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

Diagnosis: Dental disorder. 
Treatment: Braces and monthly visits. 
The insurer denied the braces and monthly visits. 
The determination is overturned. 

The patient is a male with a skeletal Class I malocclusion and significant crowding. He has an anterior open bite. He is missing teeth 6 and 11 with retained primary teeth C and H. He is treatment planned for 30-36 months of orthodontics with extraction of teeth C, H, 21, and 28 to address the crowding and open bite. At issue is the medical necessity of braces and monthly visits. 

Orthodontic treatment is medically necessary for this patient due to the side effect described below and the fact that this is not something that will self-correct without orthodontic intervention. 

Anterior open bite patients are among the most difficult patients to treat. (1) One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2) Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. (3) This patient is treatment planned for extractions, which is less invasive than orthognathic surgery.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity 
Treatment: Mounjaro (Trizepatide) 
The health plan denied: Mounjaro (Trizepatide) 
The determination is: overturned.

The patient is a female who was prescribed Mounjaro. She has had previous bariatric surgery. She lost a significant amount of weight, but after couple years, she gained some back and her hemoglobin A1c climbed a bit higher; she was put on Trulicity, which caused bloating and nausea. She stopped Trulicity and tried diet and exercise, which did not work. Then she was started on Ozempic, which worked for her, but she suffered severe constipation. She has also tried metformin in the past, but that caused her to constantly feel sick to her stomach. Her hemoglobin A1c was 6 percent (%) off of metformin, 6.1 % on metformin, and 6.3 % on Trulicity. The health plan denied the Mounjaro as the policy criteria require the trial and failure of three formulary alternatives including Trulicity injection, Ozempic injection, Rybelsus and Victoza injection. The patient is reported to have failed Victoza, Trulicity and Ozempic.  At issue is the formulary exception for Mounjaro.
The patient is reported to have failed Victoza, Trulicity and Ozempic. The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide receptor (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss. There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 receptor agonists as a first line agent. There is no preference for the requested medication over GLP-1 receptor agonists. However, the patient has failed the formulary medications Victoza, Trulicity and Ozempic. The request is consistent with generally accepted standards of medical practice and is, therefore, indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Down Syndrome Regression Disorder. 
Treatment: Privigen (code J1459). 
The insurer denied: Privigen (J1459). 
The denial is overturned. 

The patient is an adult female with Down syndrome. She is diagnosed with Down syndrome disintegration disorder (DSDD). Her evaluation included magnetic resonance imaging (MRI), electroencephalogram (EEG), and spinal fluid studies, and none revealed an etiology for her symptoms. She had a low B12 level that was treated. She had elevated thyroid antibodies. The patient's neurologist requested a three-month treatment course of intravenous immunoglobulin (IVIG) to treat Down syndrome disintegration disorder to determine if she is a responder. The request for Down syndrome disintegration disorder was denied coverage by the health plan as experimental/investigational due to not meeting off-label criteria. The treating physician appealed the decision with a letter stating Down syndrome disintegration disorder is associated with inflammatory etiologies in some cases, which leads to immune modifying treatment. The letter states the patient's thyroid antibodies support the patient having an autoimmune tendency and the patient should have a trial with intravenous immunoglobulin. This review is in regard to intravenous immunoglobulin use. 

The health plan should cover the treatment with Privigen. 

The requested Privigen is more beneficial than any standard treatment for the patient's condition or disease. The patient has Down syndrome disintegrative disorder. This is an incompletely understood disorder in certain patients with Down syndrome, but an autoimmune/inflammatory cause is the main hypothesis. Intravenous immunoglobulin has been studied for this indication. In one series, 88% of patients with Down syndrome disintegrative disorder responded to intravenous immunoglobulin treatment (1). Another case series showed improvement of symptoms in four out of four patients (2). In both studies, patients were treated with intravenous immunoglobulin for 12-18 months. In this case, the patient has Down syndrome disintegrative disorder and has evidence of autoimmunity based on elevated anti-thyroid antibodies. There are few other treatment options available to the patient. Other immune modifying treatments have less supportive evidence than intravenous immunoglobulin for treatment of Down syndrome disintegrative disorder. The studies above support a trial with intravenous immunoglobulin to determine if the patient will be a responder. As discussed above, intravenous immunoglobulin is beneficial in up to 88% of patients. No other treatment has this level of support for treatment of Down syndrome disintegrative disorder. Intravenous immunoglobulin is supported as medically appropriate per up-to-date literature.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Down Syndrome Regression Disorder. 
Treatment: Privigen (code J1459). 
The insurer denied: Privigen (J1459). 
The denial is overturned. 

The patient is an adult female with Down syndrome regression disorder. She has catatonic symptoms of decreased eating and dressing, slowed movements, decreased verbal output, and atypical use of fourth/fifth digits on hands to point/grasp. She has had revealing magnetic resonance imaging (MRI), electroencephalogram (EEG), serology, and cerebrospinal fluid (CSF) studies. She has had elevated thyroid antibodies, suggestive of autoimmune tendency and potential role of immune therapy to treat her regression. The patient's neuroimmunologist requested coverage of Privigen (intravenous immunoglobulin 
[IVIG]) 2 grams/kilogram to treat Down syndrome regression disorder. The request was denied coverage by the health plan as experimental/investigational. The denial is being appealed. 

The health plan should cover the treatment with Privigen. 

The requested Privigen is more beneficial than any standard treatment for the patient's condition or disease. Down syndrome regression disorder in a disease progress present in Down syndrome that is growing in recognition. It is neuropsychiatric and neurodegenerative decline in individuals with Down syndrome that presents as subacute loss of language, communication, cognition, adaptive skills, and behavioral and executive functioning skills. The disorder has been described in 2020 (1). 
Among several etiologies proposed for this disorder, an autoimmune process has been proposed. Evidence of neuroinflammation in this disorder has been presented in an observational study in 2022 showing changes on electroencephalogram (EEG), neuroimaging, and cerebrospinal fluid (CSF) in patients with Down syndrome regression disorder compared to patients with Down syndrome without Down syndrome regression disorder (2). A later group of 82 individuals with Down syndrome regression disorder were studied in a prospective, multi-center, observational study in which they were treated with intravenous immunoglobulin for nine-12 months and followed a standardized wean-off therapy (3). Compared to baseline, patients on intravenous immunoglobulin therapy had lower symptoms on neuropsychiatric and catatonia rating scales. A subset of participants with more severe findings on neurodiagnostic imaging had relapse on wean of intravenous immunoglobulin. Down syndrome regression disorder is a recently described disorder that effects a small population in a rare disease. The clinical features are clearly defined and there is reasonable evidence to support treatment of this neurodegenerative disorder. The patient has had a sub-acute loss of skills and neuropsychiatric decline. Her immunologic serologies have showed elevated anti-thyroid antibodies suggestive of a predisposition to autoimmunity. There has been suboptimal improvement with antidepressant medication. Based on the above, the requested treatment is expected to be more beneficial than any standard treatment for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Down Syndrome Regression Disorder. 
Treatment: Privigen (code J1459). 
The insurer denied: Privigen (J1459). 
The denial is overturned. 

This patient is an adult female with Down syndrome regression disorder. Her workup has been unrevealing for alternative etiologies for regression and behavior and communication. The provider wishes to start treatment with Privigen. The request was previously denied coverage by the health plan as experimental/investigational. The denial is being appealed. 

The health plan should cover the treatment with Privigen. 

Data from medical literature supports the use of intravenous immunoglobulin (IVIG) in Down syndrome regression disorder. Data from a multi-center study has shown benefit of intravenous immunoglobulin in those with Down syndrome regression disorder and those with and without neuro-diagnostic abnormalities. Another study done in 2023 showed that 85% of those with Down syndrome regression disorder were respondent to intravenous immunoglobulin. Given lack of United States Food and Drug Administration (FDA) approved medications and rarity of this condition, there is no standard treatment for this condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient has a benign past medical history who presented to the hospital with complaints of pain and swelling of left hand following injury from a punch. 

Vitals on presentation included: Temperature (T) 99.0 Fahrenheit (F), blood pressure (BP) 131/55, pulse (P) 78, respiratory rate (RR) 23, oxygen (O2) saturation 99% on room air (RA). Laboratory results included the following: white blood cell (WBC) count 5.8, hemoglobin (Hgb) 14.2, hematocrit (Hct) 44, creatinine 0.9, glucose 82, erythrocyte sedimentation rate (ESR) 14, and lactic acid 2.7. 

The patient was started empirically on intravenous antibiotics (Unasyn) for cellulitis of the left hand. X-ray of the left hand showed no evidence of fracture or dislocation. The abscess was drained (1 cubic centimeter [cc]) while in the emergency department. The patient remained afebrile, hemodynamically and clinically stable. The patient was discharged to continue oral antibiotics as an outpatient.       

According to documentation, the patient presented with left hand abscess/cellulitis. Otherwise, the patient was afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal WBC; x-rays were negative. The patient had no evidence of a disseminated infection and no co-morbid conditions. Based on above findings, the patient met criteria for observation level of management.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleep Apnea
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.


The patient is male with a history of severe obstructive sleep apnea with a polysomnogram demonstrating an apnea-hypopnea index of 74, not well controlled on continuous positive airway pressure (CPAP) therapy. He underwent adenotonsillectomy, uvulectomy, septoplasty, and inferior turbinate reduction to reduce upper airway resistance and improve nasal obstruction symptoms. He was admitted overnight for pain control and for continuous pulse oximetry monitoring due to a significantly elevated risk of postoperative obstructive complications after upper airway surgery. He was discharged after the patient's respiratory status clinically improved. At issue is the medical necessity of inpatient admission.

Inpatient level of care was not medically necessary for this patient. Based on the available records and any available peer-reviewed medical literature, given the absence of significant cardiopulmonary disease, inpatient level of care was not necessary in this instance. The patient had potential risk factors for having a potential respiratory complication in the post surgical setting including very severe obstructive sleep apnea as demonstrated on a prior polysomnogram. However, continuous pulse oximetry monitoring could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular tachycardia.
Treatment: Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

The patient is a female for whom an inpatient hospitalization is under review. She has a history of panic attacks, asthma, fatty liver, and alcohol use. She also had multiple sclerosis and was admitted electively for a supraventricular tachycardia (SVT) ablation. The vital signs were normal. She was in no distress. The electrocardiogram (ECG) demonstrated sinus rhythm with a right bundle branch block per report. She underwent a successful SVT ablation, remained stable, and was discharged. At issue is the medical necessity of an inpatient stay.

This patient underwent a successful and uncomplicated elective SVT ablation. There was an adequate post procedure monitoring period without hemodynamic instability, recurrent unstable arrhythmia, bleeding, heart block, acute coronary syndrome, hemodynamic instability, severe electrolyte abnormality, need for ongoing intravenous medications or oxygen support, or administration of high-risk medications requiring prolonged in-hospital monitoring. In this setting an inpatient hospital stay has not been established as standard of care, compared to for example outpatient, towards improved procedure or cardiac outcomes. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Nerve Treatment in the Spine
The insurer denied: Nerve Treatment in the Spine
The denial is upheld.

The patient is an adult male. He has had left low back pain that began last year. Past treatments include radiofrequency ablation, lumbar epidural steroid injections, physical therapy, massage, diclofenac, and Flexeril. His pain ranges from 4/10 to 9/10. Magnetic resonance imaging (MRI) of the lumbar spine from last year shows small disc herniation at L5-S1 with posterior annular fissuring and acute endplate degenerative changes with mild disc desiccation. The request for Intracept was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The requested health service was not medically necessary.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure. As such, the requested health service is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine
Treatment: Aimovig 140mg/mL (milligrams per milliliters) pen
The insurer denied Aimovig 140mg/mL (milligrams per milliliters) pen.
The denial is upheld.

The patient is an adult female with migraine headache disorder. She has tried and failed or could not tolerate Qulipta, topiramate, amitriptyline, The provider has requested Aimovig for migraine prevention. This was denied coverage as she has not tried and failed the preferred formulary medications or does not have a contraindication to using the preferred medications.

The health plan should not cover the proposed treatment.

There is no reason the member cannot be treated with the preferred formulary agents. Qulipta, Ajovy and Emgality are considered standard of care migraine preventive agents (Burch, 2021). There is no evidence to support that switching to a preferred agent would jeopardize the patient's clinical stability. The clinical trial leading to the FDA (Food Drug Administration) approval of Aimovig tested efficacy against placebo (Khan et al., 2019). There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Aimovig relative to the preferred, Qulipta, Ajovy and Emgality.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colon cancer, osteoarthritis, and dementia
Treatment: Personal Care Assistance Services Level II, 12 Hours Per Day 7 Days Per Week for a Total of 86 Hours Per Week (Monday - Sunday)
The insurer denied Personal Care Assistance Services Level II, 12 Hours Per Day 7 Days Per Week for a Total of 86 Hours Per Week (Monday - Sunday).
The denial is overturned.

The patient is an elderly female. Her medical conditions include colon cancer, osteoarthritis, and dementia. She was hospitalized and underwent laparotomy and loop ileostomy due to small bowel obstruction 2 months ago. She lives alone. Denial of personal care assistance services 12 hours per day 7 days per week, for total of 86 hours per week is being appealed. The health plan approved 56 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 3 months ago shows modified independent cognition and functional status: extensive to maximal assistance with all ADLs (activities of daily living), except limited assistance with bed mobility and eating. She is continent of bowel and bladder. An appeal letter reports that the patient is in hospice care due to terminal illness. She is bedbound and needs assistance with all ADLs (activities of daily living). She is incontinent and at risk of bed sores. A statement from the patient's grandchild reports the patient's condition has declined since surgery. She is unable to stand, walk, or reposition herself. She is developing pressure sores. The patient is blind and hard of hearing. She has difficulty vocalizing her needs.

The requested Personal Care Assistance Services Level II, 12 Hours Per Day 7 Days Per Week, Total of 86 Hours Per Week is medically necessary.

Denial of personal care assistance services 12 hours per day 7 days per week, for total of 86 hours per week is being appealed. The health plan approved 56 hours per week. This patient has a terminal illness due to stage 4 colon cancer. She underwent loop ileostomy due to small bowel obstruction 2 months ago. Uniform Assessment System (UAS) evaluation completed 3 months ago, shows she required extensive to maximal assistance with all ADLs (activities of daily living), except limited assistance with bed mobility and eating. She was continent. Since surgery, the patient's condition has deteriorated. She is now bedbound and incontinent. She is developing pressure sores. The information provided shows a deterioration in the patient's functional status since UAS (Uniform Assessment System) evaluation performed 3 months ago. The approved personal care services of 56 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase to a total of 86 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:	C difficile	

Treatment: 	Antibiotics and admission

The insurer denied inpatient admission

The denial is overturned

The patient has a past medical history significant for immune compromise, asthma, depression, bipolar disorder, and neuropathy who presented to the emergency department with complaints of fevers, chills, and weakness. 

Vitals on presentation included the following: Temperature-103, Blood Pressure-115/63, Pulse-115, Respiratory Rate-18, Oxygen Saturation-98% on room air. Laboratory results showed: white blood count (WBC)-15.8, hemoglobin (Hgb)-10.6, Hematocrit-32.7, sodium-134, creatinine-0.77, glucose-111. Chest x-ray (CXR) was negative.

The patient was empirically started on broad-spectrum antibiotics (vancomycin and Zosyn). She was also started on valacyclovir for herpes zoster. The patient tested C difficile positive and was started on oral vancomycin. The patient improved clinically, remained hemodynamically stable. She was discharged to continue outpatient management. 

According to the medical records, the patient presented with high fevers (103) and tachycardia (heart rate-115). Laboratory results revealed significant leukocytosis (15.8).  Based on above findings, in an immunocompromised patient, hospital admission was medically necessary to rule out sepsis and administration of antibiotics with further evaluation. 

Based on the above, the insurer's denial must be reversed. 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 an inpatient admission is substantiated.