Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Post Traumatic Stress Disorder
Treatment: Brand Valium with thirty 10 mg tabs 
The insurer denied the Brand Valium with thirty 10 mg tabs.
The denial is overturned.

This case involves an adult treated with brand Valium, 10 mg with 30 tabs prescribed. The patient has failed to respond to generic Valium (diazepam) and to oxazepam and lorazepam and alprazolam, as noted by the prescribing physician without specifying the adverse results.

The health plan has denied authorization for coverage of the Brand Valium indicating that this medication is non-formulary and that at least three or four alternative formulary medications, diazepam, lorazepam, alprazolam and oxazepam, as well as meprobamate must have been been tried and failed due to lack of efficacy or tolerability issues/adverse effects. Again, the patient has failed to benefit from treatment with generic formulation of Valium with an adverse effect; the health plan's pharmacy benefit manager indicates that treatment failure due to an adverse effect with the generic formulation of a drug does allow for approval of the Brand formulation as long as step therapy and treatment failure with the required number of formulary alternatives has occurred.

Yes, the health plan should cover the proposed treatment.
The formulary drug alternatives have been ineffective for this patient due to adverse effects, and therefore, the formulary drug alternatives would not be as effective as the requested non-formulary drug. The only remaining formulary alternative indicated is meprobamate which is an older sedative-hypnotic-anxiolytic agent that has significant addiction liability and is not appropriate in clinical use compared to the proposed treatment with Valium due to higher risk for adverse effects, as opposed to the request for coverage of Brand Valium.

Additionally, the health plan's requirements for a coverage exception is met in this case, and the approval for the requested treatment as proposed is reasonable, in the patient's best interest and reflects sound medical judgment in keeping with NY (New York) State instruction for this review and prevailing standards of medical practice.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe crowding, very narrow arches and impacted permanent teeth. 
Treatment: Braces (D8080), Pre-service. 

The insurer denied the Braces (D8080). 
The denial is overturned. 

The patient is a male. The request is for orthodontic benefits. He has severe crowding, very narrow arches and impacted permanent teeth. 

Yes, the braces are medically necessary. 
The patient has a very narrow upper arch and severe crowding of his teeth. This has caused his upper permanent canines, teeth 6 and 11, to be impacted. These teeth need to be orthodontically extruded to put them in their proper places. Having permanent anterior teeth like these canines being impacted, where extractions are not indicated, is an "automatic qualifier" according to the handicapping index scale. This case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Anemia

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient has a history of diabetes (DM), hypertension (HTN), fibroids, and anemia who presented to the emergency room (ER) with vaginal bleeding. She had a hemoglobin (hbg) of 42. She was admitted for symptomatic anemia.

This patient presented with severe anemia with a hbg of less than (<) 6g/dl (grams per deciliter) with ongoing bleeding. Per Milliman Care Guidelines (MCG) this would warrant acute level care. This level of anemia would be considered to be life threatening in an individual with ongoing bleeding. At this level patients are at risk for high output cardiac failure, hypoxia, heart attack, especially given her comorbidities of DM and HTN. Therefore, acute level hospitalization was medically necessary for this patient.

Turner, J. et al., "Anemia due to acute blood loss- Treat with IV (intravenous) fluids, crossmatched packed red blood cells, oxygen. Always remember to obtain at least two large-bore IV lines for the administration of fluid and blood products. Maintain hemoglobin of > (more than) 7 g/dL in a majority of patients. Those with cardiovascular disease require a higher hemoglobin goal of > 8 g/dL... Anemia, if undiagnosed or left untreated for a prolonged period of time can lead to multiorgan failure and can even death."

Wouk, N., "Multiple factors should be considered when choosing among treatment options for abnormal uterine bleeding (Table 4),3742 including the cause and acuity of the bleeding, fertility and contraceptive preferences, medical comorbidities, adverse effects, cost, and relative effectiveness. If the underlying cause of bleeding can be identified and treated, symptoms may resolve without the need for additional intervention. Anemia is an indication for treatment, as is bleeding that negatively affects the patient's quality of life. Because exposure to unopposed estrogen increases the risk of endometrial cancer, treatment of anovulatory abnormal uterine bleeding involves inducing ovulatory cycles or administering supplemental progesterone to antagonize estrogen's proliferative effect on the endometrium."

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

Diagnosis: Acute Appendicitis

Treatment inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a male patient presented to the Emergency Department (ED) with right lower quadrant abdominal pain. There was no nausea or vomiting. The patient was afebrile. The patient was subsequently transferred. An ultrasound was performed and was positive for acute appendicitis. There was no abscess or perforation. The patient underwent an uneventful laparoscopic appendectomy and was discharged on the same day.

Admission may be necessary for patients with severe systemic illness (e.g., sepsis), poorly controlled comorbidities (e.g., chronic obstructive pulmonary disease [COPD], chronic heart failure), or complications from the procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care. 

This patient did not require more than 24 hours of postoperative care, and they were discharged within this time frame. There were no immediate complications documented after the surgery. According to clinical documentation, the patient was treated under observation standards. Peer-reviewed literature also indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis. Outpatient management of uncomplicated appendicitis in pediatric patients has been shown to be safe with low morbidity, low re-admission rates, and cost savings to the hospital. Suitable criteria for same-day discharge include hemodynamic stability, tolerating liquids, and pain controlled on oral medications. Per clinical documentation, there are no indications for inpatient admission. The hospital admission was medically necessary. 

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient. 

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

Diagnosis: bilateral flat feet

Treatment: custom orthotics

The insurer is denied coverage for custom orthotics

The denial is overturned. 

This male patient has a history of bilateral flat feet

It is well documented in the literature, that in cases where all conservative measures have been attempted, custom orthotics play a major role prior to and after surgical intervention. "Children with flexible flatfoot who wore customized arch support insoles for 12 weeks exhibited significantly improved pain/comfort, physical health, stair ascent time, upper extremity and physical function, and transfer and basic mobility." (1) Furthermore, a systematic review found that orthotics "show potential as a treatment method for children with flexible pes planus." (2) As such, it is in the best interest of this young patient to use custom orthotics prior to having to undergo any type of surgical intervention for his ongoing pain and discomfort.

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

The carrier's denial of coverage for the custom orthotics is overturned.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory Problems. Treatment: Surgical Services. The insurer denied hypoglossal nerve stimulator. The denial is overturned.

The patient is a female with a known history of severe obstructive sleep apnea (OSA). She was seen in the office and at that time reported that she could not tolerate continuous positive airway pressure (CPAP) due to a feeling of suffocation while wearing the device. She used nasal steroids in the past for greater than (>) 30 days with no improvement. Her sleep study was repeated and showed an apnea hypopnea index (AHI) = 46.2 with less than (<) 25% central or mixed apneas. Body mass index (BMI) at the time was 29.
The patient underwent a drug induced sleep endoscopy which showed no sign of concentric collapse of the velopharynx.
The patient was felt to be a good candidate for hypoglossal nerve stimulation. This was denied by her insurance since it is considered not to be the standard of care.

Yes, the proposed treatment is more likely to be beneficial than any standard treatment for the patient's severe OSA. The first line treatment for OSA is CPAP, since the patient has failed this, then surgical options are the considered.
Other surgical procedures for the treatment of OSA have poorer outcomes with higher morbidity.
The patient meets all Food and Drug Administration (FDA) indications for the implantation of this device which are:
1)	CPAP/bi-level positive airway pressure (BiPAP) intolerance
2)	OSA with AHI 15-65
3)	Age >22
4)	BMI < 32
5)	Non concentric collapse of the velopharynx (documented in operative note)
6)	< 25% central or mixed apneas
Untreated sleep apnea is associated with a significantly increased risk of sudden death, hypertension, stroke, coronary artery disease, congestive heart failure, type 2 diabetes, depression, motor vehicle accidents, occupational accidents, lost productivity, and decreased quality of life.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic Procedure
The health plan denied comprehensive braces as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient in question has anterior and bilateral posterior crossbites. He is severely crowded. He is treatment planned for 24-30 months of orthodontics to correct his bite, but the claim was denied on the basis that treatment is not medically necessary. His family appealed this ruling.

The patient has anterior and posterior crossbite with severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.1,2,3
This patient presents with anterior and posterior crossbites, crowding, and constricted arches. He would be an excellent candidate for orthopedic rapid maxillary expansion to assist with orthodontic correction. Such a procedure can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced.4 The patient is nearly at the end of the time that orthodontics alone can correct his crossbite. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis. 
Treatment: Remicade 10 milligrams per kilogram every 6 weeks. 

The insurer denied Remicade 10 milligrams per kilogram every 6 weeks. 
The determination is upheld. 

The patient is under treatment for ulcerative colitis (UC). There is very little clinical data provided. The patient has longstanding UC, which ultimately flared on mesalamine and then thiopurine therapy. His Remicade was increased to 10 milligrams per kilogram (mg/kg) every (Q) 6 weeks and he has had a good response. The patient's provider has recommended continuing the use of Remicade 10 mg/kg Q 6 weeks. This request was denied by the plan as not medically necessary as the dose exceeds the quantity limits of the plan. The plan's approved dosing is 5 mg/kg every 8 weeks. 

At issue is the medical necessity of the Remicade 10 milligrams per kilogram every 6 weeks. 

There is no justification provided for a dose of Remicade which exceeds the Food and Drug Administration (FDA)-approved threshold. There is no information given by the provider to justify the recommended dose of Remicade that was submitted for this appeal. Maximum conventional dosing of Remicade is 5 mg/kg Q 4 weeks or 10 mg/kg Q 8 weeks.[1] In order to justify using the dose proposed by the provider there would have to be evidence of the following: the serum trough level of infliximab is below the desired serum concentration of 5 to 10 micrograms per milliliter (ug/mL) or there is objective definitive improvement in inflammatory disease with the very high dose, not achieved with lower dosing.[2] This would include either improvement in the Mayo Score including endoscopic subscore or a marked decrease in inflammatory activity demonstrated by either a reduction in the serum C-reactive protein (CRP) level or stool calprotectin/lactoferrin level. None of this data was given by the provider and the dosing proposed is not consistent with recent American Gastroenterological Association (AGA) [1] or American College of Gastroenterology (ACG) guidelines.[3] 

Additional data was requested, provided and includes the following: The patient failed tofacitinib. The patient has antibodies to adalimumab. He has Mayo 3 disease left sided colitis. He has required steroids in the past. There is no small bowel disease. However, this reviewer still does not see the rationale as to how the dose was escalated to 10 mg/kg Q 6 weeks. The information provided is from more than 2 years ago. 
Therefore, based on the information provided the Remicade 10 milligrams per kilogram every 6 weeks is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Knee Problem/Pain. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient hospital admission for medical necessity. 
The denial was upheld. 

The patient is a male, who underwent hardware removal with extensive debridement and patellectomy with tenorrhaphy and vicryl meshing due to failed open reduction internal fixation (ORIF) of a periprosthetic patella fracture. He was discharged to a subacute rehabilitation facility. The patient was initially admitted as an inpatient and this status has been denied by the health plan as not medically necessary. 

At issue is the medical necessity of the Inpatient stay. 

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

The requested health service/treatment of Inpatient stay was not medically necessary for this patient. 

Matar et al (2020) state that satisfactory clinical outcomes can be achieved with extensor mechanism reconstruction and tubeplasty in patients with previous patellectomy undergoing primary and revision knee arthroplasty. The requested inpatient stay for this patient was not medically necessary.  The patient was placed into a brace post-operatively with 45 degrees of flexion.  He was instructed to be weight bearing as tolerated with a walker and therefore was not non-ambulatory.  An inpatient stay generally would not be warranted in this setting. 

Therefore, the requested health service of Inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-seizures
Treatment: Inpatient stay
The health plan denied the inpatient stay as not medically necessary.
 The reviewer has overturned in whole the health plan's determination.

The patient was born prematurely at 31 weeks' gestation with complicated medical history including sepsis, necrotizing enterocolitis requiring colectomy and ileostomy followed by re-anastomosis, short gut syndrome, asthma, seizure disorder, bilateral hearing loss status post cochlear implants, congenital blindness, and global developmental delay due to neonatal periventricular and intracranial hemorrhages, that was referred to the emergency department (ED) for intractable seizures. She was previously stable on phenobarbital with occasional brief seizures. The seizures became more frequent, so her dosing was increased. However, on the day of presentation, she experienced multiple prolonged seizures despite therapeutic phenobarbital level (38.7), including one in the clinic. Vital signs included temperature 98.2, heart rate 125, and respiratory rate 24. Examination was significant for no acute distress, moist mucous membranes, clear lungs, benign abdomen, and non-focal neurological exam. Laboratory testing revealed unremarkable white blood cell (WBC) count 6.5 thousand (K), negative extended respiratory panel, and metabolic panel significant only for elevated alkaline phosphatase 345. She was treated with a loading dose of Keppra and admitted for further care. Admission orders included regular diet, seizure precautions, continued phenobarbital, maintenance Keppra, video electroencephalogram (EEG), and formal Neurology consultation. The video EEG revealed very frequent epileptic spikes, including bilateral independent epileptic spikes on either side with variable distribution. The plan was to optimize phenobarbital level greater than 30, continue Keppra, follow-up with Neurology, and obtain brain magnetic resonance imaging (MRI). The Keppra dosing was switched to oral, and upon completion of 24 hours of video EEG, tolerating both anticonvulsant medications, she was deemed stable for discharge.

Yes, the full duration of her acute hospital stay was medically necessary and appropriate.

This young girl with complex medical history and seizure disorder presented with increasing frequency and duration of seizures, despite outpatient evaluation and increase in phenobarbital dosing. She was referred to the ED with medically refractory breakthrough seizures, with no evidence of infection or other inciting situation. Despite the short duration of her hospital stay, with the complexity of her medical history and current medical problems, the care that she received was most consistent with acute inpatient management. She had already failed outpatient management and could not be safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroparesis
Treatment: Motegrity, Pre-service
The insurer denied the Motegrity, Pre-service
The denial is overturned. 

This patient is a female with albinism, blindness, restrictive eating disorder, gastroparesis, and gastrostomy-jejunostomy (GJ) tube dependence.  She has been on total parental nutrition (TPN) in the past.  She has tried mirtazapine.  She has received pyloric botox.  She has tried and failed Reglan and Zofran.

Yes, the proposed treatment with Motegrity is medically necessary.
Motegrity is used off-label for gastroparesis. Alternative medications such as Reglan may cause tardive dyskinesia. Per study by Carbone F et al, thirty-four patients with gastroparesis (28 idiopathic, seven men, mean age 42  13 years) were evaluated in a double-blind crossover trial of four-week treatment periods with placebo or prucalopride two milligrams daily, separated by two weeks of washout. For the entire patient group, compared with placebo, prucalopride significantly improved the total Gastroparesis Cardinal Symptom Index and the subscales of fullness/satiety, nausea/vomiting, and bloating/distention. Prucalopride significantly improved the overall Patient Assessment of Upper Gastrointestinal Disorders-Quality of Life score and the domains of clothing and diet. The gastric half emptying time was significantly enhanced by prucalopride compared with placebo and baseline.

The patient has no reasonable alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Noninfective Gastroenteritis and Colitis
Treatment: Mesalamine/Canasa 1000 milligrams (mg) suppository
The insurer denied the Mesalamine/Canasa 1000 milligrams (mg) suppository.
The denial is upheld.

The patient is a male with ulcerative colitis. Colonoscopy early last year revealed mild colitis. He was started on mesalamine. He was seen recently with increased rectal bleeding.  Canasa was added. The doctor (MD) feels the patient is much improved with dual (oral and suppository) mesalamine. The doctor (MD) is requesting continuation of Canasa suppositories.

No, the proposed treatment is not medically necessary.
Canasa was denied as the patient has not tried and failed the two preferred formulary alternatives, Rowasa and hydrocortisone enemas. There is no medical literature to support that Canasa is more effective than Rowasa or hydrocortisone enemas for the treatment of ulcerative colitis.  There is no contraindication to the formulary alternatives documented for this patient in the records received.  Therefore, the proposed Canasa is not medically necessary.

As there are formulary alternatives that are as safe and as effective as Canasa, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.