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

The patient is a twin male that was born prematurely via cesarean complicated by intrauterine growth restriction with birth weight 1635 grams. His Apgar scores were 9 at 1 minute and 9 at 5 minutes. The mother was GBS (group B strep) positive and Quantiferon positive. His neonatal period was complicated by respiratory distress, suspected sepsis, hyperbilirubinemia requiring phototherapy, and retinopathy of prematurity. He has since been diagnosed with mild left hydronephrosis, umbilical hernia, and mild branch peripheral pulmonic stenosis. He was initially placed on nasal continuous positive airway pressure (CPAP) with FiO2 0.30 and started on ampicillin and gentamicin. The antibiotics were discontinued after 72 hours with negative cultures. He remained on nasal CPAP for 27 days, and then weaned to high flow nasal cannula for 12 days, meeting criteria for chronic lung disease. He was doing well at his 6-week follow-up. 
The use of Synagis is under review.

The health plan's determination is overturned. Synagis is medically necessary for this patient. In this case, the baby was born with respiratory distress syndrome requiring non-invasive ventilatory support for more than 28 days (CPAP for 27 days and HFNC for 12 days) and birth weight 1635 grams, placing him at risk for development of severe disease should he become infected with RSV. Synagis is medically necessary and appropriate for the full duration of the RSV season based on the literature and the current standards of care. In 2014, the American Academy of Pediatrics issued new guidelines for the administration of Synagis for respiratory syncytial virus (RSV) prophylaxis based on review of current peer-reviewed literature related to burden of RSV in infants and children with emphasis on those at highest risk of severe disease.  The following groups of patients are considered at highest risk, with recommendations for administration of Synagis: infants born before 29 weeks' gestation younger than 12 months of age at the start of RSV season; infants with chronic lung disease of prematurity born before 32 weeks' gestation during the first year of life, with some consideration during the second year of life if continued medical support is necessary; infants 12 months of age or younger with hemodynamically significant congenital heart disease (excluding those with lesions adequately corrected by surgery unless medication is necessary for ongoing congestive heart failure); consideration for infants 12 months of age or younger with anatomic pulmonary abnormalities or neuromuscular disorders that have difficulty clearing secretions; consideration for infants less than 24 months of age that are profoundly immunocompromised; and consideration for infants with Down syndrome or cystic fibrosis that have evidence of other risk factors such as chronic lung disease or congenital heart disease.
Appeal type: Formulary Exception
Decision: Upheld

The patient is a woman with chronic migraines. She has tried and failed the following medications: venlafaxine, verapamil, amitriptyline, valproate, propranolol, and topiramate. She has also tried and failed Emgality. Treatment with Ajovy is the subject of this review.

The health plan's determination is upheld. The formulary alternatives are Emgality and Aimovig. The patient has already tried and failed Emgality. The patient has not tried and failed Aimovig. There is no indication that Aimovig would not be as effective as the non-formulary drug or would have adverse side effects.
Of note, Emgality and Ajovy (the requested medication) have the same mechanism of action which is binding to the CGPR (calcitonin gene-related peptide) ligand. Aimovig has a different mechanism of action and binds to the CGRP reception. As such, a drug such as Aimovig would generally be tried after failing Emgality.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history of muscular dystrophy, peripheral vascular disease, hypoglycemia, anorexia, major depressive disorder and recurrent sacral decubitus ulcers. The patient has had 3 pressure ulcers over a year period of time. She has little use of her hands and the description in the notes indicates chronic decorticate position. The patient is wheelchair bound and is transferred only by Hoyer lift. The patient was evaluated with the Uniform Assessment System-New York assessment tool and was approved for 24 hour care, 7 days a week to total 91 hours per week. The patient had visiting nurse services to help with wound care and a report indicated the wound was healing.  The patient's provider wrote a letter indicating 24 hour care in 12 hour split shifts, 7 days a week to total 168 hour/per week was recommended and felt to be medically necessary. The patient required frequent repositioning, specifically every 2 hours, to allow healing and prevent recurrent sacral ulcers. The health plan recommended a wedge for the patient to use to help to heal and prevent sacral ulcers. The health plan denied 24 hour, 12 hour split shift, personal care assistance, 7 days a week, to total 168 hours/week. The health plan's determination is overturned.
The patient has muscular dystrophy and is not able to reposition herself on her own. She has had three decubitus ulcers over several months. Her medical provider felt that the requested PCA services were medically necessary. Per Uptodate for treatment of pressure ulcers - "a two-hour interval is recommended for repositioning. It has been demonstrated that skin erythema and ischemic changes can occur in healthy adults in less than two hours on a standard mattress. Skin and soft tissues with borderline perfusion at baseline can develop irreversible changes with even shorter intervals of pressure."
In addition, personal care services can be provided only if these services are medically necessary and the authorizing agency reasonably expects that the patient's health and safety in the home can be maintained by the provision of such services.
It is medically necessary for the patient to have repositioning every 2 hours to help with healing of and prevention of sacral ulcers. Personal care assistant services 24 hours and day/7 days a week (split-shift) for a total of 168 hours/week are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems - Teeth spacing problem
Dental/Orthodontic Procedure

The patient has a skeletal Class II malocclusion, mild maxillary crowding and mild mandibular crowding.  He also has a moderate overjet and mild overbite.  Congenitally, he is missing tooth #29, and retained tooth #T.  The proposed treatment is braces.  The subject to be determined is the medical necessity for braces. 

The health plan's determination is upheld, in whole. 

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 9 with no auto qualifiers.  Auto qualifiers include cleft palate deformity or cranio-facial anomaly, severe traumatic deviation, impacted permanent anteriors where extraction is not indicated, deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9mm or greater and underbite 3.5mm or greater.  The case requires a score of 26 or more for treatment to be considered medically necessary.  The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary.  Thus, braces are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid arthritis 
Treatment: Humira
The Humira is not medically necessary.

The patient is a female with seronegative erosive rheumatoid arthritis (RA).  Per attached documentation, one dose of methotrexate 0.5 cubic centimeters (cc) was administered, and prednisone was prescribed on an as-needed basis.  Attached pharmacy claims do not show any methotrexate prescriptions as filled.  Sulfasalazine was filled on three occasions, although details regarding the use of sulfasalazine, continued use of methotrexate, or need for Humira are not documented in the attached progress notes.  Appeal is for Humira for the treatment of RA.

Per attached documentation, this patient with RA was administered one dose of methotrexate, and treated with an unknown dose of sulfasalazine for an unspecified duration of time.  There is no clear documentation that this patient has failed an optimized dose of methotrexate, sulfasalazine, or another disease modifying anti-rheumatic drug (DMARD) (i.e., leflunomide or hydroxychloroquine).  Per 2015 American College of Rheumatology published guidelines for the treatment of early RA, optimized DMARD monotherapy would be the first line of treatment before consideration of a biologic therapy such as Humira.  The requested Humira for the treatment of RA in this patient at this point in time is not in accordance with standard of care in the rheumatology community, or clinically appropriate.  Therefore, the requested Humira is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with request for Residential Treatment Center (RTC). Prior to admission, the patient had eloped from home in an effort to avoid rehab. The patient had recently been in another rehab facility. The patient, prior to that, had overdosed on Benadryl and dextromethorphan (DXM). The patient has history of outpatient treatment refusal, mood lability, eloping from home, being threatening when under the influence. The patient has been diagnosed with opioid use disorder, stimulant use disorder, cannabis use disorder, and attention deficit hyperactivity disorder (ADHD). The patient also has a history of suicidal ideation and self-harm. The patient was admitted to RTC.

The health plan's determination is upheld

For the dates of service under review, the patient actively participated in care including individual, group, and family therapy. The patient was medically stable. The patient was not suicidal, homicidal or psychotic. The patient has a sponsor at home. The patient's family was involved in his care. The patient was cooperative and participating in care, he had no acute behavioral issues. The patient had no cravings. He was seen by psychiatry once a month. There were no significant issues with medications or side effects to medications.

There was no indication for around the clock monitoring. Given the information provided, the patient would be benefited from a substance abuse (SA) outpatient individual, group and family therapy, sponsor support and psychiatric follow up using Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) criteria.
Appeal type: Medical necessity
Decision: Overturned

Back Pain
Durable Medical Equipment (DME) (including Wearable Defibrillators)

The patient is a male with chronic, 10 years, axial and radicular leg pain. Under review is the medical necessity of a spinal cord stimulator.

The health plan's determination is overturned. A a spinal cord stimulator is medically necessary for this patient. This patient is a male with a 10 year history of low back pain with radicular symptoms. His magnetic resonance imaging (MRI) Lumbar Spine is significant for multilevel disc disease with herniations at L2-3, L3-4 and L5-S1 and associated severe stenosis. His physical examinations were significant for positive straight leg raises, muscle spasms and antalgic gait. It is medically necessary that this patient undergo a spinal cord stimulator trial, and if good results are obtained, proceed with spinal cord stimulator implantation. This is considered standard of care as the patient was evaluated by a neurosurgeon, Dr. Varma, who recommended against surgery as it would require a multi-level fusion with unreliable results. This patient has tried and failed years of medication management, physical therapy and spinal injections. He has no other available treatment options available.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Universalis
 
Treatment: Xeljanz

The insurer denied the medication Xeljanz. The denial was reversed.

This is a male patient with a history of alopecia universalis since childhood. It was reported that the patient suffers from social isolation because of his condition. The treatment plan was Xeljanz 10 mgs. 

Jabbari, A., et al. (2016) states, "Alopecia areata (AA) is a highly prevalent autoimmune disease in the US with a lifetime risk of 1.7%. However, AA remains a significant unmet need in dermatology and treatments are lacking. Janus kinase inhibitors are emerging as potential therapies for many autoimmune conditions, including most recently AA (1, 2). We report a patient who was treated with oral tofacitinib citrate, a preferential JAK3/JAK1 inhibitor, for AA, resulting in significant hair regrowth and concurrent skin and blood biomarker changes". They go on to state, "AA is an autoimmune disease with strong associations with genetic loci in close proximity to genes with immune functions (4). Targeting candidate immune pathways that may be contributing to disease pathogenesis is an active area of investigation (5), and JAK inhibitors target multiple immune signaling pathways involved in AA. We have previously shown systemic and topical tofacitinib to be effective in preventing the development of AA, as well as reversing established AA, in the graft model of AA in C3H/HeJ mice (3). We report here effective treatment of a human subject with persistent patchy AA, correlating with a diminished ALADIN profile compared to baseline".

The prescription Xeljanz (tofacitinib), a janus kinase inhibitor medication is considered medically necessary for this patient's diagnosis of alopecia universalis. The claimant has a long-standing diagnosis of alopecia universalis. This is an autoimmune disease and a pathologic condition. The claimant has tried and failed topical, intralesional, and oral corticosteroids. There is no plan approved or FDA approved therapy for alopecia universalis. This is an orphan disease.  As noted above, the patient has tried and failed conservative therapy for years. Xeljanz has been found to be safe, effective, and durable in the treatment of alopecia universalis. For these reasons the request for Xeljanz should be approved.

Based on the above, the medical necessity for the prescription Xeljanz to treat the patient's diagnosis of alopecia universalis is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stenosis of the right carotid artery 
 
Treatment: Inpatient Surgery

The insurer denied the Inpatient Surgery. The denial was upheld.

This is a patient with a medical history of hypertension and serum cholesterol 152mg/dl, triglycerides 72mg/dl, HDL 54, LDL 84, with a right carotid bruit noted on physical examination. It was reported that a non-invasive imaging study revealed a 70-90% stenosis of the right carotid artery. A Carotid endarterectomy was recommended. 

Patients with asymptomatic carotid artery stenosis greater than or equal to 70% and favorable anatomy have a class I indication for carotid endarterectomy according to American Heart Association (AHA) guidelines. (1)  However, these guidelines were based on trials where statin therapy was not widely available. More recent guidelines published by the European Society for Vascular Surgery recommend medical therapy as a class I indication for patients with high grade carotid stenosis and favorable anatomy. (2) According to these guidelines, carotid endarterecotmy should be considered as a IIa indication only in patients with high risk imaging or clinical findings, such as silent infarction on CT brain, stenosis progression, large plaque area or plaque echolucency and history of transient ischemic attack. There is no evidence of high risk findings in the medical record. This patient is also not treated with statin therapy and LDL is above the recommended goal of less than 70.

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

Based on the above, the medical necessity for the inpatient surgery scheduled (carotid endarterectomy) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Injury
Inpatient hospital

The patient is an infant who fell from 3 feet height and had parietal scalp hematoma, initial somnolence, and was brought to the emergency department (ED) via ambulance. In the ED, the patient was awake and acting as expected for age. A computed tomography (CT) scan showed a linear non displaced skull fracture, and no intra cranial lesion. The patient was admitted to the pediatric intensive care unit based on neurosurgery recommendation for the sole purpose of q (every) 1hour neurochecks.

The health plan's determination is upheld. The inpatient stay was not medically necessary. Given the lack of intracranial trauma lesions in a non-displaced linear parietal fracture, the patient could have been observed with q4h vitals and neurochecks. Given the evidence-based literature in this area, isolated nondisplaced skull fractures in neonates do not need intensive care monitoring. In addition, there was a lack of neurological symptoms, and a CT scan proving no intracranial traumatic bleed/lesion. The patient could have been safely cared for at a lower level of care. Even though patient had oxygen monitoring, this was not necessary as the patient's oxygen saturations were always normal. In this setting, even though the child is very young, the patient did not need intensive care monitoring. Isolated nondisplaced skull fractures very rarely result in deterioration and incredibly rarely would require neurosurgical intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep Impinging Overbite with Severe Soft Tissue Damage.

Treatment: Interceptive Orthodontic Treatment of the Transitional Dentition

The insurer denied the interceptive orthodontic treatment of the transitional dentition. The denial was reversed. 

This is a female patient who consulted an orthodontist for orthodontic treatment.
Diagnostic testing was performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral, intraoral clinical images and a HLD index exam. Orthodontic therapy was recommended due to the patient's deep impinging overbite and excessive overjet.

Upon review of the submitted documentation (study models were not provided for review), it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claimed an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. Based on the review of the clinical guideline, this patient met the automatically qualifying condition criterion and support for comprehensive orthodontic care. In this case, it is determined that the clinical circumstance of this patient met the insurer and plan criteria to justify for orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies. Each of the peer reviewed articles noted below concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The healthcare 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 interceptive orthodontic treatment of the transitional dentition is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dizziness
Treatment:  Inpatient admission
The insurer denied the inpatient admission.  The denial was upheld.  The inpatient admission was not medically necessary. 

The patient is a male with hypertension and coronary artery disease (CAD) who presented with the complaint of chest pain, dizziness and difficulty finding words.  At presentation, his National Institute of Health (NIH) stroke scale was one and computed tomography (CT) of the brain was negative.  His symptoms improved and the patient refused magnetic resonance image (MRI). 

The patient presented with acute dizziness and had a normal neurological examination at baseline.  The evaluation, diagnostic studies, monitoring and treatment could have been safely and effectively competed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inguinal hernia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.
The proposed inpatient stay was not medically necessary.

The patient is a male who underwent elective right inguinal hernia repair with mesh. Postoperatively, he began swelling in the scrotum and had to be taken back to the operating room for evacuation of hematoma. The bleeding vessel was found and ligated. 

The patient had a known and well recognized postoperative complication that was quickly identified and repaired in a timely fashion. There was no hemodynamic instability, change in vital signs, or need for further inpatient monitoring. 

Bruising, seroma, and hematoma formation are relatively common following inguinal and femoral hernia repair. In the surgery versus watchful waiting trial, 6.1 percent of patients undergoing open, mesh repair developed a wound hematoma, 4.5 percent developed a scrotal hematoma, and 1.6 percent developed a seroma. Seromas and hematomas are reported in approximately five percent of laparoscopic hernia repairs.

Seromas and hematomas are due to the collection of fluid or blood in the dead space that remains once a hernia sac has been reduced. They can present as significant scrotal swelling (if the original hernia involved the scrotum) or inguinal swelling (if the original hernia did not involve the scrotum).

During laparoscopic access, vascular injury, most commonly of the epigastric artery or vein, or external iliac artery or vein, can cause bleeding resulting in hematoma formation.

Seroma or hematoma may be mistaken as (ie, pseudohernia), and must be differentiated from, a hernia recurrence since the typical clinical presentation is similar (ie, groin mass and pain). Cross-sectional imaging, for example computed tomography (CT), can help distinguish hernia recurrence from a seroma or a hematoma.

Most fluid collections resolve without specific treatment. Fluid collections should not be aspirated in the absence of accompanying clinical features of infection, as this poses a risk for introducing infection into a sterile site. Hematomas may spontaneously decompress through the wound, which can be unsettling to the patient but is generally not serious.