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

Diagnosis: Dry eye syndrome
Treatment: Formulary exception for Cequa 0.09%
The insurer denied the formulary exception for Cequa 0.09%.
The denial is overturned.

The patient is an adult female with dry eye syndrome for whom coverage of non-formulary Cequa is the subject of review. Coverage was previously denied by the health plan, as it was not identified that the patient had failed or could not use the formulary alternative, Restasis (cyclosporine). An exam note documents complaints of gritty, burning, and watery eyes, which feel worse at the end of the day. Reportedly, the patient has been on Restasis in the past. The patient is also identified as having facial rosacea for which she uses wipes. Both corneas were reported as clear. It was recommended that the patient start Cequa and Miebo as well as artificial tears. Blink breaks were recommended, and the patient could consider IPL (intense pulsed light) treatment.

The health plan should cover the formulary exception for Cequa.

The Preferred Practice Patterns of the American Academy of Ophthalmology recommend the use of topical cyclosporine [Restasis 0.05% (percent), Cequa 0.09%] for patients with dry eye syndrome who have failed to respond to ocular lubricants. More recently, Miebo (perfluorohexyloctane ophthalmic solution) was FDA (United States Food and Drug Administration) approved for the treatment of the signs and symptoms of dry eye disease. Miebo prevents tear evaporation, whereas cyclosporine formulations increase tear production. In this case, documentation provided states that the patient has already tried Restasis. Rajpoot, et al found that increasing strength of cyclosporine from 0.05% to 0.09% better improves corneal staining, tear production, tear film osmolarity in patients with dry eyes. Therefore, the medical appropriateness of the requested Cequa is established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a past medical history (PMH) of alcohol abuse, cirrhosis, peripheral neuropathy, and bipolar disorder (d/o) who was admitted with complaints of (c/o) alcohol withdrawal. Her vital signs were notable for tachycardia, blood pressure (BP) 112/82. The physical exam notable for anxious appearing, awake, alert, oriented times 3 (AAOx3), tremulous, normal strength, Clinical Institute Withdrawal Assessment (CIWA) 3-4. Lab work was notable for potential hydrogen (pH) 7.15, bicarbonate less than (<) 10, lactate 11.8, anion gap (AG) 30. An electrocardiogram (EKG) showed sinus tachycardia without acute ischemia. The patient was diagnosed with alcohol withdrawal and treated with in vitro fertilization (IVF), benzodiazepines (BZDs), and Clinical Institute Withdrawal Assessment (CIWA) protocol. The patient was discharged against medical advice (AMA). At issue is the medical necessity of an inpatient level of care.
The hospital stay was medically necessary at an acute inpatient level of care. This patient with a known history of alcohol abuse and cirrhosis presented to the emergency department (ED) with c/o alcohol withdrawal. The patient was found to have profound metabolic derangements, including severe acidosis with a pH of 7.15 and bicarbonate of < 10, significant lactic acidosis, and elevated anion gap, in the context of alcohol withdrawal. The patient was initially consulted with the Medical Intensive Care Unit (MICU) due to severe acidosis, but due to improvements in lab values with IVF and serial monitoring, the patient was recommended for inpatient admission instead. This patient with severe metabolic derangement in the context of acute alcohol withdrawal and risk for decompensation could not have received the required close clinical monitoring for decompensation at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and nausea
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This adult patient underwent a distal pancreatectomy for a neuroendocrine tumor of the pancreas 6 months ago. 1 month later she developed a wound dehiscence and was initially treated as an outpatient and given oral antibiotics. She subsequently presented to another hospital with abdominal pain and nausea. Computed Axial Tomography (CAT) scan showed a fluid collection felt to be a pseudocyst. She was transferred to the treating hospital and was afebrile with stable vital signs, no abdominal rebound or guarding. There was no leukocytosis, and it was felt that she did not have an infectious process. Pain control was given with nutritional and physical therapy evaluations. The pseudocyst did not require any acute interventions. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-250 for Pancreatitis. The patient did not have acute pancreatitis. Clinical indications for admission for acute or chronic pancreatitis include having evidence of infection, severe pain, hemodynamic instability, severe vomiting, stage 3 acute renal failure, altered mental status, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient developed a pancreatic pseudocyst after having pancreatic surgery. She was treated with pancreatic enzymes, a low-fat diet, and pain control. She did not require any acute interventions. She could have been treated with observation care. She did not meet Milliman Care Guidelines (MCG) criteria for admission for Pancreatitis. 

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

Diagnosis: Obesity

Treatment: for Ozempic (1 milligram [mg]/dose) Solution (Soln) Pen-Injector (Inj) 4mg/3 milliliters (ml)

The insurer denied coverage for Ozempic (1 milligram [mg]/dose) Solution (Soln) Pen-Injector (Inj) 4mg/3 milliliters (ml)

The denial is upheld 

This is a patient diagnosed with obesity. The request is for Ozempic. As reported, the patient has hypertension (HTN), obstructive sleep apnea (OSA), dyslipidemia, fatty liver (abdomen sonogram showed mildly increased hepatic echogenicity; borderline for fibro fatty; infiltration; otherwise, it is a normal sonogram). The patient is obese with a body mass index (BMI) of 31.  The patient's most recent hemoglobin A1C was 5.1%.

The policy criteria require the submission of medical records indicating a diagnosis of type II diabetes which is the approved indication of Ozempic. The patient does not have type II diabetes. The patient has prediabetes and obesity. The request does not meet the policy criteria. The health plan reasonably denied the request. 

Semaglutide is a glucagon-like peptide-1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer reviewed medical journals have shown safety and efficacy of Semaglutide for the treatment of obesity (5-7). This medication is now available for the treatment of obesity in the form of Wegovy. There are no studies showing safety or efficacy of the requested medication for patients who do not have diabetes such as this patient. There are no extenuating circumstances in this case. The request is, therefore, not medically necessary.  

The request does not meet the policy or the standard of care and is therefore not medically necessary. The denial is upheld.

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 Ozempic (1 milligram [mg]/dose) Solution (Soln) Pen-Injector (Inj) 4mg/3 milliliters (ml) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing Loss

Treatment: medical equipment (V5261 x 1, V5264 x 4, V5267 x 1, and V5160 x 1) - binaural (2) hearing aids.

The insurer denied coverage for medical equipment (V5261 x 1, V5264 x 4, V5267 x 1, and V5160 x 1) - binaural (2) hearing aids.

The denial is overturned.

This is an adolescent patient with a history of leukemia.  The patient has had chemotherapy and stem cell transplantation.  The patient has had chronic otitis media with resultant tympanic membrane perforation and chronic bilateral hearing loss.  Speech recognition thresholds were 40 decibels (dB) on right and 30 dB on left.  The patient is not a good surgical candidate due to their history.  The patient has difficulty hearing in school and home and hearing aides have been recommended.  The patient lives with their mother, and they are able to take care of a hearing aide.

Hearing aides are recommended for anyone having more than 35dB speech recognition threshold (SRT).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for medical equipment (V5261 x 1, V5264 x 4, V5267 x 1, and V5160 x 1) - binaural (2) hearing aids services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a boy with a history of asthma who presented with a worsening cough.
He was well until 2 months prior to presentation when he was exposed to asbestos, lead, and mold from a damaged wall in his apartment. He began to cough after this, and his cough progressed over time. Over the week prior to presentation, he also developed post-tussive emesis. His mother then noted blood in his sputum. He was seen in urgent care, and was prescribed 5 days of corticosteroids. However he continued to have symptoms, and on the night prior to presentation he was seen in the emergency department where he was given albuterol/Atrovent nebulized treatments as well as Decadron. 

Inpatient Hospital Admission was medically necessary for this patient. This is a boy with asthma who presented with persistent cough and hemoptysis, likely related to toxic environmental exposures in his home. He required hospital admission in order to remove him from this exposure, provide him with needed treatments and preventive care management, and provide specialist consultation. He received the appropriate and intensive treatment as an outpatient and in the emergency department setting, including bronchodilators and a course of corticosteroids. However, he continued to have a persistent cough, likely related to the toxic environment at home with recent exposure to black mold and asbestos. 
He required inpatient hospital admission to remove him from this harmful environment and to provide treatments as needed for his significant cough. He also required specialist consultation from the pulmonary team for persistent asthma with hemoptysis, and from social work in order to develop a safe discharge plan to avoid further harmful exposures.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.

Treatment: Wegovy Injection 0.5MG (2 per month).

The insurer denied coverage for a Wegovy Injection of 0.5 milligrams (MG) (2 per month).

The denial is overturned.
 

This is a teenage adult diagnosed with Obesity. This request is for Wegovy. As per the letter, his weight is 109.8 kilograms (kg) and his Body Mass Index (BMI) is 36.23. He has attempted weight loss efforts through increased physical activity and a reduced-calorie diet without success. 

Semaglutide is a glucagon-like peptide 1 receptor (GLP1R) agonist [1] that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity [2-4]. Recent studies published in major peer-reviewed medical journals have shown the safety and efficacy of semaglutide for the treatment of obesity [5-7]. This medication is now available for the treatment of obesity in the form of Wegovy. The standard of care based on multiple societal guidelines [8-13] requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia. 

The patient has a BMI of 36.2 and participates in lifestyle modifications such as diet and exercise. The patient can re-initiate treatment.  

The request meets the standard of care and is, therefore, medically necessary. 

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 Wegovy Injection of 0.5MG (2 per month) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia
Treatment: Endosteal implant (D6010)
The insurer denied coverage for endosteal implant (D6010).
The denial is upheld.

Based on review of the submitted documentation which includes copy of post implant placement panoramic radiograph, oral maxillofacial surgeon (OMFS) treatment/progress notes of varying dates including consult note operative note, post operative note, contact notes, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion of prosthetic rehabilitation for the mandible in the area of edentulous # (number) 28. The oral surgeon recommended endosteal implant in area of #28 after discussion with the patient's dentist. The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants. The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and, therefore no benefit is available. Further, the insurer cites the alternate benefits provision of the patient's contract and suggests that either removable partial dentures or conventional fixed bridge placement are covered and allowed alternative therapies. The patient is appealing the decision.

Upon review of the objective documentation which primarily consists of the panoramic radiograph and treatment notes, the patient exhibits oligodontia and is missing #18. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable partial denture or a fixed denture prosthesis/bridge. In this case, the removable partial denture in the mandible would be acceptable given the other missing teeth in the arch. Further, the documentation provided does not support, justify, or substantiate the requested treatment. Therefore, as removable partial dentures or a fixed bridge remain standards of care in general dental practice, the endosteal implant is considered elective and not medically necessary.

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

The medical necessity for endosteal implant (D6010) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hodgkins lymphoma

Treatment: Proton Beam Therapy (PBT) (codes 77387, 77525, G6002)

The insurer denied coverage for Proton Beam Therapy (PBT) (codes 77387, 77525, G6002)

The denial is upheld
 

This is the case of teenage adult patient who presented with stage 4 Hodgkin lymphoma. The patient was treated with chemotherapy. The patient had relapse and was treated with Nivolumab and chemotherapy. This was followed by different chemotherapy. Positron Emission Tomography (PET) scan showed positive Left submandibular node. The patient underwent autologous stem cell transplant and was recommended radiation to this PET positive node using Proton beam . This is the subject of review.

The Health plan policy does not cover Proton beam for this  clinical scenario.

Attending physician provided dose volume histogram (DVH) comparison of intensity modulated radiation therapy (IMRT) and PBT. The radiation dose to organs at risk (OAR) are within acceptable tolerance and not very high. The prescribed dose is moderate 30 gray (Gy) in 15 fractions.

The standard of care (SOC) for this clinical condition where prescribed dose is not high, is IMRT.

National Comprehensive Cancer Network (NCCN) guidelines do not recommend PBT for this clinical condition.

There are no published data to support PBT for this clinical condition.

Medically necessary treatment is defined as those treatments which are in accordance with generally accepted standards of medical practice in the USA. PBT is NOT  in accordance with generally accepted standard of medical practice in USA (United States of America). IMRT is the generally accepted standard of medical practice in the USA for this treatment.

Proton Beam Therapy (codes 77387, 77525, G6002) is NOT  considered medically necessary for this patient.

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 Proton Beam Therapy (codes 77387, 77525, G6002) for future dates of service at New York Proton Center is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Substance-related Rehabilitation Services.
The insurer denied Inpatient Substance-related Rehabilitation Services.
The determination is upheld.

The patient is an adult female who was admitted to inpatient rehabilitation substance use disorder treatment for stimulant (crack cocaine), alcohol, and cannabis (marijuana) use disorders. Her referral was prompted by the desire to stop using substances of abuse. She had a history of multiple past substance use disorder treatment episodes with the last occurring in the month prior to presentation.
The patient had no acute general medical issues that were a focus of treatment. 
There were co-occurring psychiatric disorder best characterized as schizoaffective disorder, bipolar type and post-traumatic stress disorder (PTSD) managed with outpatient treatment that included Depakote, Seroquel, gabapentin, and Paxil with supplemental use of trazodone.
The inpatient level substance-related rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions, and 12-step recovery groups with peer support. 
At issue is the medical necessity of Inpatient Substance-related Rehabilitation Services.
The requested health service/treatment of Substance Abuse Inpatient Rehabilitation Level of Care was not medically necessary for this patient.
The structure and intensity of services necessary for the rehabilitation/substance use disorder treatment could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that the inpatient level structure and 24-hour nursing monitoring is medically necessary for a successful outcome in this case. There were no biomedical, psychiatric, or general medical issues that warranted the requested inpatient level services. The patient's alcohol, stimulant (cocaine), and cannabis use disorders were amenable to treatment at a lower level of care in this case scenario.
The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure of an inpatient setting to effectively participate in rehabilitation substance abuse treatment, or to continue effective treatment for the co-occurring psychiatric disorders.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a female with a history of coronary artery disease (CAD) and gastroesophageal reflux disease (GERD) who presented with epigastric burning pain started after eating lunch. The pain was non-radiating and 6/10 in intensity. The pain was gradually worsening. She was sent to the emergency room (ER) to rule out acute coronary syndrome (ACS). She has a cardiac stent a couple of years prior showing 30 percent (%) left anterior descending (LAD) stenosis. In the emergency room (ER), she was hemodynamically stable. She had a non-ischemic electrocardiogram (EKG). Her cardiac enzymes and brain (or B-type) natriuretic peptide (BNP) were within normal limit. Her pain as reproducible. She was evaluated by cardiology. A stress test was recommended that was negative. No further work-up was recommended. She remained hemodynamically stable. She was eventually discharged with changes in her GERD medications.
At issue is the medical necessity of an inpatient stay.
The requested inpatient admission was not appropriate. The patient had atypical chest pain, had no difficulty taking oral medications and the cardiac work up revealed no acute pathology. Inpatient admission was not indicated. The patient was hemodynamically stable. She had atypical chest pain, and the presentation was not consistent with active cardiac etiology. Her pain was reproducible, and it was persistent for over 2 days favoring non-cardiac chest pain [1]. Her thrombolysis in myocardial infarction (TIMI) score was low at 1 point with 5% risk of all cause mortality. Therefore, cardiac work up was reasonable to do as in this patient, however that work up was suitable to be done at a lower level of care [2]. The patient had no problem taking oral medications, did not have any active infection and need for cardiac intervention such as active acute coronary syndrome (ACS). Therefore, the inpatient admission was not indicated in this patient.