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

Diagnosis: Atopic Dermatitis
Treatment: Dupixent Syn 300
The insurer denied coverage for Dupixent Syn 300
The denial is overturned.

The patient is an adult female with a diagnosis of atopic dermatitis (AD) affecting 30% (percent) total body surface area (TBSA), including the scalp and body. The patient has failed topical therapy with corticosteroids, but requires systemic therapy given the large surface area involved the requested medication is Dupixent.  

The patient has severe atopic dermatitis that involve a large surface area, including the scalp. As such, light therapy would not be a practical treatment option. The patient requires systemic therapy given the extent of involvement and the use of Dupixent would appear to be reasonable given that it is Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis and the inability to use systemic light therapy due to sensitive areas of involvement. The request for Dupixent is supported by the medical literature and specialty society guidelines. Dupixent is the only systemic therapy approved by the FDA for the management of atopic dermatitis. The FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments (1-3). According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD. Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment ... with moderate-to-severe AD who are uncontrolled with topical therapies" (1). As such, the decision is overturned and Dupixent is approved at the medical discretion of the physician based on the standard of care and the provided medical documentation.

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

The insurer's denial of coverage for the Dupixent Syn 300 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara. 

The insurer denied coverage for Stelara. 
The denial is overturned. 

The patient has Crohn's disease. She had a colonoscopy and was started on Entocort. After she did not show improvement, she was started on Humira. Magnetic Resonance Enterography (MRE) showed new active disease. The MRE continued to show active inflammation. There was a consideration to starting Entyvio, but the patient has difficult intravenous (IV) access. Her physician has now advised Stelara since after a one-time infusion she could be given subcutaneous injections. 

Gastroenterology 2021; 160:2496-2508 has an article titled "Clinical Practice Guidelines- [American Gastroenterological Association] AGA Clinical Practice Guidelines on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn's Disease." There are several biologics recommended for moderate to severe luminal Crohn's disease. Ustekinumab is an advised treatment for both the induction and maintenance of remission. 

This patient has failed treatment with Humira and now requires a new biologic agent. Both Entyvio and Stelara are advised biologic agents for Crohn's disease. However, in this case, the physician has documented that there would be great hardship in using Entyvio due to its requirement for continued IV infusions. Giving Stelara is a reasonable alternative for this patient. 

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

Diagnosis: Seizures
Treatment: inpatient stay
The health plan denied the requested inpatient stay as not medically necessary. The health plan's determination is upheld.

The patient is a woman diagnosed with intractable epilepsy who was admitted to the hospital for video electroencephalogram (EEG) monitoring. Records indicate that the purpose of the monitoring was to better characterize the seizures and develop a treatment plan. Prior to admission, the patient was treated with Keppra. The patient was monitored for approximately 48 hours. She did not have any events or seizures. The EEG showed some left hemispheric focal slowing. The monitoring was terminated, and the patient was discharged on Keppra with outpatient follow-up.
At issue is the medical necessity for the inpatient admission.

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

No. The requested acute inpatient admission was not medically necessary for video EEG monitoring. The patient had an established diagnosis of epilepsy. She was admitted for video EEG monitoring for better characterization of the seizures. During the monitoring, the patient did not have any seizures. She was essentially continued on her home medication at lower doses while in the hospital and then was discharged on her home dose. The patient did not have any significant laboratory, imaging, or physical exam abnormalities that would support an acute inpatient admission. The patient was monitored by video EEG, which can be completed in an alternate level of care, especially when performed for 48 hours or less. There are no medical findings to support an acute inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis; Class III malocclusion
Treatment: D8080 braces D8670 monthly visits
The insurer denied D8080 braces D8670 monthly visits.
The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on teeth 7 and 10. She presents with a skeletal Class III malocclusion with moderate crowding in the maxilla and mandible. She has a bilateral posterior crossbite. She is treatment planned for Braces and Monthly Visits to address the crowding and crossbite. 

Braces and monthly visits are medically necessary. This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant 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.
If left untreated, the damage that will likely occur to the patients teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the braces/monthly visits are medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Burn.
Treatment: Laser therapy (0479T x 1 and 0480T x 1).
The insurer denied coverage for laser therapy (0479T x 1 and 0480T x 1).
The denial is overturned.

The patient is a female status post (s/p) full- thickness skin graft (FTSG) to hand due to contact thermal burn. She now has contractions and decreased range of motion due to hypertrophic scarring. Fractional ablative therapy has been proposed. 

The scientific literature supports the use of fractional ablative laser in hypertrophic scarring after burns. Per the FDA (Food and Drug Administration), this treatment is not considered to be experimental. It has FDA approval and does not require an institutional review board (IRB). 

This patient is a good candidate for laser therapy. She has hypertrophic scarring with loss of function after more than one year post injury/treatment. 

Laser therapy is the best available treatment for the patient at this time. It is considered first line therapy for traumatic scars. It is less invasive than surgery. It has been shown to be successful in podiatry patients. There are no adverse increased risks over alternative treatments. Alternatives include surgery to release contractions and radiation therapy which is not recommended in a child. 

This treatment is likely to be more beneficial than surgery or radiotherapy for the condition. It is safe and has been shown to be effective in children. It is less invasive than other options. 

"Background: Treatment of scars continues to be a persisting challenge. Scar classification is paramount in determining an appropriate treatment strategy. They can be classified into hypertrophic, keloid, or atrophic scars. With the increasing demand for less invasive procedures that result in equal or greater outcomes, there has been an increase in the variety of procedures for the management of scarring. Methods: A Pubmed search was performed for the most recent papers on scar treatments. Findings and applications are discussed in this review. Results: Studies evaluating the efficacy and safety of microneedling, filler agents, toxins, silicone gels, and laser devices such as ablative, non-ablative, fractional, SRT [superficial radiation therapy], and radiofrequency are discussed. Conclusion: Review of the literature revealed a myriad of options for the treatment of different scar types. Although there is not vast evidence in the literature in regard to combination treatments, these are becoming more popular, and it is the author's opinion that combination treatments yield better overall results. J Drugs Dermatol. 2019;18(6):550-555." (Gonzalez, N. et al. 2019). 

"Conclusions: Fractional ablative laser treatment provides significant, sustained improvement of elasticity, thickness, appearance, and symptoms of mature hypertrophic burn scars." (Ogawa, R. et al. 2021). 

The carrier's denial of laser therapy (0479T x 1 and 0480T x 1) should be overturned. This procedure is likely to be more beneficial than any other standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is upheld. 

The patient is a male with medical history of polysubstance dependence, bipolar 1 disorder, manic depressive disorder, diabetes mellitus, hypertension, and bilateral digital amputations. He presented to the emergency department with progressive coffee-ground emesis and suicidal ideation. He also reported headache, heartburn, mild abdominal cramping, and diarrhea, as well as multiple painful leg wounds. He reported a suicide attempt the day before, and multiple recently. The assessment was that he had chronic lower extremity changes, was likely malingering for bed, and reported cocaine use for five consecutive days, as well as heavy daily use of alcohol.  

The inpatient hospital stay is not medically necessary. In this case, the patient presented with coffee-ground emesis suggestive of upper gastrointestinal bleeding, and anemia. Close monitoring was warranted, as bleeding can be severe and sudden in onset. However, he did not have ongoing gastrointestinal bleeding, and his hemodynamic status and hemoglobin remained stable. Although endoscopy would have been appropriate, he elected to leave rather than to undergo upper endoscopy or other interventions to evaluate for sources of blood loss. He was maintained on a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol, but no ongoing acute alcohol withdrawal was documented. He reported suicidal ideation and was appropriately placed on a 1:1 sitter during his short stay, but psychiatry did not recommend inpatient hospitalization. For these reasons, the inpatient levels of care is not supported, and the care provided, including observation, monitoring, labs, specialist consultations, and endoscopy (had it been performed), could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Muscular Atrophy
Treatment: Onasemnogene Abeparvovec (Zolgensma) 
The insurer denied Onasemnogene Abeparvovec (Zolgensma) . The health plan's determination is overturned. 

The patient is a boy who was diagnosed presymptomatically with spinal muscular atrophy (SMA) on the New York State newborn screening test. He was subsequently had confirmatory testing and was found to have pathogenic homozygous mutations in the survival motor neuron 1 gene (SMN1), with 4 copies of the survival motor neuron 2 gene (SMN2). He had persistently elevated levels of AAV9 (Adeno-associated virus) antibodies which precluded him from starting gene therapy in the form of Onasemnogene Abeparvovec (Zolgensma). He was started on risdiplam (a survival of motor neuron 2 (SMN2) splicing modifier). Retesting of AAV9 antibodies on 6/13/2022 showed that his antibody levels are no longer elevated, at 1:25. His treating pediatric neuromuscular specialist has recommended that the patient now be treated with Zolgensma, with the subsequent discontinuation of risdiplam.

Onasemnogene Abeparvovec (Zolgensma) is medically necessary for this patient.

Zolgensma is an adeno-associated virus vector-based gene therapy indicated for the treatment of pediatric patients less than 2 years of age with spinal muscular atrophy (SMA) with bi-allelic mutations in the survival motor neuron 1 (SMN1) gene. The Food and Drug Administration (FDA), in its approval of Zolgensma for SMA, did not specify that the treatment should be only for patients with 3 or fewer copies of the SMN2 gene. In conclusion, Zolgensma is medically necessary for this patient. It is currently the optimal treatment for motor neuron survival in SMA. Its administration to children with 4 copies of the SMN2 gene is recommended as the standard of care in the US (United States) by the national physician panel of Cure SMA.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Muscular Atrophy
Treatment: Onasemnogene Abeparvovec (Zolgensma) 
The insurer denied Onasemnogene Abeparvovec (Zolgensma).
The health plan's determination is overturned. 

The patient is a boy who was diagnosed presymptomatically with spinal muscular atrophy (SMA) on the New York State newborn screening test. He subsequently had confirmatory testing and was found to have pathogenic homozygous mutations in the survival motor neuron 1 gene (SMN1), with 4 copies of the survival motor neuron 2 gene (SMN2). He had persistently elevated levels of AAV9 (Adeno-associated virus) antibodies which precluded him from starting gene therapy in the form of Onasemnogene Abeparvovec (Zolgensma). 

Onasemnogene Abeparvovec (Zolgensma) is medically necessary for this patient.
Zolgensma is an adeno-associated virus vector-based gene therapy indicated for the treatment of pediatric patients less than 2 years of age with spinal muscular atrophy (SMA) with bi-allelic mutations in the survival motor neuron 1 (SMN1) gene. The Food and Drug Administration (FDA), in its approval of Zolgensma for SMA, did not specify that the treatment should be only for patients with 3 or fewer copies of the SMN2 gene. In conclusion, Zolgensma is medically necessary for this patient. It is currently the optimal treatment for motor neuron survival in SMA. Its administration to children with 4 copies of the SMN2 gene is recommended as the standard of care in the US (United States) by the national physician panel of Cure SMA.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperbilirubinemia
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission
The denial is overturned.

This is the case of a male infant born at 38 weeks gestation, breast fed, who required phototherapy. Family history of a sibling requiring phototherapy. The patient was admitted for treatment of hyperbilirubinemia with intensive phototherapy. Prior to admission, his serum total bilirubin was 18.6 milligrams (mg) / Deciliter (dL). Subsequently, with phototherapy, the bilirubin level decreased to 12.2 mg/dL prior to discharge.

The insurer denied coverage of an in-patient admission citing Milliman Care Guidelines MCG: P- 265, Neonatal Jaundice. This guideline specifies:

Admission is indicated for 1 or more of the following:

	Total serum bilirubin (TSB) exceeding risk threshold for infant's age
	Gestational age
	and clinical risk factors, as indicated by 1 or more of the following:

	TSB greater than 17 mg/dL (291 micromoles/L) at 96 hours or more in medium-risk infant

According to the American Academy Guidelines, this infant was at medium-risk (prior sibling needing phototherapy). Therefore, the above criteria were met.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrolithiasis.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult male with a history of nephrolithiasis. He was admitted with flank pain. He was noted with nephrolithiasis. The patient on admission was treated with increased oral hydration, and intravenous fluid and started on Flomax along with pain control. The health plan denied coverage of inpatient admission. The denial is being appealed.

The Inpatient admission was not medically necessary.
Based on available documentation, there was no reported hemodynamic instability, acute renal failure, bilateral obstruction, single kidney with obstruction, transplanted kidney with obstruction, or severe pain requiring acute inpatient management in this patient's case. There was no report of vomiting that is severe or persistent, urinary tract infection, or need for IV (intravenous) hydration support despite observation care or other condition, treatment, or monitoring requiring inpatient admission. Based on available data, inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic Inflammatory Disease
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


This is a patient with an active pregnancy and past medical history (PMH) of generalized anxiety disorder (GAD) and major depressive disorder (MDD) who was admitted with complaints of (c/o) chest pain and body aches. Her vital signs were notable for a temperature (T) of 102.4 degrees Fahrenheit, blood pressure (BP) 93/48, and pulse 112. The physical exam was significant for an ill-appearance. Lab work was notable for an elevated D-dimer, a urinalysis (UA) showed small leukocytes (leuks). A computed tomography (CT) scan of the chest showed no central pulmonary embolism. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with pelvic inflammatory disease and treated with intravenous (IV) antibiotics and intravenous fluids (IVF). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The inpatient hospital stay was medically necessary. This patient with an active pregnancy presented to the emergency department (ED) with c/o chest pain and body aches associated with abdominal pain, back pain, and dysuria. The patient was ill-appearing, had unstable vital signs with a fever, tachycardia, and hypotension, and met systemic inflammatory response syndrome (SIRS)/sepsis criteria, as well. The patient was diagnosed with pelvic inflammatory disease and started on IV antibiotics and close clinical monitoring, which was necessary given the patient's high-risk feature of an active pregnancy. Given the patient's high-risk features and clinical presentation, the patient required aggressive treatment with IV antibiotics, gynecological consultation, and close clinical monitoring that could not have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: D8080 braces, D8670 monthly visit, and D8680 retainer.

The insurer denied coverage for D8080 braces, D8670 monthly visit, and D8680 retainer.  The denial is upheld.

Upon review of the submitted documentation including lateral cephalic radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as
well as insurer correspondence, it appears that this patient presented for evaluation for
orthodontic care. The orthodontist identified several clinical findings including overjet and overbite and has recommended orthodontics. The orthodontist has
completed the Handicapping Labio-Lingual Deviation (HLD) index, attaining 8 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index, attaining 7 points by internal reviewers. The patient's mother is appealing the decision.

Upon review of the submitted, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. 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 8 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 8 points on the HLD index (3 overjet, 2 overbite, 3 labiolingual spread), which is below the threshold of 26 points to support orthodontic care. Of note, in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval. 

Regarding the validity of the HLD index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The insurer's denial of coverage for D8080 braces, D8670 monthly visit, and D8680 retainer is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Weakness and Elevated Liver Tests.
Treatment:  Inpatient Hospital Admission.

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

This patient is an adult male who presented to the emergency room with jaundice and weakness/fatigue.  The patient had body aches, chills, diarrhea, headache, dizziness, nausea and vomiting, low grade fevers up to 100.5.  He was drinking alcohol at around six beers per day.  The patient had elevated transaminases and was placed as nothing by mouth (NPO), received intravenous (IV) fluids, and subcutaneous Lovenox.  Abdominal ultrasound showed mild non-specific gallbladder wall thickening. Magnetic resonance image (MRI) of the abdomen/pelvis showed mild pericholecystic and perihepatic fluid. Two days post admission, the aspartate aminotransferase (AST) was 57 and alanine aminotransferase (ALT) was 812.  The following day, the patient reported some mild abdominal pain/nausea.  

The proposed treatment was not medically necessary.

Inpatient level of care was not medically necessary for the dates of service in question, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not have acute liver failure, did not have encephalopathy, did not have intractable ascites, and was not being evaluated for liver transplant.  In addition, the patient did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.