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

Diagnosis: Pulmonary embolism.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld. 

The patient has a history of hypertension (HTN), breast cancer, and recent surgery.  The patient presented to the hospital with complaints of shortness of breath and pleuritic chest pain of 1 day duration.  The patient's vital signs were Temperature (T) 97.9 (degrees) Fahrenheit (F), heart rate (HR) 90, respiratory rate (RR) 19, blood pressure (BP) 130 over 90 (130/90), oxygen (O2) saturation 100% (percent) on room air (RA).  The patient was in no acute distress.  The patient's lungs were clear, cardiovascular sounds in S1 and S2 were normal.  The patient was alert and oriented to person, place and time.  

Laboratory tests showed: white blood cell (WBC) count 6.9, hemoglobin (Hgb) 10.9, D-dimer elevated, B-type natriuretic peptide (BNP) and troponin within normal limits.  An electrocardiogram (EKG) showed normal sinus rhythm with no acute changes.  A pulmonary computed tomography angiogram (CTA) was done which revealed a right middle lobe segmental pulmonary embolism (PE).  The patient was started on a Heparin infusion.  The patient was also treated with pain medications for chest pain.  A transthoracic echocardiogram (TTE) was done which revealed a left ventricular ejection fraction (LVEF) of 69% and normal right ventricular size and function.  The patient was seen by pulmonary who recommended the patient be switched to direct oral anticoagulation (DOAC).

The patient remained afebrile and hemodynamically stable after admission.  The patient was not hypoxic.  The patient was discharged home the next day on oral anticoagulation and pain meds with follow-up in the outpatient setting.

This patient did not need acute inpatient hospitalization.  The patient could have been placed in observation while diagnostic testing and treatment were initiated.  Observation could have been for up to 48 hours.  The patient had been stabilized and discharged home before that time frame.  

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: atrial-septal defect
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This case involves a female with a past medical history significant for hypertension (HTN), obesity, large secundum ASD (atrial septal defect) who presented for elective transcatheter closure of ASD. The procedure was performed under general anesthesia. The patient underwent successful close of the ASD with a 34 millimeter (mm) Amplatzer septal occluder device. There were no procedural complications and the patient remained hemodynamically stable post-procedurally. The patient was admitted to the telemetry service under inpatient level of care for overnight monitoring. The patient remained stable and was discharged home the following day. 

The inpatient hospital stay was not medically necessary in this case for overnight monitoring after ASD closure. The patient's procedure was successful. There were no procedural related complications. The patient remained hemodynamically stable and overall asymptomatic. Rather, overnight monitoring under ambulatory status would have been appropriate and safe in this case and is supported by the peer reviewed medical literature and expert consensus guidelines on ASD closure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.

Treatment: Tremfya.

The insurer denied coverage for Tremfya.

The denial is overturned.
 

The patient is an adult female with a diagnosis of severe psoriasis.  The patient has been treated with Tremfya and Otezla for over one year to achieve psoriasis control.   The requested medication is Tremfya to be used in conjunction with Otezla for treatment of psoriasis.  

The use of Tremfya is medically necessary in this clinical scenario based on the standard of care and the documentation provided.  The patient has a documented diagnosis of severe psoriasis and has been treated with a combination of Tremfya and Otezla for over one year.  Despite both agents, she still has periodic flares that require topical therapy.  Discontinuing either Otezla or Tremfya would likely exacerbate her symptoms.   The combination of Tremfya and Otezla is needed to adequately control the patient's psoriasis based on the medical documentation.  These medications have distinct mechanisms and do not have overlapping side effect profiles which would limit their combined use.  As such, the use of Tremfya in the setting of Otezla is medically appropriate based on the standard of care and the provided documentation. The decision is reversed and the use of Otezla and Tremfya to treat the patient's psoriasis is approved under the medical supervision of the treating physician.

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 Tremfya is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: ADHD (attention deficit hyperactivity disorder)
Treatment: Formulary exception for Adderall XR (extended release)
The insurer denied the formulary exception for Adderall XR.
The denial is overturned.

The patient is a school aged male with ADHD (attention deficit hyperactivity disorder). The request is for the use of Adderall XR (extended release). The health plan denied coverage of the requested, noting that the patient did not meet criteria for being approved for the Adderall XR. The appeal noted that the requested medication is medically necessary because the patient did use multiple formulary versions before the requested medication worked for his symptoms, therefore he did meet criteria.

The health plan should cover the formulary exception for Adderall XR.

The health plan's formulary notes that this medication may be approved when the patient is unable to take the required number of formulary alternatives for the given diagnosis due to an intolerance or contraindication, or the patient has tried and failed the required number of formulary alternatives. The formulary alternatives are amphetamine-dextroamphetamine mixed salts extended-release, dexmethylphenidate extended-release, dextroamphetamine extended-release, methylphenidate extended-release, and Azstarys. The requirement is 3 in a class with 3 or more alternatives, 2 in a class with 2 alternatives, or 1 in a class 1 alternative. This patient has a physician letter noting that three formulary alternatives have been used: amphetamine-dextroamphetamine mixed salts extended-release, dextroamphetamine extended-release, and Azstarys. These formulary drugs have not been effective for the patient, and there is documented behavioral agitation and headaches that were side effects caused by these medications. The medication requested, Adderall XR, has been tried in this patient and has been shown to more effective for this patient with no side effects, better efficacy, and more effective than the other formulary medications. Therefore, given the above, the health plan should cover the formulary exception for Adderall XR.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck and arm pain with numbness
Treatment: Procedure to fuse together bones in the neck (vertebral bones)
The insurer denied coverage for procedure to fuse together bones in the neck (vertebral bones).
The denial is upheld.

The patient reports neck and arm pain with numbness, tingling, and weakness. Non-operative management has included physical therapy (PT) and non-steroidal anti-inflammatory drugs (NSAIDs). The request is for preservice procedure to fuse together bones in the neck (vertebral bones); cervical (C) 4-C5/C5-C6 anterior cervical discectomy and fusion (ACDF). 

According to Iyer, S., & Kim, H. J. (2016), "Cervical radiculopathy is a common clinical scenario and typically presents with unilateral neck pain, arm pain, or both. Patients may also present with neurologic signs such as sensory or motor deficits. It is important to differentiate cervical radiculopathy from other items on the differential diagnosis including peripheral nerve entrapment syndromes and shoulder pathology. Most cases of cervical radiculopathy are self-limited and may be managed conservatively in the absence of progressive neurologic symptoms or other concerning symptoms such as osseous lesions, etc. There are several options for conservative management, but there is little evidence to suggest that any of these interventions substantially alter the natural history of the disease. While exact surgical indications have not yet been elucidated, surgery may be considered in patients that have not responded to conservative management at about 6 months." 

"Neck and upper extremity pain can be successfully treated conservatively. In those cases, when surgical intervention is pursued, patients with shorter duration of symptoms (DOS) have better improvement in radiculopathy symptoms that is statistically significant." (Burneikien, S., et al, 2015)

For patients with cervical spondylotic myelopathy with concomitant myelomalacia, anterior cervical discectomy and fusion would be medically necessary. "ACDF leads to significantly improved outcomes for all primary diagnoses and was sustained for > [greater than] 10 years' follow-up." (Buttermann G. R., 2018). However, this patient does not have evidence of myelopathy or myelomalacia. Therefore, the requested procedure to fuse together bones in the neck (vertebral bones) is not considered 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 preservice procedure to fuse together bones in the neck (vertebral bones) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a female who presented to the hospital with complaints of generalized abdominal pain. She reported having six episodes of vomiting during her visit to the emergency room, where acute appendicitis was suspected. Subsequently, the patient was transferred for further evaluation.
A computed tomography (CT) scan of the abdomen and pelvis revealed mild thickening of the colon wall, possibly due to underdistention. The appendix measured up to 8.7 millimeter (mm) with enhanced wall, raising suspicion of acute appendicitis, either primary or secondary to inflammatory changes in the colon.

The inpatient hospital stay was not medically necessary for this patient.
The patient's abdominal pain was not associated with hemodynamic instability or peritoneal signs. There was no evidence that the abdominal pain was severe enough to justify admission for pain control, which would require admission at the acute inpatient level of care.
There was no evidence that the abdominal pain was the result of serious medical conditions such as aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, or intestinal obstruction. There was no mention that the abdominal pain was associated with bacteremia or toxic megacolon. The evaluation of the abdominal pain did not require the patient not to eat or drink for an extended period. There was no need for surgical intervention or administration of intravenous antibiotics beyond the observation period. Therefore, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 Braces

The insurer denied coverage for D8080 Braces. The denial is upheld. 

Upon review of the submitted documentation, including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, and insurer correspondence, this patient was evaluated for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements, attaining 11 points on the HLD index by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess the severity of the malocclusion and, therefore, medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual 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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, severe or otherwise, and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet the insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labio-Lingual Index, it has been shown through scientific scrutiny in peer-reviewed journals that this methodology for assessing orthodontic needs is valid. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, it has been determined to represent an appropriate approach for assessing orthodontic needs.

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

The medical necessity for D8080 Braces is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion
Treatment: D8080 comprehensive orthodontic treatment of 
the adolescent dentition; D8670 - periodic orthodontic treatment visit x 12
The insurer denied: D8080 comprehensive orthodontic treatment of the adolescent dentition; D8670 - periodic orthodontic treatment visit x 12
The denial is overturned.

The patient is an adolescent male requesting orthodontic benefits and monthly (periodic) visits. He has a Class II malocclusion with severe overjet and moderate upper and lower crowding. Prior denial was due to handicapping index score of 23 points.

The requested health service is medically necessary.

The patient has a deep, impinging overbite with soft tissue damage on the palate. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this. The monthly visits are necessary to make sure the treatment progresses properly. This case is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lupus
Treatment: Saphnelo
The insurer denied Saphnelo
The health plan's determination is overturned. 

The patient is a woman with a history of lupus. The issue in this case is that Saphnelo is being denied by the health plan. Prior treatment (tx) has included plaquenil, prednisone, cytoxan, imuran, cellcept, methotrexate (MTX), rituxan and benlysta. Per a note, the patient has fatigue at present but typical manifestations of lupus are fatigue, joint pain, myalgias, Raynaud's, dizziness, photosensitivity, skin changes, inflammatory bowel disease (IBD) and aphthous ulcers. Also, per this note, she has had pericarditis and alopecia as well in the past.

Saphnelo is necessary for this patient. As previously stated, the patient has lupus and has tried all other therapies, including plaquenil, prednisone, cytoxan, imuran, cellcept, MTX, rituxan and benlysta. At this point, it is reasonable to undergo a trial of Saphnelo, which is interferon receptor antagonist, approved for the treatment of lupus.
A study published in Ann Rheum Dis 2022 concluded that 'overall, this study supports the consistent efficacy and safety of anifrolumab across a range of patients with moderate-to-severe systemic lupus erythematosus (SLE). In a few subgroups, small sample sizes limited conclusions from being drawn regarding the treatment benefit with anifrolumab'.
Another study published in N Engl J Med in 2020 concluded that 'monthly administration of anifrolumab resulted in a higher percentage of patients with a response (as defined by a composite end point) at week 52 than did placebo, in contrast to the findings of a similar phase 3 trial involving patients with SLE that had a different primary end point. The frequency of herpes zoster was higher with anifrolumab than with placebo'.
Finally, a study published in Arthritis Rheumatol in 2017 concluded that 'anifrolumab substantially reduced disease activity compared with placebo across multiple clinical end points in the patients with moderate-to-severe SLE'.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: thyroglossal duct cyst 
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a woman with a history of total nephrectomy who was diagnosed with a midline neck mass consistent with a thyroglossal duct cyst based on magnetic resonance imaging (MRI) imaging. She underwent thyroglossal duct cyst excision and was subsequently admitted to the hospital for intravenous antibiotic therapy, surgical drain/care management and for pain control. 

The inpatient hospital admission was medically necessary. 
The Standard of care for midline neck mass/thyroglossal duct cyst includes post operative admission for intravenous antibiotic administration, surgical drain management, intravenous hydration, and pain control. This cannot be safely performed in an alternative setting that meets a safe standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned



Diagnosis: alopecia areata

Treatment: Xeljanz 5 milligram (mg) Tablet (procedure code J8499)

The insurer denied coverage for Xeljanz 5 milligram (mg) Tablet (procedure code J8499)

The denial is overturned.

The patient is a child diagnosed with severe alopecia areata (AA), which developed after a viral infection. The patient has tried and failed treatment with topical, intralesional and systemic steroids, and oral minoxidil. The treating provider is requesting approval of Xeljanz five (5) milligram (mg) oral tablet, which is currently under review.

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes with Xeljanz.

Current medical literature shows positive treatment responses from Xeljanz, as well as other medications in the Janus kinase (JAK) inhibitor class.      

Xeljanz five (5) milligram (mg) oral tablet (procedure code J8499) does not have final approval from the appropriate regulatory bodies for this diagnosis.     

The patient is a good candidate for Xeljanz five (5) milligram (mg) oral tablet (procedure code J8499) as there are currently no Food and Drug Administration (FDA) approved treatments for pediatric patients with a diagnosis of alopecia areata (AA).  

There is current medical literature that demonstrates the safety and efficacy of using oral Xeljanz (tofacitinib) for the treatment of pediatric patients with severe alopecia areata.     

Xeljanz five (5) milligram (mg) oral tablet is the best available treatment for this patient at this time as the patient has tried and failed several treatment options.  

Xeljanz has been shown to be safe and effective in treating this patient's condition and there are no current FDA approved alternatives for pediatric patients.     
  
There are no adverse risks increased over standard treatment/services. 

The patient has tried and failed what have been considered as standard treatments. These standard treatments have been historically disappointing as far as their ability to adequately treat this difficult autoimmune disease. 

Xeljanz has demonstrated a greater efficacy than the standard treatments with demonstrated safety as it's use has been evaluated in other pediatric medical conditions.  

As such, the request for Xeljanz is approved in this patient's case, and the denial should be overturned.

Current medical literature supports Janus kinase (JAK) inhibitors, such as Xeljanz, in the treatment of pediatric severe alopecia areata (AA). 

In summary, the denial of Xeljanz 5 mg Tablet (procedure code J8499) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned



Diagnosis: alopecia areata

Treatment: Xeljanz 5 milligram (mg) Tablet (procedure code J8499)

The insurer denied coverage for Xeljanz 5 milligram (mg) Tablet (procedure code J8499)

The denial is upheld.

The patient is a child diagnosed with alopecia areata (AA). The patient originally contracted COVID, and has been struggling with hair loss since. The patient has tried and failed topical and internal steroids, minoxidil, and scalp injections. Prednisone has been helpful for short periods; however, it has caused behavioral issues at school and at home. The treating provider is requesting approval of Xeljanz five (5) milligram (mg) oral tablet, which is currently under review.

Scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes for Xeljanz.

Any time a patient with alopecia areata regrows hair there is an improvement in health outcome, but the drug was denied due to being used for a non Food and Drug Administration (FDA) approved indication, and there are drugs in the same class with the FDA approved indication.      

Xeljanz five (5) milligram (mg) oral tablet (procedure code J8499) does not have final approval from the appropriate regulatory bodies for this diagnosis.     

The patient is a good candidate for a Janus kinase (JAK) inhibitor for alopecia areata (AA), however, there are two (2) others medications, Litfulo and Olumiant, that have the FDA indication, and have not been trialed yet.     

Xeljanz five (5) milligram (mg) oral tablet (procedure code J8499) is not the best available treatment for this patient at this time.

Litfulo and Olumiant are FDA approved for treating AA, therefore, these treatments would be more appropriate for this patient's condition.     
  
There are more adverse risks associated with oral JAK inhibitors such as Xeljanz.

As such, the request for Xeljanz five (5) milligram (mg) oral tablet is not appropriate in this patient's case, and the denial should be upheld.

Litfulo or Olumiant would be more beneficial than standard treatments, as a Janus kinase (JAK) inhibitor such as Xeljanz is not FDA approved for this condition, and has more potential risks associated with its use. 

In summary, the denial of Xeljanz 5 mg Tablet (procedure code J8499) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are potentially  increased over standard treatments.