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

Diagnosis: Diabetes Mellitus, Multiple Myeloma, Ankle/Foot Osteomyelitis, CVA (cerebrovascular accident), Peripheral Vascular Disease and Poor Visual Acuity secondary to macular degeneration
Treatment: 12-24 hours (split-shift), 7 days a week for a total of 168 hours for Personal Care Services
The insurer denied the 12-24 hours (split-shift), 7 days a week for a total of 168 hours for Personal Care Services. 
The denial is overturned. 

The patient is a female with a history of Diabetes Mellitus, Multiple Myeloma, Ankle/Foot Osteomyelitis, CVA (cerebrovascular accident), Peripheral Vascular Disease and Poor Visual Acuity secondary to macular degeneration. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of an increase in Personal Assistance Services to 12-24 hours (split-shift), 7 days a week for a total of 168 hours to offer increased ADL support.

Yes, the proposed treatment of an increase in Personal Assistance Services to 12-24 hours (split-shift), 7 days a week for a total of 168 hours/week for Personal Care Services is deemed medically necessary. 

Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). In addition, recent correspondence from the patient's providers indicate that the patient has demonstrated progressive functional decline including worsening cognitive impairment, gait ataxia and mobility. For these reasons, the currently approved plan of 9 hours a day, 7 days a week, for a total of 63 hours/week Personal Assistance Services is no longer sufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in Personal Assistance Services to 12-24 hours (split-shift), 7 days a week for a total of 168 hours/week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Stelara. 
The denial was upheld in whole.

The patient is a male with psoriasis. He has been treated with Halobetasol and calcipotriene. The treating provider is requesting Stelara.

No, Stelara is not medically necessary for this patient. According to the health plan, the patient must have tried and failed phototherapy and systemic therapy with optimized dose of cyclosporine or methotrexate. These agents are widely used in pediatric psoriasis and there is substantial peer reviewed literature data regarding these therapies in pediatric psoriasis. Therefore Stelara is not medically necessary at this time.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine Headaches.
Treatment: Treximet.
The insurer denied the Treximet.
The determination is upheld.

The patient has a listed diagnosis of migraine without aura, not intractable, without status migrainosus. It is unclear how such diagnosis was established. There is no detailed headache related history; its clinical characteristics, and duration are not documented. It is reported that she has had migraines since the teenage years.
Treximet is reported as having had efficacy reduced, requiring two doses. Migrelief and Imitrex subcutaneous were added. Ubrelvy was added at a later date as well. No evaluation for rebound headaches is documented.
The notes also indicate failed trials of sumatriptan, Maxalt and Zomig. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

There is no evidence, either from the patient's limited medical documentation or from high quality medical literature, large randomized trials, to support that the requested medication, Treximet, which is a combination of sumatriptan and naproxen, would be more effective than all of the available formulary drugs.
Side-effects are largely patient dependent, and therefore largely unpredictable. However, there is no evidence, either from the patient's limited medical documentation or from high quality medial literature, large randomized trials, to support that the requested medication, Treximet, would have less adverse effects than all available formulary agents.
The submitted medical records do not support a diagnosis of migraines, given the lack of a detailed description of headache characteristics that would match any widely accepted diagnostic criteria. Records also do not support that proper first line migraine abortive agent trials have failed at accepted doses. There is similarly no report to support the presence of intolerance or Food and Drug Administration (FDA) listed contraindications to all such available agents.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a male. He has a past medical history significant for HTN (hypertension), CAD (coronary artery disease), PAD (peripheral arterial disease), and chronic atrial fibrillation on Xarelto. He presented for evaluation of atrial fibrillation with rapid ventricular rate at 111 BPM (beats per minute).

The patient was hemodynamically stable, with no evidence of hypotension. Cardiac troponins were negative. BNP (brain natriuretic peptide) was mildly elevated at 292. Chest X-ray revealed no evidence of pulmonary edema. The patient admitted to recent use of cocaine, and his urine toxicology was positive for cocaine. 

The patient was admitted to telemetry. The patient was seen in consultation by cardiology. Calcium channel blocker (diltiazem) was started for rate control. Anticoagulation was continued. Lasix was given. Echocardiogram was obtained, revealing EF (ejection fraction) of 50%, mild mitral regurgitation and left atrial dilatation. He was discharged home with a plan for outpatient follow-up.

The patient has a known diagnosis of atrial fibrillation, managed with beta-blocker and maintained on Xarelto for anticoagulation. He presented with A. fib (atrial fibrillation) with heart rate of 111/minute after cocaine use. The patient was hemodynamically stable. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), or ventricular arrhythmia. The heart rate was mildly increased on arrival to ER and was promptly controlled with Cardizem. Thus, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sialoadenitis 
Treatment: Inpatient admission 
The insurer denied coverage for inpatient admission.
The denial is upheld.
The patient was a female who presented to the Emergency Department (ED) complaining of several day history of worsening left-sided facial swelling and pain. At the time of initial examination, a left submandibular swelling was noted and the decision was made to admit the patient for evaluation and treatment based on these findings and significant pain. While admitted, the patient received antibiotics and pain management including Ketorolac, morphine, Unasyn, dexamethasone. The patient's computed tomography (CT) scan and dental consultation confirmed this patient's diagnosis of a left-sided sialoadenitis.

Upon comprehensive review of the documentation as provided it appears that this patient presented with a left sided submandibular swelling of several days duration with increasing severity of pain. This prompted the patient's visit to the Emergency Department (ED). At the time of evaluation, the patient was reporting pain and swelling but otherwise all vital signs were stable. It was unclear and unstated as to why a dental consult was not performed at time of this patient's emergency visit. From the time the patient presented to the Emergency Department to her entire medical stay, this patient's vital signs remained stable. This patient's swelling did not worsen causing difficulty breathing or swallowing. In addition, the patient's computed tomography (CT) scan revealed a sialoadenitis but no abscess formation.

Based on the stated clinical findings at the time of initial Emergency Department (ED) consultation and throughout this patient's entire hospital stay it appears that the sialoadenitis, while painful, was not significant enough to justify or warrant an inpatient admission. The level of presentation of the sialoadenitis as documented could have been managed in an outpatient setting. In fact, this would be the general standard of care given the clinical presentation at that time. Appropriate evaluation with the assessment of the patient for stability of vital signs, diagnosis of sialadenitis and referral to the dental service line for further evaluation and definitive treatment on an outpatient basis would have been indicated. The patient could have been discharged from the ED to seek care in the outpatient setting with appropriate antibiotics and pain management. Lastly the clinical circumstance as presented does not fulfill any of the Milliman Care Guidelines for Systemic or Infectious Diseases GRG.

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

The inpatient admission was not medically necessary.

The carrier's denial of coverage for the inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Coccygodynia
Treatment: Nerve Block Treatment (ganglion impar block)
The insurer denied the Nerve Block Treatment (ganglion impar block).
The denial was upheld. 


This case involves a female patient who had been treated for chronic, debilitating distal sacrum/coccyx pain.  The physician indicated that the patient had an evidence of an old sacral fracture on imaging which was possibly contributing to her ongoing pain. The patient had several injections which included a caudal epidural steroid injection, sacroiliac joint injection, and trigger point injections with only minimal results.  The physician detailed that the patient's pain was debilitating and greatly affected her standard of living.  It was recommended that the patient undergo a trial of ganglion of impar block.  The patient was only able to tolerate sitting on a gel pillow for up for several minutes before her pain became intolerable. The patient was utilizing pain medications without resolution.  

The scientific evidence in peer-reviewed literature does not support that ganglion of impar block results in improvement in health outcome.  The patient presented with chronic, debilitating distal sacrum/coccyx pain.  The physician indicated that the patient had evidence of an old sacral fracture on imaging which was possibly contributing to her ongoing pain. The patient had several injections including a caudal epidural steroid injection, sacroiliac joint injection, and trigger point injections with only minimal results. It was recommended that the patient undergo a trial of ganglion of impar block.  The effectiveness of ganglion impar block for patients with coccydynia in providing pain relief is possible with injection. [1]  However, the study was conducted in the absence of a control group for comparison, and the follow-up period was only six months. Thus, it is unclear how long of an effect the ganglion impar block has on pain control. The Nerve Block Treatment (ganglion impar block) does not have final approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for Nerve Block Treatment (ganglion impar block).  Coccydynia refers to pain in the terminal segment of the spine caused by abnormal sitting and standing posture. Nerve Block Treatment (ganglion impar block) is not the best available treatment for this patient at this time.  Coccydynia is usually managed conservatively.

The requested procedure is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of Nerve Block Treatment (ganglion impar block) should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Coccygodynia
Treatment: Nerve Block Treatment (ganglion impar block)
The insurer denied the Nerve Block Treatment (ganglion impar block).
The denial was overturned. 


This is a female patient with a past medical history of chronic coccygodynia (coccydynia).  The patient had been under the care of the physician for chronic, debilitating distal sacrum/coccyx pain.  The patient had evidence of an old sacral fracture on imaging, which was opined to be contributing to the patient's pain.  The patient had undergone several injections for the treatment of the pain including caudal epidural steroid injection (ESI), sacroiliac joint injection, and trigger point injections with minimal results.  The provider opined the patient would greatly benefit from the trial of a ganglion impar block. It was reported that the patient's pain was debilitating and affected her standard of living.  The patient could only tolerate sitting on a gel pillow for several minutes.  The patient was on a significant amount of pain medications.  The provider noted if the injection were denied the next option would be a surgical consultation.

Peer-reviewed literature as referenced in "A Review of Current Treatment Options for Coccygodynia" support improvement in health outcome and function as a result of local anesthetic blocks and injections. Local anesthetic typically used for the procedure such as lidocaine has the FDA approval.  The FDA does not regulate injections; however, relevant medical societies, such as the American Society of Interventional Pain Physicians recognizes the efficacy of ganglion of impar block as an appropriate procedure. 

In this case, this patient had failed other treatments including medication, physical therapy, and other injections.  To minimize the use of oral medications (opioids) and avoid the need for surgery, a trial of ganglion of impar block would be appropriate. Nerve Block Treatment (ganglion impar block) is the best available treatment for this patient at this time.  The patient has exhausted all other appropriate conservative measures at this point. 

The requested service would likely be more beneficial and have less morbidity versus other options such as opioid pain medications and surgery. Thus, the requested procedure is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of Nerve Block Treatment (ganglion impar block) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Coccygodynia
Treatment: Nerve Block Treatment (ganglion impar block)
The insurer denied the Nerve Block Treatment (ganglion impar block).
The denial was overturned.


The patient is a female who has a history of chronic coccygodynia.  There is evidence of an old sacral fracture on imaging which may be contributing to the patient's pain. Ganglion impar block has been advised.

LeClerc et al.(1) found that repeated ganglion impar blocks allowed short-term reduction of pain intensity with a moderate intermediate term effect.  They concluded that: "Ganglion impar appears to be a useful therapeutic target to block the nociceptive message by acting on sensitization phenomena." Similarly, Foye(2) found that ganglion impar block was a commonly used procedure and spared some patients coccygectomy surgery.  Gonnade et al.(3) found statistically significant reduction in pain scores in patients with coccydynia who received ganglion impar blocks with long acting anesthetic agents.

In another review, Protzer et al. (4) stated: "Initial treatment begins with a coccygeal or doughnut cushion, heat, ice, and nonsteroidal anti-inflammatory medications.  Physical therapy and manual manipulation may also be of benefit.  If there is no improvement, an MRI should be obtained to rule out other etiologies including chordomas.  For refractory cases, steroid injections or ganglion impar blocks are appropriate.  As a last resort, a coccygectomy or surgical removal of a coccyx may be in order." 

The scientific evidence supports an improvement in health outcome. Ganglion impar nerve block is conducted with FDA approved anesthetic agents.  This patient is a good candidate for ganglion nerve block and it is the best treatment available for this patient at this time.  The requested procedure is likely to be more beneficial than any of the standard treatments/ procedures for this patient.

The carrier's denial of Nerve Block Treatment (ganglion impar block) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Class I crowded malocclusion
Treatment: Braces
The insurer denied the braces and monthly periodic dental visits. 
The health plan's determination is upheld. 

The patient in question is a female with a Class I crowded malocclusion. She has a deep bite. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. 

Braces and Monthly Periodic Dental Visits are not medically necessary for this patient.
There is no medical reason to correct this patient's malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Furthermore, masticatory efficiency is highest in patients with a Class I occlusion. If her teeth were aligned it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/circulatory problems. Treatment: Prescription Drugs. 
The insurer denied Omega-3-acid Ethyl Esters (Lovaza). 
The denial is overturned in whole. 

The patient is a male with hyperlipidemia and a family history of coronary artery disease. On rosuvastatin 10 milligrams (mg) daily and fenofibrate his triglyceride level was 415 milligrams per deciliter (mg/dl). The patient has started on Lovaza. His triglyceride level fell to 109 mg/dl. The subject under review is the medical necessity for Omega-3-acid Ethyl Esters 1 G or caps (Lovaza) medically necessary for this patient.

The health plan's determination is overturned in whole. 

Yes, Omega 3 acid Ethyl Esters (Lovaza) is medically necessary in the instance. This patient had moderate hypertriglyceridemia (triglyceride level 415 milligrams per deciliter [mg/dl]) while on rosuvastatin and fenofibrate. Epidemiological studies show that patients with moderate hypertriglyceridemia generally are at increased risk of atherosclerotic cardiovascular disease. On Lovaza, the patient's triglyceride level fell to 109 mg/dl. 

The Plan alternatives to Lovaza include several fenofibrate preparations. Since fenofibrate has already proven ineffective in this patient, those are not appropriate options. The remaining option is extended release niacin. While extended release niacin preparations are generally safer and better tolerated than immediate and sustained release preparations, they still present a risk for hepatoxicity either through direct liver injury or an immune mediated mechanism. In addition, side effects often limit their use and patient compliance. In the study reported by Goldberg, et al, 49% of patients discontinued use due to rash or flushing. 

Lovaza is a combination of EPA and DHA. Per the 2019 science advisory from the American Heart Association, "Prescription n-3 FAs at the Food and Drug Administration (FDA)-approved dose of 4 grams per day (g/d) are safe and generally well tolerated.
We conclude that prescription n-3 fatty acids (FA)s, whether EPA+DHA or EPA-only, at a dose of 4 g/d, are clinically useful for reducing triglycerides." 

Given the superior safety and tolerability profile of Lovaza, as compared to extended release niacin, as well as this patient's proven beneficial response, Lovaza is medically necessary in this instance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Short Stature
Treatment: Humatrope 36-unit cartridge, quantity 30 per 30 days
The insurer denied the Humatrope 36-unit cartridge, quantity 30 per 30 days.
The denial is upheld. 

This patient is a male diagnosed with idiopathic short stature (ISS). This request is for Humatrope. The patient started Adderall ten milligrams (MG). His growth hormone (GH) stimulation test with glucagon and L-dopa peaked 11 and 6.3 respectively. His height velocity is reported to be three centimeters per year (cm/yr). 

No, the proposed treatment with Humatrope is not medically necessary.

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

Classic GH deficiency
Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH Research Society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, 3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3.0 SD below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2.0 SD below the mean and a height velocity over one year more than 1.0 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over one year in children over two years of age; 4) in the absence of short stature, a height velocity more than 2.0 SD below the mean over one year or more than 1.5 SD sustained over two years. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than ten nanograms per milliliter (ng/mL).

The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than ten.

Idiopathic Short stature
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines  [4, [5, [6, [7, [8, [9]. FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient does not have a pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria. 

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.