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

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: deep bite
Treatment: Periodic Monthly Visit (x12) and Orthodontic Retention (Removal of Braces of upper and Lower Arch)
The insurer denied Periodic Monthly Visit (x12) and Orthodontic Retention (Removal of Braces of upper and Lower Arch). The health plan's determination is overturned. 

The patient in question is a male who has a deep bite and is class II. Under review is the medical necessity of Periodic Monthly Visit (x12) and Orthodontic Retention (Removal of Braces of upper and Lower Arch). 

The Periodic Monthly Visit (x12) and Orthodontic Retention (Removal of Braces of upper and Lower Arch) is medically necessary for this patient.
The patient has a deep bite and is class II. Both of these are risk factors for tooth wear. Tooth wear can lead to the need for restorations due to damage to the teeth. Treatment was initiated to correct this. Treatment has not been finished. The bite is still deep, and the patient is still Class II. 
It is medically necessary to complete the orthodontic treatment that has already been started. There are many risks to going an extended period of time with braces, including root resorption, tooth decay, and periodontal inflammation. This treatment needs to be completed so the requested health services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems. 
Dental/Orthodontic Procedure. 

Diagnosis: Skeletal Class I malocclusion and significant crowding. 
Treatment: Braces/monthly visits. 

The insurer denied Braces and Monthly Visit (x4). The health plan's determination is overturned. 

The patient in question is female with impacted teeth #6 and #11. Neither of these teeth have enough room to erupt. Tooth 27 is displaced labially and has recession. She presents with a skeletal Class I malocclusion and significant crowding. She is treatment planned for orthodontic treatment to address the crowding and impacted teeth. 

Braces and Monthly Visit (x4) are medically necessary for this patient. The patient has impacted teeth #6 and #11. Neither of these teeth have enough room to erupt. Tooth 27 is displaced labially and has recession. She has a skeletal Class I malocclusion and significant crowding. If left untreated, the damage that will likely occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Tremfya 100MG/ML PEN.
The insurer denied the Tremfya 100MG/ML PEN. The determination is upheld.

The patient has moderate to severe psoriasis (10-15% body surface area involvement). The patient has tried and failed topical betamethasone and Clobetasol. Swollen joints and possible psoriatic arthritis are reported. The patient recently stopped breast-feeding, according to a clinic note. The patient and her dermatologist wish to start the patient on topical tacrolimus and the biologic agent Tremfya. At issue is the medical necessity of Tremfya.

Tremfya is not medically necessary. The patient is no longer breast-feeding, so that oral methotrexate and phototherapy, which are time-tested first-line systemic therapies that are appropriate for this patient's particular clinical scenario. Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Tremfya, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario.
Therefore, consistent with current medical literature [1-4] and standards of care, the requested Tremfya is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Skin
Inpatient hospital

Diagnosis: decubitus ulcer 
Treatment: Alternate Level of Care Admission 
The insurer denied the Alternate Level of Care Admission. 
The health plan's determination is overturned.

The patient is a female with multiple past medical problems. She was admitted to skilled services. The patient was being treated with rehabilitation services along with treatment for decubitus ulcer in sacral region. She had an anticipated discharge; however, the discharge was held secondary to not having disposition plans in regard for home services. She had functional issues and was not able to care for herself.

The Alternate Level of Care Admission is medically necessary for this patient.  It is clear from the information provided that the patient requires custodial services. There were several notes stating that the patient is medically stable to be discharged but cannot be discharged because of social/custodial reasons. The patient lacks family and other supportive measures and is not able to function independently on her own.
She was initially admitted to the nursing home and had a planned discharge. Treatment was mainly for her underlying medical conditions, physical therapy and rehabilitation along with treatment of a sacral decubitus ulcer. Her ulcer persisted but was improved.
The chart states that the patient has plateaued in her physical rehabilitation however requires assistance with transportation and all activities of daily living (ADL). Therefore, it is reasonable to say that at this time, her care would be considered custodial nature. As the patient's care is considered custodial, is not able to function on her own, and requires assistance with all ADLs. the alternate care admission on the days in question was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Mental Health-High risk Suicide.
Treatment:  Inpatient hospital stay.

The health plan denied the inpatient admission as not medically necessary.  The reviewer has overturned in whole the health plan determination.

The patient presented to the emergency department with a history of hypertension, depression, suicidal ideation, multiple psychiatric admissions, and hypothyroidism.  The patient presented after a suspected overdose and had taken trazodone and clonazepam.  Family members came to the home and found the patient to have slurred speech and altered mental status.  The patient denied fevers, chills, chest pain, shortness of breath, nausea, and vomiting.  Vital signs showed blood pressure 156/95 temperature 36.8 Celsius oxygen saturation 97% heart rate 84.  On physical exam, heart was regular, breath sounds were normal, cranial nerves were intact, and the abdomen was soft and nontender.  An electrocardiogram showed a prolonged QT interval and a right bundle branch block.  Labs showed a white blood cell count 15 potassium 3.8 troponin 0.32 lactate 2.7 alanine aminotransferase 27 aspartate aminotransferase 56.  Head computed tomography scan was negative for acute stroke.  Chest x-ray was negative for pneumonia.  QT interval was 520.  The patient was admitted for suspected drug overdose with prolonged QT interval.  The plan of care included telemetry, psychiatry consult, monitor QT interval, cardiac enzymes, intravenous  fluids, simvastatin, aspirin, and continue other home medications.  The New York Poison Control Center was also contacted and had no additional suggestions.  Psychiatry saw the patient, and their assessment was that the patient should remain on 1:1 observation, due to concerns for repeat suicidality.  The patient's creatinine kinase was also initially elevated to approximately 2000 and there was concern for rhabdomyolysis. It subsequently trended downward to 1080 and was subsequently medically cleared for discharge to inpatient psychiatry.

The requested health service/treatment of Inpatient hospital admission was medically necessary.  The patient presented with a suicide attempt, was assessed early by psychiatry and was thought to pose a persistent suicide risk, and had medical complications including low-grade rhabdomyolysis, elevated troponin, and prolonged QT interval.  The electrocardiogram abnormalities increased the patient's risk for ventricular tachycardia/unstable cardiac arrhythmia, and the low-grade rhabdomyolysis increased the risk of acute kidney injury, which could decrease excretion of QT prolonging medications associated with the overdose.  The care the patient received was medically necessary.  The patient was at increased risk of repeat suicide attempt, unstable cardiac arrhythmia, cardiac ischemia, and acute kidney injury from rhabdomyolysis.  Elevated troponin is often seen in the setting of rhabdomyolysis, but cardiac ischemia was a consideration during  presentation.  Because of the intensity of care required to safely manage this patient, it was appropriate to manage the patient at the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Other-Crowns/Veneer
Treatment: Dental/Orthodontic Procedures
The health plan denied the requested health service of crowns and labial veneer as not medically necessary for the patient. 
The reviewer has upheld the determination in whole.

The patient  presented to the office of the dental provider for evaluation and treatment of teeth #5,6,7,10,11,12,22,23,24,25,26,27. Provided for review are patient medical history intake forms, results of genetic testing and a narrative of the genetic counselor, facial photos, full mouth radiographic images, four pages of American Dental Association (ADA) claim forms, clinical notes, narratives from prosthodontists, and a narrative from the primary care MD. From the provided documentation the patient has congenitally missing tooth #10 as well as peg lateral incisors and pointed canine teeth. There is no evidence of decay from any of the provided images nor from the notes.

Based on the provided documentation, the requested service of crowns for teeth #5, 6, 12 and labial veneer for tooth #7 are not medically necessary for this patient.
As there is no decay and as the teeth were healthy enough periodontally and structurally to undergo orthodontic therapy, they are functional and do provide for mastication. There is no documentation of limitation in any other capacity for the teeth in question. Based upon the standard of care, there is no requirement to crown teeth based upon their appearance. The teeth in question do not have decay nor any structural issues that are affecting their structure and function. The teeth do not require any therapy, and the therapy in question, is completely elective in nature. There is no medical necessity to manage the appearance of the teeth through veneers or crowns.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Desmoid Tumors. 
Treatment: Percutaneous Cryoablation. 

The health plan denied the requested cryoablation. 
The health plan's determination is overturned. 

The patient is a male. By magnetic resonance imaging (MRI) scan the patient has extensive tumors of the anterior abdominal wall/bilateral recti abdominal muscles. He has failed steroid injections. The patient was experiencing pain. It does not appear that systemic therapy options were considered or tried according to the files submitted for review. 

The health plan's determination regarding the proposed health service or treatment is overturned, in whole. 

Yes, the proposed treatment is likely to be more beneficial than any standard treatment or treatments for the patient's condition. Surgery or ablation procedures (including cryotherapy) are acceptable treatments for symptomatic or progressing desmoid tumors, according to National Comprehensive Cancer Network (NCCN) guidelines. 

There is no comparative data available in the literature comparing the various standard of care options. However, for this patient, surgery is deemed too morbid and therefore ablation or radiation therapy or systemic therapies are all options per the National Comprehensive Cancer Network (NCCN) Sarcoma version 2.2020 DESM-4, which includes Desmoid tumors. Ablation is a very reasonable first option, given the extent of the patient's problem and the pain it is causing. Other options generally take much longer to get a response.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Desmoid Tumors. 
Treatment: Percutaneous Cryoablation. 

The health plan denied the requested cryoablation. 
The health plan's determination is overturned. 

This patient is a male with a history of recurrent abdominal wall desmoid tumors. These are symptomatic but small. He also has a history of a magnetic resonance imaging (MRI) noting several abdominal wall tumors consistent with desmoids, smaller post-treatment and with no new lesions noted. 

A computed tomography (CT) guided biopsy was actually the CT and ultrasound (US) guided cryoablation procedure of the 4 separate abdominal wall lesions. Past medical and surgical history was reviewed. Pertinent past medical records note previous steroid injection into the desmoid tumors. The current treatment plan is completed, in that the image guided cryoablation procedure was performed of several abdominal lesions. 

The health plan's determination regarding the proposed health service/treatment is overturned. 

Yes, the proposed health service/treatment procedure, that uses energy to destroy a small area of tissue in the body, is likely to be more beneficial than any so-called standard treatment or treatments, for the insured's life threatening or disabling condition or disease, desmoid tumors of the abdomen. 

While cryoablation for renal tumors is effective and covered in the policy, desmoid tumor ablation is not addressed specifically. Cryoablation is also used for other non-renal tumor ablations and is considered medically proven as effective in those treatment locations. There is often failed surgical resection of these, with high recurrence rate. Radiation therapy is possible, but also has risk of recurrence. Chemotherapy can also be used. There are few other therapies. Desmoid tumors are best suited for cryoablation over other heat-based technology energy ablations, such as radiofrequency. This patient's desmoid tumors required targeted image guided, minimally invasive therapy, as provided. This should be a covered procedure for this particular patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple sclerosis

Treatment: Continued rehabilitation stay

The insurer denied coverage for the continued rehabilitation stay.

The denial is upheld. 

This is a female with a diagnosis of multiple sclerosis. The patient was admitted to the hospital for progressive upper and lower extremity weakness. The patient was also diagnosed with urinary tract infection (UTI) for which she was treated with antibiotics. The patient was admitted to an acute inpatient rehabilitation unit on day 11 of admission to the hospital. Currently under review is the medical necessity for the continued rehabilitation stay from day 6 to day 15 of admission to the acute inpatient rehabilitation unit. 

The patient initially showed a level of medical acuity and rehabilitation intensity to support her inpatient rehabilitation admission on day 11 of admission to the hospital.  However, subsequent treatment notes document only limited improvement and they do not support the continued inpatient rehabilitation stay from day 6 to day 15 of admission to the acute inpatient rehabilitation unit.  According to the occupational therapy notes, the patient's functional status upon discharge was much the same as the initial evaluation on day 2 of admission to the acute inpatient rehabilitation unit. The patient initially required essentially maximal assistance for activities such as bed mobility, lower body dressing and toileting. The patient's toilet transfers had improved to minimal assistance; however, she remained otherwise (maximally) functionally dependent. A similar lack of improvement was documented by the patient's physical therapist. The patient required maximal assistance for bed/mat mobility and she remained a non-functional ambulatory status. There were also no acute medical or complex nursing issues that warranted this patient's continued acute inpatient rehabilitation for the time period under review.  

From a physical medicine and rehabilitation/pain management perspective, as well as, within a reasonable degree of medical certainty, the clinical records do not support the medical necessity for the continued inpatient rehabilitation stay from day 6 to day 15 of admission to the acute inpatient rehabilitation unit. The healthcare plan acted reasonably with sound medical judgment, and in the best interest of the patient. (Taken under consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).

Based on the above, the medical necessity for the continued rehabilitation stay is not substantiated. The insurer's denial should be upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Digestive system/Gastrointestinal.
Treatment:  Prescription Drugs/Pharmacy (Xeljanz).

The insurer denied the prescription drug Xeljanz.  The denial was upheld in whole.

The health plan denied the formulary exception for Xeljanz, as it does meet the criteria.  The reviewer has upheld in whole the health plan denial.

This patient has a history of ulcerative colitis, which has been refractory to therapy with Remicade.  The patient is steroid dependent and has most recently been treated with Entyvio and now Xeljanz.  According to the documentation submitted for review, the patient has been receiving Xeljanz through samples and/or the manufacturer.  The provider seeks approval of treatment with Xeljanz.

The formulary drug, Humira, has not been ineffective for this patient.  There is no indication that it would not be as effective as Xeljanz.  The formulary drug Humira has not been shown to be less effective in terms of safety and efficacy compared to the non-formulary drug, Xeljanz, based on a lack of well-designed randomized controlled trials in reviewing the current peer reviewed medical literature.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines. 
Treatment: Aimovig. 

The insurer has denied a formulary exception for the drug Aimovig.  The health plan's determination is upheld. 

The patient is a woman with chronic migraines.  Treatment with Aimovig is being requested. Office notes indicate that the patient has tried and failed a beta-blocker (drug name not provided).  The note also questions that the patient has tried topiramate (documented as "?topiramate?").  Under review is the use of a non-formulary drug (Aimovig).

A formulary exception is not indicated. 

There is no indication that the available formulary agents will be or have been ineffective.  The plan alternatives including topiramate, divalproex, and propranolol.  There is no documentation that the patient has tried and failed any of these medications.  These agents are considered first-line for prevention of migraine.  It is noted that the patient has tried and failed a beta-blocker, but propranolol is not specifically documented, and it is the preferred beta-blocker, as it has the best penetration of the blood-brain barrier.  Additionally, it is unclear as to whether the patient has tried and failed topiramate.  In clinical trials, the first-line oral agents, such as topiramate, divalproex, and propranolol, generally result in an approximate 50% decrease in migraine frequency, which is similar to Aimovig.  The drugs have never been compared head to head with Aimovig.  The use of Aimovig in this case is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Pharmacy/Prescription Drugs

Diagnosis:  chronic obstructive pulmonary disease (COPD)
Treatment: Trelegy Ellipta 
The insurer denied Trelegy Ellipta. The health plan's determination is upheld. 

This is the case of a female patient who suffers from chronic obstructive pulmonary disease (COPD). The treating provider is requesting the coverage of Trelegy Ellipta (fluticasone furoate, umeclidinium and vilanterol). The patient was tried in the past on Advair and Incruse, Breo and Incruse and Symbicort. The patient's pulmonary function test (PFT) showed reduced FEV1 (forced expiratory volume in one second) down to 51%. The patient's chest x-ray (CXR) was consistent with COPD.

The use of Trelegy Ellipta (fluticasone furoate, umeclidinium & vilanterol) is not medically necessary for this patient
This patient suffers from COPD. There is no convincing or objective evidence in the submitted documents that the patient has contraindication to or a potential drug interaction with formulary alternatives (combination of anoro and arnuity). There is no evidence that the patient is intolerant to or has had a confirmed adverse event with formulary alternatives (combination of anoro and arnuity). There is no evidence that the patient has demonstrated an inadequate treatment response after a trial of formulary alternatives (combination of anoro and arnuity).
There are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long term efficacy and safety of Trelegy over preferred formulary (such as combination of anoro and arnuity) for the treatment of this patient's medical condition. There is no high-quality literature showing an improvement in health outcomes with the use of Trelegy over preferred formulary (combination of anoro and arnuity) for this patient condition.