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

Diagnosis: Alzheimer's dementia
Treatment: Personal care assistance (12 hours per day, seven days per week [Monday through Sunday]) for a total of 84 hours per week
The insurer denied the Personal care assistance (12 hours per day, seven days per week [Monday through Sunday]) for a total of 84 hours per week
The denial is overturned.

The patient is a female patient who reportedly lives alone and has history of Alzheimer's dementia. Due to underlying history of Alzheimer's dementia she cannot self-administer her medications. The patient needs supervision and close monitoring.  

This is a review for personal care assistance (12 hours per day, seven days per week [Monday through Sunday]) for a total of 84 hours per week.

Yes, the proposed personal care assistance (12 hours per day, seven days per week [Monday through Sunday]) for a total of 84 hours per week is medically necessary. The patient takes medications Seroquel, Neurontin and carbamazepine. She has underlying dementia and needs close monitoring and supervision. She cannot take medications by herself due to her current clinical condition. The patient needs services to assist with personal care and light housekeeping tasks. The patient needs help throughout her tasks and performs less than 50% (percent) of tasks on her own. The patient has occasional incontinence as well. 

The requested services are medically necessary and appropriate.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient needs help and supervision because of her dementia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid Arthritis.
Treatment: Humira.
The insurer denied the Humira.
The determination is upheld.

The patient has seropositive rheumatoid arthritis (RA). She was diagnosed with RA and treated with (w/) methotrexate (MTX) at the time. The Humira is being denied by the health plan. Prior tx: MTX (it was not effective), Plaquenil (caused an allergic reaction). The reason for the denial is that patient has not tried and failed maximally tolerated doses of MTX or equivalent x 12 weeks, e.g cyclosporine, sulfasalazine (SSz) or Arava. The health plan is stating it is unclear how long the patient was on MTX and at what dose. At issue is the medical necessity of Humira.

No, the requested health service/treatment of Humira is not medically necessary for this patient. Additional information is required before Humira can be considered. The patient must try and fail a 3 month trial of MTX at maximal doses. Records were reviewed and it is unclear how long the patient was on MTX and at what dose. Additional information: documentation of what dose of Methotrexate (MTX) the patient was on and for how long is needed. This information was requested but not received. A note from the patient's provider states the patient was treated with MTX without success but no additional information was provided (e.g. dose or duration of therapy). MTX is a core drug used to treat rheumatoid arthritis (RA). According to UpToDate, 'we suggest MTX as the disease-modifying anti-rheumatic drug (DMARD) of choice for the initial treatment of patients with active RA. MTX typically serves as the "anchor" drug for the most commonly used DMARD combinations. In addition, an article in Semin Arthritis Rheum in 2004 concluded that 'MTX is an effective DMARD with a relatively safe profile compared with other therapies. Thus, there is no medical reason the patient cannot try MTX at maximal doses for 3 months before Humira will be considered.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ulcerative Colitis. 
Treatment: Stelara 90MG (milligrams) every 4 weeks. 

The insurer denied: Stelara 90MG (milligrams) every 4 weeks. 
The denial is overturned. 

The patient is an adult female with a history of ulcerative colitis.  The patient was started on Humira (later discontinued due to lack of effect). The patient failed vedolizumab due to side effects, and failed mesalamine (5ASA) (Apriso, Lialda).  The patient started on ustekinumab 90 milligrams subcutaneous every eight weeks.  Despite the standard maintenance dose, the patient continued to have flare symptoms of urgency, bleeding, multiple bowel movements, and required multiple courses of uceris. The patient's colonoscopy noted active colitis remaining in the rectum. The attending physician requested dose escalation to capture remission. 

The health plan should cover the requested service. 

Stelara dose escalation to every four weeks is a successful strategy to capture response in more patients and induce remission when the standard dose failed to induce full response. In a new multicenter cohort study that was published in 2021, 108 ulcerative colitis patients were initiated on Stelara after failing anti-tumor necrosis factor (TNF). Among those patients, 42.6% (46/108) were escalated to every four weeks (n=33) or every six weeks (n=13) after median of 95 days (interquartile range [IQR] 65208 days) primarily for no/minimal response to induction (22/46) or loss of response (20/46). It was found that dose escalation resulted in recapturing clinical remission in greater than 50% of ulcerative colitis patients and was more effective in those with loss of response compared to no/minimal response after induction with the standard dose. 

Dose escalation of ustekinumab is the most conservative course of action for this patient based on the patient's prior response to the mechanism of action of ustekinumab. In addition, changing this patient to an alternative medication prior to a trial of dose escalation could put the patient at risk to develop anti-drug antibodies and may limit future use of ustekinumab.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - syncope. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient hospital admission. 
The denial is upheld.

This case involves a female with a history of human immunodeficiency virus (HIV) who presented to the hospital from work with acute onset of diaphoresis and syncope. Coworkers witnessed this and noted that the patient struck her face as she fell and complained of jaw pain. She was brought into the emergency department, where on the exam, she had a normal appearance, with intact pupils, a normal cardiopulmonary exam, and no focal neurologic deficits. electrocardiogram (EKG) showed normal sinus rhythm without ST-segment elevations. computed tomography (CT) scan of the head was performed, which showed no acute pathology. Glasgow Coma Scale was 15, and the Braden scale was 22.

The subject under review is the medical necessity for the inpatient admission. 

Inpatient admission is not medically indicated. This is a vasovagal syncope episode without any injuries or comorbidities. The patient did not have evidence of cardiac arrhythmia, as the EKG was normal. The troponin was normal, therefore, highly unlikely for cardiogenic causes of syncope. The head CT was unremarkable, and the patient had a negative electroencephalogram (EEG), thereby ruling out neurologic causes of syncope. This is a typical vasovagal syncope presentation, which per standards of medical care, is managed under lower level status, with IV fluids, monitoring for recurrence, and ruling out life-threatening conditions. The medical literature supports managing this type of presentation at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspepsia and epigastric pain
Treatment: Diagnostic esophagogastroduodenoscopy (EGD) for epigastric abdominal pain and functional dyspepsia
The insurer denied coverage for diagnostic EGD for epigastric abdominal pain and functional dyspepsia
The denial is upheld

The patient was complaining of indigestion. She was having epigastric discomfort. There was a history of gallstones. On a provider visit she was started on Omeprazole and scheduled for an endoscopy. The indications listed for the endoscopy on the endoscopy report were dyspepsia and epigastric pain. The endoscopy revealed mild gastritis and esophagitis. She did not have Barrett's esophagus or Helicobacter Pylori. 

Clinical indications for doing an Upper Gastrointestinal (UGI) Endoscopy are listed in Milliman Care Guidelines (MCG) ACG: A-0203. Dyspepsia is an indication to do the procedure if it is associated with certain other criteria. These include age of 60 years or older, dysphagia, failure of medical therapy, family history of UGI cancer, iron deficient anemia, prolonged symptoms, vomiting, and weight loss.

This patient had dyspepsia but had not failed a course of medical therapy. She was started on the proton pump inhibitor (PPI) at the same visit that the endoscopy was advised. There is no history provided of persistent symptoms, vomiting, anemia, or weight loss. She did not meet MCG criteria for performing an UGI Endoscopy. 

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

The insurer's denial of coverage for diagnostic esophagogastroduodenoscopy (EGD) for epigastric abdominal pain and functional dyspepsia is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain and vomiting
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This is a patient with past medical history significant for immunocompromised status, asthma, marijuana use, and colitis who presented to the emergency room with complaints of abdominal pain and vomiting, but no diarrhea.

Vitals on presentation included: Temperature 97.4 Fahrenheit, Blood Pressure 154/94, Heart Rate 80, Respiratory Rate 20, oxygen (O2) saturation 99%. Laboratory results showed: white blood cell (WBC) count 12.8, hemoglobin- 14.8, hematocrit- 42.8, creatinine- 0.78, glucose- 119, and lactate- 4.0. 

Patient was empirically started on antibiotics (ceftriaxone and metronidazole) for possible infectious diarrhea. Computed tomography (CT) scan of abdomen/pelvis showed thickening of the entire colon versus underdistension. Infectious Diseases was consulted, antibiotics were changed to Unasyn. Patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged home to continue outpatient management.

According to medical records, patient presented with abdominal pain and vomiting. She was unable to tolerate oral intake. She was afebrile and normotensive. Laboratory results was notable for elevated WBC and lactate. CT scan was suspicious for pan-colitis. Based on above findings in a high-risk patient with multiple co-morbid conditions including immunocompromised status, hospital admission was medically necessary.

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 inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Skyrizi Pen 150MG (milligrams) per ML (milliliter) Injection.
The insurer denied: Skyrizi Pen 150MG (milligrams) per ML (milliliter) Injection.
The denial is overturned.

The patient is an adult male with psoriasis, treated with topicals, Enbrel, methotrexate, and Taltz.  His provider is requesting Skyrizi. The health plan requires the use of Humira.

The requested Skyrizi is medically necessary.

Skyrizi is an approved, appropriate, and effective medication for psoriasis. Several biological agents are available for the treatment of moderate-to-severe plaque psoriasis. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. Skyrizi is among the most effective therapies for psoriasis according to current peer-reviewed literature.

According to the meta-analysis by Sbidian et al, compared to placebo, the biologics infliximab, ixekizumab (Taltz), risankizumab (Skyrizi), bimekizumab, secukinumab (Cosentyx), guselkumab (Tremfya) and brodalumab were the most effective treatments for achieving PASI 90 (90% reduction in Psoriasis Area and Severity Index score) in people with moderate-to-severe psoriasis based on moderate- to high-certainty evidence.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Crown Tooth #2.
The insurer denied the Crown Tooth #2.
The determination is overturned.


The patient presented for evaluation and treatment of tooth number (#) 2. Provided for review are radiographic images, letters of appeal and denial, a clinical image of the tooth in question showing a composite cuspal repair that was performed on the tooth previously, a clinical image of the tooth preparation, a radiographic image from, and health plan language. According to health plan language, indirect restorations are covered benefits when decay and/or injury exist that cannot be restored with a direct restoration and crowns are benefits when more than 50% of the tooth is decayed, is completely fractured, and or previously restored, and or more than 50% of a cusp is restored or fractured.
At issue is the medical necessity of a porcelain crown (D2740) for tooth #2.

The requested service/treatment is medically necessary. In this case, due to the involvement of more than 50% of the tooth as well as the cuspal involvement, the tooth qualifies for the porcelain crown (D2740). Hence the requested treatment of the porcelain crown for tooth #2 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Dental Treatment.
Treatment: Dental/Orthodontic Procedure/Placement of device to facilitate eruption of impacted tooth for teeth #'s 6 & 11.
The health plan denied the requested Dental/Orthodontic Procedure/Placement of device to facilitate eruption of impacted tooth for teeth #'s 6 & 11.
The health plan's determination is overturned.

The patient is a male who is in active orthodontic treatment. Preauthorization was requested for the exposure and bonding of orthodontic brackets to the unerupted maxillary upper right and left canines - teeth # 6 and #11. 
At issue is the medical necessity for placement of a device to facilitate the eruption of the impacted tooth for teeth #'s 6 & 11.

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

Yes, the placement of a device (orthodontic brackets) to facilitate the eruption of teeth #6 and #11 is medically necessary.
The placement will ensure that teeth #6 and #11 can be brought into place in the dental arch. It is standard of care to place orthodontic brackets when uncovering unerupted teeth to aid in their eruption. The adult maxillary canines usually erupt into the oral cavity between ages 11 - 12 years. By the age of 13 years, most of the permanent teeth will be in place. The more the canine roots develop, the lower the natural eruption impetus. In the images reviewed it appears that the roots of both canines are fully developed. If the teeth are only covered, there is a possibility that the orthodontist will have to re-expose these teeth when the brackets are placed. The use of a bracket placed at the time of exposure will expedite the movement of the canines into a proper position.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 Diabetes.
Treatment: Ozempic 1/0.75 (3) Pen Injector 3 For 30 Days.
The insurer denied: Ozempic 1/0.75 (3) Pen Injector 3 For 30 Days.
The denial is upheld.

The patient is an adult male with type 2 diabetes. The request for Ozempic is under review. The prior request was denied coverage by the health plan, because the patient has not tried and failed, or had intolerance, or contraindication to Byetta, Bydureon, and Victoza. The provider is appealing this determination. The patient was intolerant to Trulicity and was previously successful on Ozempic.

The requested Ozempic is not medically necessary.

This request is for Ozempic for the treatment of type 2 diabetes. The prior request was denied coverage by the health plan, because the patient has not tried and failed, or had intolerance, or contraindication to Byetta, Bydureon, and Victoza. The patient has tried and was intolerant to Trulicity, but has not had a documented trial of any of the formulary alternatives. Victoza is expected to have similar safety and efficacy as compared to Ozempic. Therefore, no, the requested Ozempic is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's ileocolitis
Treatment: Rinvoq 45mg
The insurer denied: Rinvoq 45mg
The denial is overturned

This is a young adult female with Crohn's ileocolitis who has previously failed treatment with Remicade, Mercaptopurine (6-MP), Humira, and Stelara.  Since starting Stelara, the patient has ongoing inflammation.  The patient underwent ileocecal resection.  The request is for Rinvoq.

The proposed treatment with Rinvoq is medically necessary.
This patient has Crohn's ileocolitis and has previously failed treatment with Remicade, Mercaptopurine (6-MP), Humira, and Stelara.  The patient has failed all alternatives.

In a double-blind, phase II trial in adults with moderate to severe Crohn's disease (CD) and inadequate response or intolerance to immunosuppressants or tumor necrosis factor antagonists, patients were randomly assigned (1:1:1:1:1:1) to groups given placebo; or three milligrams, six milligrams, 12 milligrams, or 24 milligrams upadacitinib twice daily; or 24 milligrams upadacitinib once daily and were evaluated by ileocolonoscopy at weeks 12 or 16 of the induction period. Patients who completed week 16 were re-randomized to a 36-week period of maintenance therapy with upadacitinib. The primary endpoints were clinical remission at week 16 and endoscopic remission at week 12 or 16 using the multiple comparison procedure and modeling and the Cochran-Mantel-Haenszel test, with a two-sided level of ten percent.

Among the 220 patients in the study, clinical remission was achieved by 13% of patients receiving three milligrams upadacitinib, 27% of patients receiving six milligrams upadacitinib (P greater than [<] 0.1 versus placebo), 11% of patients receiving 12 milligrams upadacitinib, and 22% of patients receiving 24 mg upadacitinib twice daily, and by 14% of patients receiving 24 milligrams upadacitinib once daily, versus 11% of patients receiving placebo. Endoscopic remission was achieved by ten percent (P less than [<] 0.1 versus placebo), eight percent, eight percent (P less than [<] 0.1 versus placebo), 22% (P less than [<] 0.01 versus placebo), and 14% (P less than [<] 0.05 versus placebo) of patients receiving upadacitinib, respectively, versus none of the patients receiving placebo. Endoscopic but not clinical remission increased with dose during the induction period. Efficacy was maintained for most endpoints through week 52 (Sandborn WJ, et al, 2020).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned. 

The patient is a male who initially presented to the emergency department for concerns of a seizure. Pertinent history included seizure disorder, alcohol abuse, and hypertension. Initial examination documented the patient as easily arousable with a left forehead abrasion without hematoma and a resting tongue tremor. Initial laboratory testing revealed a white blood cell count (WBC) 7.4, Hemoglobin (HGB) 11.0, platelets (Plt) 129, Na (sodium) 131, K (potassium) 3.2, blood urea nitrogen (BUN) 16, Cr (creatinine) 0.7, carbon dioxide (CO2) 21, Glucose 143, and Lactate 1.5. Alcohol level was undectectable. An electrocardiogram (EKG) revealed sinus tachycardia. Chest radiograph was unremarkable. An XR (x-ray) of the pelvis was unremarkable. A computed tomography (CT) head and CT C (cervical)-spine were unremarkable. A maxillofacial CT revealed a displaced fracture of the right nasal bone. A surgeon was consulted and did not recommend surgical intervention. Lorazepam was administered for a Clinical Institute Withdrawal Assessment (CIWA) > 15. Repeat after lorazepam was 8. The patient was placed in the hospital thereafter. 

The inpatient hospital stay was medically necessary. In this particular situation, the patient had a history of alcohol abuse and seizure disorder and presented to the hospital after a witnessed generalized seizure. Initial evaluation found the patient to be drowsy and disoriented to time as well as an elevated lactate of 10.8 and a displaced fracture of the right nasal bone. CIWA was documented at > 15 and lorazepam 2 mg IV was administered. After administration, CIWA decreased to 8. The admitting physician had an impression of alcohol withdrawal seizure and treatment included scheduled benzodiazepines as well as lorazepam as needed. Two doses of intravenous lorazepam were given per scale thereafter. Following observation care, intermittent confusion, tachycardia, and hypertension remained. Benzodiazepines were continued.
Moreover, clinical indications for admission to inpatient care were met. The patient had signs of withdrawal (tachycardia and tremor) as well as an elevated risk due to history of repetitive seizures due to alcohol withdrawal and/or intrinsic seizure disorder.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis and heart failure
Treatment: Home Care/ Personal Care Live-in Per diem (7 days per week)
The insurer denied: Home Care/ Personal Care Live-in Per diem (7 days per week)
The denial is overturned

The patient is an adult female. Her conditions include multiple sclerosis and heart failure. She is on home oxygen. Denial of home care/personal care live-in per diem, 7 days per week, is being appealed. The health plan is reducing care to 70 hours per week.  The patient states she needs assistance to get her ready for sleep. Uniform Assessment System (UAS) evaluation shows modified independent cognition and functional status: total dependence with housework, shopping, bathing, lower body dressing, walking, and locomotion; maximal assistance with bed mobility; extensive assistance with managing finances and medication, phone use, personal hygiene, and upper body dressing; and limited assistance with eating. The patient has bowel and bladder incontinence. She is bedbound and requires a Hoyer lift. There is no significant change from the previous evaluation.

The requested Home Care/ Personal Care Live-in Per diem (7 days per week) is medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of home care/personal care live-in per diem, 7 days per week, is being appealed. The health plan is reducing care to 70 hours per week.

This patient's conditions include multiple sclerosis. Uniform Assessment System (UAS) evaluation shows she needs assistance with all ADLs (activities of daily living). She has bowel and bladder incontinence. She is bedbound and requires a Hoyer lift for transfers. This patient has significant functional limitations. Due to the patient being bedbound, the reduction in personal care services to 70 hours per week is inadequate to meet the patient's needs. The requested home care/personal care live-in per diem, 7 days per week is medically necessary.