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

Diagnosis: Hypertensive urgency

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This male patient has a history of hypertension, hyperlipidemia, and coronary artery disease (CAD). He presented to the Emergency Room with complaints of 10 out of 10 left sided chest pain radiating to the left upper extremity. Pain improved slightly with Tylenol and Ibuprofen. The patient reported running out of blood pressure medication. Blood pressure was 232/130. 10 milligrams (mg) of intravenous (IV) Labetalol and 5 mg of IV Lisinopril were given. Blood pressure improved to the 150s. The patient was admitted to telemetry with hypertensive urgency in the setting of mediation noncompliance. Acute coronary syndrome (ACS) needed to be ruled out. Troponins were negative and a chest x-ray (CXR) revealed no significant findings. An electrocardiogram (EKG) revealed T-wave inversions in inferior leads and v6. There were ST elevations in v1-v4 unchanged from prior. A repeat EKG revealed resolution of II and augmented vector foot (AVF). Systolic blood pressures (SBP) were labile between 150s-170s. In two instances SBP decreased to the 120s. Hydralazine was discontinued. The patient was given 6.25 mg of Coreg twice a day (BID), 30 mg of Imdur a day (QD), and 60 mg of Nifedipine QD. He was instructed to continue Ibuprofen and a Lidocaine patch as needed (PRN). He was discharged after a period of hemodynamic stability. He was instructed to follow up with the primary care physician (PCP) and cardiologist on an outpatient basis.

Hypertensive emergency is defined as blood pressure (BP)>180/120 with target organ damage.(1) This patient had no evidence of target organ damage. No evidence of renal insufficiency, central nervous system damage, cardiac ischemia or systolic congestive heart failure were noted upon arrival. The goals for treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction.(2) This patient had a hypertensive urgency, poorly controlled hypertension without target organ damage. Such patients should be managed as an outpatient or in an observation unit.(3) In conclusion, admission to the hospital for aggressive blood pressure management was not medically necessary. He could have been managed at a lower level of care.

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain.
Treatment: MRI - Neck Spine Without Dye and MRI - Spine Without Dye, Pre-service.
The insurer denied the MRI - Neck Spine Without Dye and MRI - Spine Without Dye, Pre-service.
The denial is upheld. 

The patient is a female with lower back pain and neck pain. She was noted to be ambulating with a cane. Electrodiagnostic studies showed lumbosacral radiculopathy. Magnetic resonance image (MRI) of the cervical spine showed neural foraminal stenosis but no central canal stenosis. She has completed a course of physical therapy.

No, the proposed magnetic resonance image of the cervical spine and lumbar spine is not medically necessary.

Magnetic resonance image (MRI) of the cervical spine and lumbar spine are not medically necessary. This patient has a history of chronic neck pain and lower back pain with a magnetic resonance image (MRI) showing cervical foraminal stenosis and lumbar foraminal stenosis. There is no documented neurological examination to support she has signs or symptom of cervical or lumbar spinal cord stenosis or compression that would require intervention. There are not documented symptoms other than pain that localizes to the cervical spine or lumbar spine. There are no "red flag" signs or symptoms that would support magnetic resonance image (MRI) of the cervical or lumbar spine. There is no recent physical therapy to support a trial of conservative treatment of neck or lower back pain. Therefore, standard of care guidelines do not support the utility of magnetic resonance image of the cervical or lumbar spine here as the diagnostic utility has been demonstrated to be very low.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: D8080 - Comprehensive Orthodontic Treatment Of The Adolescent Dentition,
D8220 - Fixed appliance therapy (includes appliances for thumb sucking and tongue thrusting);
D8670 - Periodic orthodontic treatment visit; 
D8680 - Orthodontic retention (removal of appliances)
The insurer denied the D8080 - Comprehensive Orthodontic Treatment Of The Adolescent Dentition; 
D8220 - Fixed appliance therapy (includes appliances for thumb sucking and tongue thrusting);
D8670 - Periodic orthodontic treatment visit; 
D8680 - Orthodontic retention (removal of appliances)

The denial is overturned. 

The patient is a male. The request is for orthodontic benefits.

Yes, the proposed treatment is medically necessary.

This patient has a Salzmann score of 27, which is more than the threshold of 26 needed for benefits. The overjet, anterior crowding and labio-lingual spread were incorrectly computed by the health plan.

The patient's proper measurements on the handicapping scale are as follows:

Overjet = 9 mm (millimeters)
Overbite = 2 mm (millimeters)
Anterior crowding (each arch had more than 3.5 mm [millimeters] crowding) = 2 x 5 = 10
Labio-lingual spread = 6

The patient's total score is 27. When the patient's score is corrected, the Salzmann score is high enough for benefits. The health plan incorrectly shorted the values seen on the photos.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.
Treatment: Saxenda 3 mg (milligram) /0.5 ml (milliliter) pen injectors.

The insurer denied coverage for the medication Saxenda 3 mg/0.5 ml pen injectors.  The denial is overturned.

The patient is a female diagnosed with obesity. Her body mass index (BMI) is 40.35. She has attempted to lose weight through Weight Watchers, My Fitness Pal and exercise programs.  However, the patient is unable to lose weight with diet and exercise alone, and she is struggling to obtain the desired weight loss. The patient has anxiety and would be at risk for palpitations and increased anxiety with oral stimulants. The patient is under the medical care of her nurse practitioner. The treatment plan would include Saxenda 3 mg/0.5 ml pen injectors to improve the patient's weight loss and lower her BMI. 

The insurer has denied coverage for the medication Saxenda 3 mg/0.5 ml pen injectors for weight loss treatment as not medically necessary. The patient is appealing. In the patient's New York State External Appeal Application, she disputed the statements in the insurer's denial letter.  The patient explained she lost a certain amount of weight in a year, but she has more weight to lose. The patient also explained she needs additional help with her weight loss before she is diagnosed with a condition such as diabetes, high blood pressure, a stroke, heart attack osteoarthritis, a hip replacement, etc. The patient further stated her health is at serious risk if she does not get additional help from the requested medication.

The health plan has a policy regarding enrollment in a qualified complete weight management program, which includes coaching/counseling. The "Lost it!' app, even with the premium subscription the patient has, does not offer coaching/counseling or have structured sessions with minimum monthly check-ins.  Although this requirement is commendable, it may not be necessary for weight loss with Saxenda (liraglutide). 

In two double-blind studies of more than 3,000 obese or overweight patients, adding liraglutide to diet and exercise modification for one year resulted in an average 8.9- to 13.3-lb (4- to 6-kg) greater weight loss. All patients in both studies received the dietary and exercise recommendations, yet the patients receiving the medication were amongst those that lost the most weight. Specific directions regarding how this information was transmitted to patients (whether via counseling/coaching sessions and how often these sessions would occur, or as written rules to follow) were not discussed in the studies.

Saxenda has been approved by the FDA for the treatment of obesity with a BMI of at least 30, as exists in this patient, as an adjunct to a reduced calorie diet and increased physical activity.  There is no specific method of dietary or exercise counseling stipulation related to its approved use.

Therefore, Saxenda 3 mg/0.5 ml pen injector for this patient's weight loss treatment is medically necessary.

Based on the above, the medical necessity for the medication Saxenda 3 mg/0.5 ml pen injectors for weight loss treatment is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent Inj 300/2 milliliter (ml)
The insurer denied the Dupixent Inj 300/2ml
The denial is overturned. 

The patient is a female with moderate atopic dermatitis affecting greater than (>) 20% body surface area (BSA), including sensitive areas. She has tried and failed topical mometasone, triamcinolone, prednisone, cetirizine, hydrocortisone and Elidel.

Yes, the proposed Dupixent Inj 300/2ml is medically necessary.

The patient has moderate atopic dermatitis affecting multiple areas of the body, including sensitive areas. She is a candidate for systemic therapy as the body surface area (BSA) is too large for reasonable control with topical medications. Topical calcineurin inhibitors (pimecrolimus) and topical steroids have failed and are not appropriate therapy for severe, widespread atopic dermatitis, affecting sensitive areas,  which should be treated with systemic therapy. Topical crisaborole (Eucrisa), likewise, is not appropriate for treatment of greater than (>) 20% affected body surface area (BSA).

Dupilumab is a monoclonal antibody that inhibits IL-4 (Interleukin-4) and IL-13 (Interleukin-13 ) signaling by blocking the shared IL-4Ra and originally demonstrated efficacy in phase II clinical trials. It was approved by the US Food and Drug Administration (FDA) for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It is a subcutaneous injection administered initially at a dose of 600 milligrams (mg) and then every two weeks thereafter.

Approval of dupilumab was based on clinical trials investigating dupilumab as monotherapy (SOLO 1 and SOLO 2 [studies]) and in concomitant administration with topical corticosteroids (CHRONOS [study]). Results from the SOLO 1 (n [number] =671) and SOLO 2 (n [number] =708) trials showed 36-38% of patients who received dupilumab had scores of zero or one (clear or almost clear) on the Investigator's Global Assessment scale compared with placebo (8-10%). Additionally, improvement from baseline to week 16 of at least 75% on the Eczema Area and Severity Index (EASI) was reported in significantly more patients who received each regimen of dupilumab than in patients who received placebo.

Given its unprecedented efficacy, dupilumab is emerging as a first-line therapeutic for moderate-to-severe atopic dermatitis (AD). This patient has failed topical steroids, calcineurin inhibitors, and systemic steroids. Additionally, topical crisaborole is not appropriate for widespread disease.

Therefore, Dupixent is medically necessary.

Topical calcineurin inhibitors (pimecrolimus) and topical steroids have failed and are not appropriate therapy for severe, widespread atopic dermatitis, affecting sensitive areas,  which should be treated with systemic therapy. Topical crisaborole (Eucrisa), likewise, is not appropriate for treatment of greater than (>) 20% affected body surface area (BSA).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Surgical Services. 
The insurer denied outpatient surgery services (heat treatments). 
The denial is upheld.

The patient is a female with a long history of essential tremor (ET). She is right-handed and the ET is significantly affecting her work. She has been tried on numerous medications, including propranolol and primidone. She was referred to neurosurgery for surgical consideration of her refractory ET. He obtained computed tomography (CT) analysis of skull density ratio, which was noted to be 0.48, making her a potential candidate for the MRgFUS procedure.

The health plan's determination is upheld in whole.

The requested procedure is not medically necessary for this patient. The procedure of MRgFUS was approved by the Food and Drug Administration (FDA) for the treatment of refractory unilateral ET. While this novel procedure is a very exciting potential addition to the other more established ablative treatments there have been no prospective randomized controlled trials of this procedure against the current standard of care which is DBS. Authors stated "Additional head-to-head comparison on matched populations are required to more accurately compare efficacy and long-term outcomes". That same group from the Department of Neurosurgery at Brigham and Women's Hospital was involved in the report of a prospective randomized trial comparing unilateral MRgFUS versus a sham procedure in patients with medically refractory ET, which did show benefit in the treated patients tremors, along with a follow-up report that the tremor suppression was shown to be stable at 2 years. However, it was also noted that persistent neurological adverse events were documented at 1 year in 9-14% of the patients, which was noted to be higher than neurological adverse events in DBS patients, although the latter had higher rates of surgery and hardware related adverse events. (Harary et al.). In a Journal of Neurological Surgery clinical article, another group noted that "Large randomized studies are needed to assess prolonged efficacy and safety" for patients undergoing MRgFUS for ET and PD. (Zaaroor et al.). 
Therefore, as the efficacy and long-term safety of this procedure has not yet been established, it is appropriately considered not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a man with a history of hypertension (HTN), diabetes mellitus (DM) II, and alcohol use disorder (AUD), who presented to the emergency department (ED) for right upper quadrant (RUQ) pain, nausea and vomiting. On presentation vital signs included a temperature of 98.5F (Fahrenheit), a heart rate (HR) of 98 beats per minute (bpm), a respiratory rate (RR) of 16/minute, and a blood pressure (BP) of 135/88 millimeters of mercury (mmHg). Oxygen saturations were 100% on room air (RA). Physical exam reported the patient to be comfortable, in no distress, abdomen was tender in the RUQ and epigastric area. Labs included a white blood cell (WBC) of 6.7, a hemoglobin of 13.2, platelets of 141, a lipase of 93, an aspartate aminotransferase (AST) of 163, an alanine aminotransferase (ALT) of 143, a sodium (Na) of 138, a potassium (K) of 3.8, a carbon dioxide (CO2) of 25, a blood urea nitrogen (BUN) of 8, and a creatinine of 0.6. The patient received 1-liter normal saline, intravenous (IV) H2 (histamine receptor antagonist) blocker, IV Zofran and IV Morphine. An abdominal ultrasound (US) was negative for acute cholecystitis, no gallstones seen. A computed tomography (CT) noted subtle nodular contour of the liver, portal hypertension, and cholelithiasis. The patient was noted to have a high ferritin and high transferrin saturation and was recommended to be evaluated for hemochromatosis and consideration of a liver biopsy. He was discharged home.
At issue is the medical necessity of the inpatient stay.

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

The patient was admitted for persistent abdominal pain and received intravenous fluids (IVF), pain control and proton-pump inhibitors (PPI). He additionally required 1 milligram (mg) IV Lorazepam for signs of ethyl alcohol (ETOH) withdrawal. Gastroenterology was consulted and recommended an esophagogastroduodenoscopy (EGD). The patient underwent an EGD which did not demonstrate varices, grade C esophagitis, severe gastritis and portal hypertensive gastropathy.
The patient presented with significant RUQ abdominal pain however there was no evidence of acute kidney injury, orthostasis or hemodynamic stability. He had no evidence of melena or hematemesis concerning for an upper gastrointestinal bleed (UGIB) and hemoglobin changes were consistent with dilution [1,2]. The patient was clinically stable with no evidence of a surgical abdomen and did not have elevated inflammatory markers to suggest a poor prognosis [3]. The patient's abdominal pain could have been managed at an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rash.
Treatment: Full Hospital Admission.
The insurer denied coverage for full hospital admission.
The denial is upheld.

The patient is a female with a past medical history significant for obesity and COVID(Coronavirus Disease 2019) infection who presented to the emergency department with complaints of bilateral inner thigh rash that spread to her face, leg, arms and abdomen.

Vitals on presentation included: Temperature 99.9 Fahrenheit, Blood Pressure 124/81, Pulse 87, Respiratory Rate 20, Oxygen (O2) saturation-98% on Room Air. Laboratory values were notable for the following: White blood cell count (WBC) 18.8, hemoglobin (Hgb) - 13, hematocrit (Hct) - 42.4, platelets-590, creatinine-0.98, glucose-115, D-dimer 2.14, C-reactive protein (CRP)-4.5, lactate dehydrogenase (LDH)-377, procalcitonin -<0.10.

The patient was admitted for evaluation of rash. She was started on intravenous (IV) fluids and IV clindamycin.  Dermatology consulted and recommended topical ointments including mupiricin, betamethasone, and hydrocortisone.  The patient improved clinically, remained afebrile, hemodynamically stable; the patient was discharged to continue outpatient management on oral antibiotics.

According to documentation, the patient presented a rash of unclear etiology.  Otherwise, she was afebrile, hemodynamically stable with stable O2 saturation on room air.  The patient was recovering from COVID infection, chest x-ray (CXR) showed no abnormalities.  Laboratory results likely reflected changes associates with prior diagnosis of COVID.  The patient had been on prednisone as an outpatient, which likely contributed to elevated WBC; procalcitonin was negative.  The patient had no evidence of a disseminated infection and no surgical intervention was required.  Based on the above findings, the patient met criteria for observation level of management; the patient did not fulfill criteria for acute care hospitalization. 

The health plan did act reasonably with sound medical judgement in the best interest of the patient.

The insurer's denial of coverage for the Full Hospital Admission is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits for medical necessity. 
The denial was upheld. 

The patient is a female with a Skeletal Class III malocclusion. She has mild maxillary crowding and mild mandibular crowding. There is a mild overjet and mild overbite with anterior crossbite at teeth number (#) 7 and 26. The patient is recommended for braces and monthly visits.

At issue is the medical necessity of braces and monthly visits.

The health plan's determination is upheld in whole.

The requested health service/treatment of braces and monthly visits is not medically necessary for this patient.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 6 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet of 9-millimeter (mm) or greater and an underbite of 3.5 mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet criteria to be classified as handicapping and treatment would not be considered medically necessary.

The patient has mild findings that include mild maxillary crowding and mild mandibular crowding. The patient also has a mild overjet and mild overbite. There are anterior crossbite at teeth # 7 and 26, both of which are a mild condition. Considering the malocclusion factors being mild, per the standard of care, braces and monthly visits are not medically necessary.  

Thus, braces and monthly visits are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headache
Treatment: Ubrelvy 100 milligrams (MG)
The insurer denied the Ubrelvy 100 MG.
The determination is upheld

The patient has a history of chronic migraine. She was seen with complaints of chronic migraine, for which she was receiving Botox. She tried and failed multiple medications and antidepressants and was currently on Abilify. She had previously failed Topamax and Sumatriptan, which "makes her feel out of it makes her feel warm throughout" and she cannot function well on it. She has two migraines weekly and had headaches more than half the month. Her neurological examination was normal. Ubrelvy was prescribed, and Botox was resumed. The reason for denial is that there must be a response to medications on the preferred drug list, such as, rizatriptan, eletriptan, naratriptan, and zolmitriptan.

At issue is the medical necessity of Ubrelvy.

There is no medical necessity for Ubrelvy. The patient had a side effect that does not contraindicate triptans and is not specific to triptans. It is possible that the adverse effect was due to a non-active ingredient, as it is not listed as a common side effect in the sumatriptan prescribing information. A trial of a different triptan would be reasonable prior to considering Ubrelvy, due to the lack of specific triptan-related adverse effects from sumatriptan. Therefore, there is no medical necessity for Ubrelvy as another triptan medication can be utilized.