lack of medical necessity.

The subject of this review is whether an increase to 84 hours per week is medically necessary for this patient.

The health plan's determination is overturned.

Yes, the requested health service of increase in personal care services from 56 hours to 84 hours per week is medically necessary for this patient.  The patient has multiple medical problems, most notably multiple sclerosis.  She has disabilities with personal care, gait abnormality and most recently a decubitus ulcer.  The patient's medical condition in regard to multiple sclerosis and her other chronic diseases have not changed; however, she has developed several areas of skin ulceration noted in the provided photographs as well as in the recent hospitalization documentation.  Additional medical services for turning the patient frequently, every 2 hours would be considered medically necessary.  Additional services are warranted.  The patient requires assistance and cannot do this on her own, as noted through previous physical therapy notes.

The Uniform Assessment System (UAS) State of New York evaluations were reviewed.  Tasking sheets noted the patient required total of 33 hours a week; this was increased to 56 hours a week.

The provider has included documentation regarding a recent hospital admission.  During this admission, the patient was found to have a large sacral decubitus ulcer 20 x 30 centimeter (cm) noted to be stage I which is noted on the hospital admission along with included photographs.  There are several areas of skin breakdown with dark eschars, which are noted to be unstageable.

The most recent physical therapy note indicates the patient needs moderate assistance for bed mobility and moderate assistance for transfers.

It is reasonable to state that the patient's medical condition has progressed.  The patient is not independent with transfer and bed mobility without moderate assistance.  In order for her decubitus ulcers to heal, the patient requires additional assistance.  This reviewer finds it prudent that the patient have additional services for this reason.  Therefore, the increase to 84 hours per week is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Skyrizi
The insurer denied coverage for Skyrizi.
The denial is upheld. 

This is a male patient with a diagnosis of severe psoriasis who has requested Skyrizi and to stop Humira. The patient is needle phobic, although both use needles. The patient has failed (lost effectiveness) for Humira and Otezla.  

The patient has been deemed as failing Humira and also stating needle phobia. There is no psychiatric documentation that the patient is trying to overcome this. The preferred agent, Enbrel, has a much longer safety record as opposed to Skyrizi, so wishing for a safer medication would point toward Enbrel. There is no evidence that Enbrel will not work for this patient and it is reasonable to trial such medication. There is substantial data for its use on safety and efficacy. According to the Food and Drug Administration (2017), Enbrel is a tumor necrosis factor (TNF) blocker that is indicated for the treatment of rheumatoid arthritis, polyarticular juvenile idiopathic arthritis (JIA) in patients above a certain age, psoriatic arthritis (PsA), ankylosing spondylitis (AS), and plaque psoriasis (PsO) in patients above a certain age. 

Per Fala, L., (2015), "The therapeutic goals for psoriasis include (1) slowing the speed of skin growth to reduce inflammation and plaque formation, and (2) smoothing the skin.11 Topical treatments for psoriasis include topical corticosteroids, vitamin D analogues, anthralin, topical retinoids, calcineurin inhibitors, salicylic acid, and coal tar.  Phototherapy with artificial ultraviolet A or ultraviolet B light is sometimes used alone or in combination with other medications. Oral or injectable therapies include methotrexate, retinoids, cyclosporine, and the biologic immunomodulator agents, including several tumor necrosis factor-alpha inhibitors (e.g., adalimumab, etanercept, infliximab) and the interleukin-12/interleukin-23 inhibitor (i.e., ustekinumab)."

According to the U.S. [United States] National Library of Medicine (2020), Enbrel is indicated for treating patients above a certain age who have chronic moderate to severe plaque psoriasis (PsO) who are candidates for systemic therapy or phototherapy. 

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

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

Diagnosis: Obesity
Treatment: Presurgical Esophagogastroduodenoscopy
The health plan denied the requested esophagogastroduodenoscopy. 
The health plan's determination is overturned.

This patient is a woman who is seeking health plan coverage for an upper endoscopy as a screening evaluation prior to bariatric surgery. The undated appeal letter states that presurgical upper endoscopy is required as a screening study prior to bariatric surgery.
At issue is the medical necessity of the requested service.

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

Presurgical endoscopy is medically necessary for this patient. Bennett et al evaluated the role for pre-surgical upper endoscopy in a meta-analysis that comprised 12,261 patients with a mean (SD) age of 40.5 (1.3) years and body mass index of 46.3 (1.5) kg/m2. The majority of patients (77.1%) were female. The proportion of esophagogastroduodenoscopies (EGDs) resulting in a change in surgical management was 7.8%. Changes in medical management were seen in 27.5%.
Published data on the role for pre-surgical endoscopy support that this evaluation should be a coverage benefit for patients undergoing bariatric surgery.
Obesity is an important risk factor for several digestive diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia (HH), Barrett's esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, non-alcoholic fatty liver disease (NAFLD), cirrhosis, and hepatocellular carcinoma. Most of these diseases are observed up to 2-3 times more frequently in obese patients than in normal weight individuals and may be asymptomatic.
Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal (GI) findings, such as a large HH or Barrett's esophagus, are detected preoperatively.
The published guidelines of the European Association for Endoscopic Surgery state that esophagogastroduodenoscopy (EGD) or upper-GI series is advisable for all bariatric procedures and strongly recommended for gastric bypass patients [Roux-en-Y gastric bypass (RYGB)]. Similarly, the recently published guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) recommended that EGD should be performed in all symptomatic patients undergoing bariatric surgery and considered in all candidates.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Internuclear ophthalmoplegia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient was admitted with complaints of (c/o) reproducible chest pain and diplopia. Vital signs were unremarkable. The physical exam was significant for internuclear ophthalmoplegia. Lab work was notable for a negative troponin. A computed tomography (CT) scan of the head and magnetic resonance imaging (MRI) of the brain both showed no acute intracranial abnormality, MRI showed mild non-specific increased white matter signal in bilateral occipital lobe on fluid-attenuated inversion recovery (FLAIR). An electrocardiogram (EKG) showed non-specific changes. Neurology evaluated the patient and considered auto-immune causes. The patient was diagnosed with musculoskeletal (MSK) chest pain and internuclear ophthalmoplegia (INO) and radiographic work-up and specialty consultation. The patient left against medical advice (AMA). At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of Inpatient Hospital Admission was medically necessary for this patient. This patient with no prior PMH presented to the ED with a new focal neurologic deficit and found to have internuclear ophthalmoplegia. This can be a presentation of serious causes of neurologic dysfunction, including auto-immune diseases such as multiple sclerosis, brainstem infarctions, or infection. These causes require close clinical monitoring, frequent neurological checks, extensive neuro-radiological work-up, urgent expert consultation, and potentially quick administration of medications to prevent further neurologic deterioration. This patient presented with new and persistent focal neurological findings that could not have been safely or appropriately worked up at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  G12.9 SMA (spinal muscular atrophy).
Treatment:  Power Assist System.

The insurer denied the Power Assist System.  The denial is overturned. 

The patient is a male with history of spinal muscular atrophy diagnosed a few years after birth and gradually losing strength in his lower extremities and transitioning to using an ultralight manual wheelchair during his early teenage years, which has allowed him to maintain his independence with mobility.  He has been using an ultralight manual wheelchair with Smart Drive power assist for many years, but the health plan believes that the patient needs a power wheelchair instead.

The request for a power-assist-system as an add-on to the patient's manual wheelchair is due to wear and tear with several repairs of the Smart Drive power assist in the past. The manufacturer of the Smart Drive has stated that after the last repair that parts for the current model Smart Drive power assist are no longer available with recommendation for a new device. 

The patient uses the wheelchair with power assist for navigation at home and in the community.  The option of a power wheelchair will not allow him to use the bilateral upper extremities negating rehabilitation principles.

Yes, the Power Assist Program is medically necessary because the Smart Drive power-assist system has been used by the patient, and a replacement is needed as the device could no longer be repaired, as stated by the device manufacturer and also because the power assist to the wheelchair will also enable member to continue to his use his upper extremities to propel the wheelchair and help him maintain strength and dexterity, which he will lose if dependent on using a powered wheelchair.  It is also medically necessary because it is not for the convenience of the patient but medically necessary to enable the patient with his condition and extensive weakness to continue to navigate paths, etc towards improving his mobility and accessibility as part of his activities of daily living (ADLs).

In the systemic review of pros and cons of power-assist wheelchair by Kloosterman et al., looking at clinical or randomized controlled trials comparing powered wheelchair with power-assist wheelchair, they found power-assisted propulsion might be beneficial for subjects in whom independent hand-rim wheelchair propulsion is endangered by arm injury, insufficient arm strength or low cardiopulmonary reserves.  Also, subjects who have difficulty propelling a wheelchair in a challenging environment can benefit from power-assisted wheelchair use.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Gastrointestinal Bleeding
Treatment: Inpatient Hospital. 
The health plan denied the inpatient stay. 
The health plan's determination is partially overturned.


The patient is a male admitted to the hospital. The patient has a history of gastric bypass and presented with rectal bleeding and vomiting; the vomit contained blood as well. The patient later admitted he did not have blood in his stool and was constipated. The patient also endorsed epigastric pain. One month prior to arrival an esophagogastroduodenoscopy (EGD) apparently showed a "stomach ulcer". He was lightheaded and dizzy. On evaluation in the emergency room (ER) the patient's vitals were stable. Heart rate (HR) = 62 beats per minute (bpm). Initial hemoglobin = 7.9 (patient is with chronic anemia). The patient received 1 unit of blood in the ER. His hemoglobin responded @ 10. He was started on Proton-pump inhibitors. The patient underwent an EGD which revealed 2 very small ulcers in the gastric remnant. The patient was uneventfully discharged.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is overturned, in part. In my opinion, 1 day of observation level of care was medically necessary. Inpatient hospital admission was not medically necessary.

No. After detailed history and additional supplemental information became available (vital signs, admitting complete blood count (CBC)) it was clear that the patient was not having a significant gastrointestinal (GI) bleed. The patient remained hemodynamically stable in the ER and responded appropriately to a red blood cell (RBC) transfusion. It was very reasonable to admit him as at an observation level of care for 1 day, but an inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic back pain

Treatment: Continued Skilled Nursing Facility stay

The insurer denied coverage for the continued Skilled Nursing Facility stay.

The denial is overturned. 

This is a female patient with a past medical history of hypertension, asthma, chronic back pain, and gastritis who underwent anterior cervical discectomy and fusion (ACDF) at cervical vertebrae 4-5 (C4-5). The patient was admitted to a Skilled Nursing Facility (SNF) for subacute rehabilitation. Under review is the medical necessity of SNF stay from day 24 of admission onward.  

The clinical records demonstrate a level of physical impairment and functional progress that supported the medical necessity of subacute rehabilitation services at the SNF for the time under review. The therapy progress notes demonstrate a level of gradual functional improvement with an eventual safe discharge home. For example, according to the physical therapy notes, the patient continued to require supervision to stand by assistance for bed mobility and transfer activities. The patient was only ambulating 90 feet. By the time of discharge, the patient was independent with bed mobility, set-up for transfer activities and ambulating 200 feet. A similar level of improvement was documented by the occupational therapist. By the time of discharge home, the patient was independent with hygiene/grooming and set-up assistance for bathing, toileting and dressing. The patient had an overall excellent functional outcome.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, SNF from day 24 of admission onward was medically necessary.

The carrier's denial of coverage for the continued Skilled Nursing Facility stay should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Obstructive pulmonary disease.
Treatment:  Prolastin-C.

The insurer denied the Prolastin-C.  The denial is upheld. 

The patient is a female with obstructive pulmonary disease.  She is prescribed Prolastin-C for alpha-1-antitrypsin (AAT) deficiency.  The patient has genotype MZ (heterozygous Z allele carrier) with AAT (alpha-1-antitrypsin) levels of 97 milligrams per deciliter (mg/dl).  The patient has pretreatment forced expiratory volume in one second (FEV1) above 80% predicted.  There is also lack of radiological documentation of emphysema.  The patient does not have AAT (alpha-1-antitrypsin) phenotype Pizz (protease inhibitor ZZ), PiZ (protease inhibitor Z) or Pi (Pi phenotype).

No, the proposed treatment with Prolastin-C is not medically necessary.

This is a patient with obstructive pulmonary disease, who is prescribed Prolastin-C for alpha-1-antitrypsin deficiency.  The patient has genotype MZ with alpha-1-antitrypsin (AAT) levels of 97 milligrams per deciliter (mg/dl).  The patient has a pretreatment forced expiratory volume in one second (FEV1) above 80% predicted.  There is also lack of radiological documentation emphysema.  The patient does not have AAT (alpha-1-antitrypsin) phenotype Pizz, PiZ or Pi (Pi phenotype). 

The request does not meet the health plan's preferences.  The requested Prolastin-C is not medically necessary over the health plan's preferences, due to lack of emphysema, FEV1 (forced expiratory volume in one second) above 80% predicated and AAT (alpha-1-antitrypsin) phenotype not being Pizz, PiZ or Pi (Pi phenotype).  There is lack of clinical evidence in the current literature that suggests AAT (alpha-1-antitrypsin) augmentation in patient's without emphysema and FEV1 (forced expiratory volume in one second) below 80% is likely to provide any benefit.