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

Diagnosis: Central Nervous System/Neuromuscular Disorder-Migraine.
Treatment: Pharmacy/Prescription Drugs-Emgality.
The health plan denied the non-formulary drug Emgality  as not meeting the Non-Formulary Marketplace exception Criteria. 
The reviewer has upheld in whole the health plan determination.

This is a patient with a history of chronic migraine. Previous preventive medications prior to Emgality were propranolol, magnesium, venlafaxine, and duloxetine. The neurological examination was normal according to the provider's notes. The patient's neurologist has recommended continued Emgality.
A  letter of medical necessity from the neurologist indicates that the patient has a history of chronic migraine and has been tried on a variety of abortive and preventive medications for migraine, including propranolol, magnesium, venlafaxine, and duloxetine, Emgality, Imitrex, and Maxalt. The patient had improvement in  migraines after starting Emgality with a reduction of 50% in frequency and severity.
According to the prior authorization requirement, there must be a trial and failure of three or more covered alternatives, two alternatives if there are two alternatives and one alternative if there is only one covered alternative.
There is no evidence that the formulary drugs would not be as effective as the non-formulary drug, Emgality. While all medications have adverse effects, there is no evidence that the adverse effect profile of Emgality is superior to that of either formulary drug, divalproex or topiramate.
Evidence-based migraine prophylactic medications that have been tried were propranolol and venlafaxine. The other medications documented are not evidence-based via randomized controlled trials as migraine prophylactic agents (magnesium, duloxetine). Other medications utilized are abortive agents (Imitrex, Maxalt). There was no documented contraindication to the formulary medications divalproex, amitriptyline or topiramate. There was no documentation why the patient could not try a medication from the anticonvulsant class.
The patient has had trials and failures of two formulary drugs with class 1/2 evidence of efficacy and migraine prophylaxis (propranolol and venlafaxine). The patient cannot take another medication from the antidepressant class, as the patient is  already on Trintellix. There was no documented contraindication to medications in the antiepileptic class (topiramate or divalproex.) There is no evidence in the peer-reviewed medical literature that Emgality is superior to either topiramate or divalproex.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders
Pharmacy/Prescription Drugs

Diagnosis: psoriasis
Treatment: Taltz
The insurer denied Taltz. 
The health plan's determination is upheld. 

The patient is a male with moderate to severe psoriasis, as well as a history of undetectable human immunodeficiency virus (HIV). The patient is on Taltz. Photographic documentation of his latest status is provided. The patient has been on samples. The patient has no reported joint pain, but has a history of psoriatic arthritis. The patient has tried and failed ultraviolet B (UVB) light therapy, oral methotrexate and acitretin, as well as the biologic treatments Enbrel, Humira, Tremfya, and Simponi.
Health plan coverage of Taltz 80mg/mL Every 2 Weeks every two weeks is under review for medical necessity.

The photographic documentation does not reveal any significant psoriasis, and the patient's skin condition appears to remain controlled. No joint pains are reported. The current medical literature supports every two week dosing of Taltz only when it is at a loading dose early in the treatment course with that biologic medication. This patient does not appear to be in a flare to the extent that a reconsideration of Taltz dosed every two weeks is medically necessary.
The patient is concerned that a flare might occur with the monthly dosing of 80 mg, which is normally used as a standard maintenance dosing of Taltz. However, the clinical documentation shows no such flaring to support the patient's concerns. Taltz dosing every two weeks is only medically necessary for a flare of the patient's skin or joint lesions. In this patient's case, there appears to be neither. Therefore, a return to the Taltz dosing every two weeks is not medically necessary for this patient at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Pharmacy/Prescription Drugs. 
The health plan denied Gamunex-C. 
The health plan's determination is upheld in whole.

The patient is a female with multiple sclerosis (MS). Treatment has included Copaxone and Lemtrada. According to a letter provided by the patient's neurologist, the patient she has been treated with intravenous immunoglobulin (IVIG) for the past one year since the birth of her son. The patient is currently breastfeeding and trying to conceive. The subject under review is the medical necessity for the Gamunex-C.

The health plan's determination is upheld in whole.

The requested treatment of injectable Gamunex-C is not medically necessary for this patient. Per Bayry et al. (2015): "Despite promising clinical trials, intravenous immunoglobulin (IVIg) therapy in relapsing-remitting multiple sclerosis (MS) has met with uncertainties that might be attributed to small patient cohorts, heterogeneity in the patients, dose of IVIg, or the duration and window of treatment."

Per Rae-Grant et al. (2018): "There is insufficient evidence to determine the efficacy of the following disease modifying therapies (DMTs) compared with placebo in reducing the risk of disability progression in people with relapsing-remitting multiple sclerosis (RRMS) (very low confidence): azathioprine, immunoglobulins, IFN--1b subcutaneous alternate day, and methotrexate."

There is insufficient evidence in the current published peer-reviewed medical literature to conclude that intravenous immune globulin (IVIG) is safe and effective for the treatment of MS (multiple sclerosis). IVIG is not medically necessary for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthodontic Needs (Malocclusion). 
Treatment: Braces and Monthly Visits x12. 
The health plan denied the requested dental procedure. 
The health plan's determination is upheld. 

The patient is a female with a Class I occlusion with appropriate overbite and overjet. She has minor maxillary and mandibular spacing. Her treatment is planned for 18-24 months of orthodontics to correct her malocclusion, but her insurance company rejected the claim on the basis that treatment is not medically necessary. The provider appealed stating the reviewer did not take into account the patient's slightly excessive overjet. 

At issue is the medical necessity of the requested treatment. 

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

The patient has minor spacing. Her overbite is appropriate and there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is any soft tissue damage on this patient. 

There is no medical reason to correct her malocclusion with braces. While the patient has slightly spaced teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. [1] This patient presents with none of those conditions. Closing her spaces will not improve her masticatory efficiency since it is highest in patients with a Class I occlusion. [2] In reference to the providers comment about her "slightly excessive overjet": The patient has an appropriate overjet but even if it was "slightly excessive" it would not affect oral health related quality of life unless it was greater than 6mm. [3] If her teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post root canal
Treatment: Crown-porcelain fused to high noble metal for tooth #18.
The insurer denied the Crown-porcelain fused to high noble metal for tooth #18.
The denial is overturned.

The patient is a female requesting benefits for a crown on tooth #18. 

Yes, a crown for tooth #18 is medically necessary. 

The patient's tooth (#18) has had root canal treatment. Due to the removal of tooth structure to do the root canal procedure, the tooth is weak and prone to fracturing. The tooth needs to have a crown placed to prevent this from happening. The crown is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right axillary discomfort, increasing size of
abscess
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female whose inpatient admission is under review. The patient presented with a two-week history of right armpit discomfort. There had been an increase in size. No fever, chills, nausea, or vomiting were reported. There was no drainage from the site.

In the Emergency Room, vital signs were as follows: temperature 98.9, pulse 89, respiratory rate 17, blood pressure 119/59, and oxygen saturation 100%. Exam showed the following:
General: No abnormality detected.
Chest: Normal.
Cardiovascular: Normal.
Abdominal: Normal.
Skin: Erythema and fullness and induration of the right axilla (4.0 x 8.0 centimeters), no drainage.

Laboratory studies revealed the following: white blood cell (WBC) count 16.84 (high), hemoglobin 10.5 (low), platelets 393, sodium (Na) 136, potassium (K) 3.9, chloride (Cl) 101, carbon dioxide (CO2) 24, blood urea nitrogen (BUN) 6, and creatinine (Cr) 0.4.

Computed tomography (CT) of the chest showed a 6.1 x 2.5 centimeter abscess of the right axilla. In the Emergency Room, the patient was thought to have a right-sided axillary abscess. She was started on intravenous (IV) clindamycin. Surgery was performed to drain the abscess and the patient was discharged on oral antibiotics shortly afterwards.

Yes, the proposed inpatient admission was medically necessary. 

The patient met the initial criteria for intravenous (IV) treatment and admission for cellulitis/abscess set forth by the Infectious Diseases Society of America (1), as she had systemic signs of infection as evidenced by an elevated white blood cell (WBC) count.  Thus, this admission was warranted as supported by standard of care. Failure to admit such as a patient can lead to loss of function, sepsis, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental problems (maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss)

Treatment: D8080 braces

The insurer denied coverage for D8080 braces.

The denial is overturned.

This is a male child who has anterior cross bite with gingival attachment loss mandibular right canine.  He presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 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 a score of 23 points on the HLD index where 26 points is required. 

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, the HLD index is utilized. 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is clearly met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.
 
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for D8080 braces is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiac/Circulatory Problems. 
Treatment:  Home Health Care (180 hours of home health aide services). 

The insurer denied 180 hours of home health aide services.  The health plan's determination is overturned in whole.

This is the case of a male with medical history of heterotaxy, developmental delay, anomaly of the larynx and epiglottis, atrial septal defect (ASD) with single atrium, anomalous atrioventricular (AV) excitation with 1st degree AV block, advanced bone age, vitamin D deficiency, hoarseness, seasonal allergies, and mild intermittent asthma.  He has a history of choking with eating due to his abnormal anatomy.

Per medical documentation provided, home medications include oral iron tablets, acetaminophen liquid as needed, albuterol nebulizer as needed, and loratadine oral tablet as needed.  He is on a pureed diet and working on solid food intake.  The patient receives speech therapy once weekly, which includes oral motor and swallowing therapies.  Per nursing recertification note, the patient is ambulatory independently, able to communicate needs verbally, reads and writes, and is continent of bowel and bladder.  

The requested service is 180 hours of home health aide services.  Specifically, his physician notes safety issues related to choking concerns.  At issue is whether this level of support is medically necessary.  Claim was previously denied due to being deemed custodial in nature.

The health plan's determination is overturned in whole.

Yes, the requested service of 180 hours of home health aide services is medically necessary.

This is a patient with developmental delays and physical anomalies that make feeding difficult.  He received speech and occupational therapy (OT) services for these deficits and is progressing, yet still requires some dietary modifications and close monitoring during eating.

Based on this child's health diagnoses and condition, HHA services is medically necessary.  This child has anatomical differences that make him susceptible to choking episodes.  He is on a special consistency diet and is receiving professional therapies to advance the diet to learn to safely chew and swallow solid foods.  

The requested service of home health aide 180 hours is considered medically necessary for this patient based on the medical documentation provided.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Essential tremor.
Treatment:  MRI (Magnetic Resonance Imaging) Guided Ablation Surgery (0398T).

The insurer denied the MRI (Magnetic Resonance Imaging) Guided Ablation Surgery (0398T).  The denial is overturned.

The patient is a male with history of essential tremor (ET).  The patient has tried and
failed all the appropriate medications.  The patient has severe disability associated with the tremor.  The patient was recommended MR (magnetic resonance) guided focused ultrasound for essential tremor.

Yes, the health plan should cover the MRI Guided Ablation Surgery (0398T).

The MRI guided ablation surgery (0398T) has been shown to be an effective treatment and is within the standard of care.  This is Food and Drug Administration (FDA)-approved treatment, has been supported by the major societies, and has been shown to be effective for the treatment of essential tremor.  This is within the standard of care and is considered medically appropriate.  Therefore, it should be approved.

Yes, the MRI guided ablation surgery (0398T) is likely to be more beneficial.  MRI guided ablation surgery (0398T) has been shown to be effective for essential tremor and is supported by the major societies and the literature.  The patient meets the major criteria for this, specifically confirmed essential tremor, medically refractory essential tremor, and appendicular tremors.  Therefore, it is considered within the standard of care and medically appropriate for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atrial tachycardia.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented to the hospital for a scheduled catheter ablation for left atrial tachycardia.  His medical history was remarkable for two prior ablations for atrial fibrillation and flutter, hyperlipidemia, diabetes, coronary artery disease and heart failure with reduced ejection fraction (15%).  Atrial tachycardia ablation was performed by the delivery of radiofrequency energy to the roof of the left atrium.  Testing showed that the right inferior pulmonary vein was not electrically isolated, and ablations were performed to re-isolate it.  The procedure was uncomplicated.  The patient was admitted to the hospital post-procedure and discharged the following day.  At issue is the medical necessity of an inpatient admission.

An inpatient level of care was not medically necessary.

This patient underwent catheter ablation of left atrial tachycardia along with re-isolation of his right inferior pulmonary vein.  Same-day discharge following catheter ablation of many supraventricular tachycardias is commonplace and has been shown to be safe.  However, given the complexity of the ablation procedures for left atrial tachycardias and for pulmonary vein isolation, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate is higher than that of catheter ablations for other supraventricular arrhythmias.  Accordingly, despite at least two reports demonstrating the safety of same day discharge after pulmonary vein isolation, most electrophysiologists admit the patients for overnight observation post-procedure.  This patient's procedure was uncomplicated, and he was hemodynamically stable and in sinus rhythm post-procedure.  The records provided do not mention any post-procedure complications, such as decompensated heart failure.  Accordingly, while it was reasonable and prudent to observe the patient overnight, the records provided do not indicate that an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis (ALS).
Treatment: Consumer Directed Personal Assistance Services (CDPAS), per 15 minutes, 63 hours per week.
The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS), per 15 minutes, 63 hours per week. The denial is overturned. 

This is a female with a medical history of amyotrophic lateral sclerosis (ALS), neurological Lyme disease, cervical myelopathy, anemia and decreased urine output. The patient has been receiving physical and occupational therapy (PT and OT). She has been receiving 30 hours of Consumer Directed Personal Care Assistance (CDPAS) hours and reports that her condition is getting worse and that it is harder for her to do things. A request was made for CDPAS, per 15 minutes, 63 hours per week which was denied by the insurer. 

This patient is in need of additional hours of home health specifically for weekend days.  Documentation detailed that this patient had increased weakness to her hands as well as arms. She could not open jars or lift her arms above her head. Her leg function is also decreased to where she will lose balance frequently. She was receiving 30 hours of aide services; however, the patient does not have any assistance on weekends. Her treating physician has indicated the patient is getting weaker with decreased ability to perform activities of daily living (ADLs) and ambulation; with reported recent falls over the weekends (when she is not receiving services). She is unable to complete ADLs related to ambulation and personal care independently. She does utilize a cane or walker to ambulate; however, using those devices she is in need of a unilateral assistance and supervision due to poor balance as a result of muscle weakness. The physician detailed it is medically necessary that she have assistance on weekends to ensure safety.

Within the submitted documentation it is noted that this is a very young patient diagnosed with ALS. ALS is a progressive neurodegenerative disorder which will require increased assistance as time passes. The submitted documentation does indicate the patient was evaluated and it was noted that limited assistance was required to complete ADLs. However, a subsequent evaluation noted that the patient needed extensive assistance. The patient has clearly worsened clinically based on assessment and therefore an increase in hours is medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for CDPAS, per 15 minutes, 63 hours per week is overturned. The medical necessity is substantiated.