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

Dental
Dental/orthodontic

Diagnosis: Class II Division 1 malocclusion 
Treatment: Braces, Monthly Visit and Retainer 
The insurer denied Braces, Monthly Visit and Retainer. 
The health plan's determination is overturned. 

The patient in question is a female with a Class II Division 1 malocclusion with maxillary and mandibular crowding. She has 10 millimeter (mm) overjet and 4mm overbite. She has lip incompetence at rest. She is treatment planned for Braces, Monthly Visit and Retainer to correct her malocclusion. 

Braces, Monthly Visit and Retainer are medically necessary for this patient.
This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. In her particular case. teeth 8 and 9 are very proclined. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjet, which this patient has. For these reasons, the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Disorder.
Treatment:  Braces.

The insurer denied braces. The determination is upheld.

The patient is a female with a Class II occlusion. She has a 3-millimeter (mm) overjet and 4 mm overbite. The maxillary arch and mandibular arch have crowding. The patient's treatment is planned for 24-30 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces.

There is no medical reason to correct the patient's malocclusion with braces. The patient has a deep bite; however, that alone is not a medical necessity to treat. Functional problems can occur in the dentition that becomes more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 3 mm overjet, but this amount of overjet does not affect oral health-related quality of life. (2) The patient's teeth being aligned would provide a minor esthetic improvement but would not significantly improve her health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female with a history of asthma who presented with chest tightness and pain. She was well until 3 days prior to presentation when she developed chest tightness. She was using her albuterol inhaler at home with no relief. Her pain continued, so she was brought to the emergency department for evaluation. Her past history was significant for asthma with several emergency department visits throughout the year.

Inpatient Hospital Admission was medically necessary for this patient.
This is a teenage girl who presented with significant asthma symptoms that did not respond to treatment with bronchodilators at home. She was evaluated and appropriately treated in the emergency department, but she continued to have significant symptoms. She therefore required an inpatient admission for ongoing treatment, initially with frequent bronchodilators (every 3 hours) as well as corticosteroid and close monitoring.
The decision making at the time of admission was consistent with her young age, the presence of persistent symptoms despite appropriate treatment both as an outpatient and in the emergency department, and the need for continued frequent treatments along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cognitive Decline

Treatment: Speech Therapy (ST) visits x 20

The insurer denied coverage for Speech Therapy (ST) visits x 20

The denial is upheld 

The patient in this case is an elderly patient who has asked for 20 visits of speech therapy for cognitive remediation.  Documents provided by their speech-language pathologist stated a diagnosis of mild deficits in attention and short-term memory. The patient did demonstrate progress in their therapy, although the frequency and amount of sessions is unusually high  (average is 1-2 x per week in an outpatient/long-term care [LTC] setting).  

However, the burden of medical necessity was not reached here. There is no underlying medical diagnosis or injury shown resulting in these mild deficits. Rehabilitative therapy must have an underlying condition/illness/injury to qualify as medically necessary (as are habilitative services for developmental disorders). 

The patient may be undergoing neurologic degeneration secondary to Mild Cognitive Impairment (MCI) or dementia, however, no neuropsychological nor neurology notes were included to support medical necessity. 

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 Speech Therapy visits x 20 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The determination is upheld.


The patient is a female with a history of obesity, thyroid disease, and allergies. She is requesting coverage for Wegovy for weight management. In a follow-up weight management program,it is noted that the patient is being treated with both Wegovy and Ozempic. In addition, her body mass index (BMI) is 27. At issue is the medical necessity of Wegovy.
The requested health service/treatment of Wegovy was not medically necessary for this patient. Based on a review of the information provided, the requested Wegovy is not medically necessary. The plan's criteria require a body mass index (BMI) greater than or equal to (>=) 27 with comorbidities, or a body mass index (BMI) >= 30, and the patient cannot be on any other weight loss medications. These criteria have not been met by this patient. A follow up progress note was reviewed. It is documented that the patient has a BMI of 22.4 and is on both Ozempic and Wegovy. Therefore, criteria for approval of Wegovy have not been met.
Randomized clinical trials have not demonstrated the safety or the superior efficacy of combining similar types of weight loss medication.
Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the Wegovy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient is an adult that presented to the hospital complaining of epigastric discomfort, nausea and vomiting.  On arrival to the hospital the patient was hypertensive with a blood pressure of 230/180 and a pulse of 80 beats per minute. Physical examination revealed no significant abnormalities.  Serum blood testing demonstrated an elevated creatinine and an elevated white blood cell count (WBC).  The patient was treated with intravenous (IV) labetalol and nicardipine. A 12 lead electrocardiogram (EKG) demonstrated normal sinus rhythm with left ventricular hypertrophy and T wave inversions in leads I, aVL, V4-V6.  A computed tomography (CT) of the chest demonstrated no evidence of aortic dissection. The patient was admitted to the hospital for treatment of hypertensive urgency.  

Hypertensive emergency is defined as blood pressure > 180/120 with target organ damage. (Reference 1). This patient presented with a systolic blood pressure of 230. Later on 9/24 the BP was 164/177 and at 16:07 was 110/95. Creatinine was 1.18 and serum troponin level and B-type natriuretic peptide (BNP) were both normal.  EKG showed left ventricular hypertrophy (LVH). There was no evidence of acute end-organ damage. Admission to the hospital for aggressive blood pressure management was not necessary in this case. 

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who was transferred to the hospital from an outlying facility where she had presented complaining of intermittent nonexertional chest pain that had been occurring for approximately one year. The indication for transfer was for cardiac catheterization. Her medical history was remarkable for asthma, type 2 diabetes, hypertension and obesity. At the original facility, her electrocardiogram showed sinus rhythm with ST segment and T wave abnormalities. Her serum troponin level was normal. An echocardiogram showed hyperdynamic left ventricular systolic function without regional wall motion abnormalities. Aspirin and a statin were prescribed. The patient was seen in consultation by a cardiologist who opined that it was "highly unlikely" that the patient's pain was cardiac in origin and recommended cardiac stress testing rather than cardiac catheterization. Exercise stress myocardial perfusion imaging was performed and showed no evidence of ischemia. The patient was discharged. At issue is the medical necessity of an inpatient hospital stay.
Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient was transferred for cardiac catheterization after being admitted to a facility with concerns for acute coronary syndrome (ACS). She was hemodynamically stable, with normal cardiac biomarkers. While her electrocardiogram was abnormal, there were no changes diagnostic of ischemia. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under "observation" status. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline
for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glomerular Disease in Lupus
Treatment: Obinutuzumab injection
The insurer denied: Obinutuzumab injection
The denial is upheld.

The patient is an adult female with systemic lupus erythematosus (SLE). Her course has been complicated by lupus nephritis, thrombocytopenia (ITP), arthritis, alopecia, myositis, leukopenia, and avascular necrosis (AVN) of her bilateral knees and ankles due to steroid use. She was treated with rituximab 10 years ago and developed an allergic reaction. She was then treated with obinutuzumab for the past 5 years with excellent response, including control of cytopenia and maintenance of renal remission. She had a flare of thrombocytopenia early last year after a lapse in obinutuzumab treatment for 2 years. She received 2 doses of obinutuzumab 8 months ago, leading to resolution of thrombocytopenia. She was evaluated 2 months ago and was doing well at that time. She was not taking Plaquenil due to ophthalmologic complications. She reported joint pains attributable to known avascular necrosis, improved with meloxicam and following with orthopedics. Labs from 2 months ago reveal a normal complete blood count (CBC), no inflammation, normal urine and quiescent markers of lupus activity. Appeal is for maintenance treatment with obinutuzumab. Obinutuzumab was denied for this patient because it is not Food and Drug Administration (FDA) approved for the treatment of 
systemic lupus erythematosus or thrombocytopenia.

The requested obinutuzumab for maintenance of remission for systemic lupus erythematosus and thrombocytopenia is not medically necessary for this patient.

Obinutuzumab is Food and Drug Administration (FDA) approved for the treatment of various hematologic malignancies. It is not Food and Drug Administration (FDA)-approved for the treatment of systemic lupus erythematosus or thrombocytopenia. This patient with systemic lupus erythematosus was treated with obinutuzumab for the past 5 years after an allergic reaction to rituximab. She had an excellent response, including control of cytopenia and maintenance of renal remission. She had a flare of thrombocytopenia earlier last year after a lapse in obinutuzumab treatment for 2 years. She received 2 doses of obinutuzumab in 8 months ago, leading to resolution of thrombocytopenia. She was evaluated 2 months ago and was doing well at that time. 
Per review of the literature, obinutuzumab may be effective and steroid-sparing in renal and non-renal systemic lupus erythematosus patients with secondary non-response to rituximab, similar to this patient. However, literature was not located to support obinutuzumab dosing for maintenance of remission in systemic lupus erythematosus or thrombocytopenia. This patient had no evidence of active systemic lupus erythematosus or thrombocytopenia at her visit 2 months ago. Therefore, the requested obinutuzumab for maintenance of remission for systemic lupus erythematosus and thrombocytopenia is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Amplified musculoskeletal pain syndrome (AMPS)
Treatment: Rehabilitation Admission
The insurer denied: Rehabilitation Admission
The denial is upheld.

The patient is a teenage female with history of weakness and pain due to amplified musculoskeletal pain syndrome (AMPS) mostly affecting her hips and knees and previously a competitive gymnast with multiple injuries. She has tried physical therapy and chiropractic manipulations. The treating physician requested the patient's admission into an inpatient acute rehabilitation facility for multidisciplinary team care including cognitive behavioral therapy, physical therapy and occupational therapy for nursing needs, medical management and rehabilitative criteria.

The proposed admission to acute inpatient rehabilitation is not medically necessary.

The patient has not met all the criteria for acute pediatric rehabilitation care per InterQual Criteria 2023 Guidelines for Inpatient Rehabilitation Pediatric Rehabilitation in a patient with no ongoing clinical issues that require acute inpatient care. The patient has a history of weakness and pain due to amplified musculoskeletal pain syndrome (AMPS) mostly affecting her hips and knees. Criteria for acute inpatient rehabilitation facility include associated acute clinical issues. This patient has no ongoing acute clinical issues that warrant an acute inpatient rehabilitation facility admission. A patient cannot be admitted to acute inpatient rehabilitation facility solely for physical therapy and occupational therapy without a need for nursing and medical care for acute medical issues. The request was for maintenance rehabilitation which could be performed at a lower level of care. Based on the above requirements, the patient has not met the criteria for intensive acute inpatient rehabilitation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg Wound
Treatment: Outpatient Procedure (37220 x (times)1, 37221x1, 37224 
x1, 37226 x1, 37228 x1)
Revascularization, endovascular, open or percutaneous, iliac artery. 
Endovascular Revascularization
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty Work
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral.
Revascularization, endovascular, open or percutaneous, tibial/ peroneal artery, unilateral.

The insurer denied Outpatient Procedure (37220 x1, 37221x1, 37224 x1, 37226 x1, 37228 x1)
Revascularization, endovascular, open or percutaneous, iliac artery. 
Endovascular Revascularization
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty Work
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral. Revascularization, endovascular, open or percutaneous, tibial/ peroneal artery, unilateral.

The denial is upheld.

The patient is an adult male with history of diabetes, foot ulcer status post toe amputation, and peripheral vascular disease. According to the office note, the patient is status post right fifth toe amputation 6 months ago. Physical exam showed palpable dorsalis pedis and posterior tibial pulses. No ulceration or venous stasis changes are noted. It is noted that the patient has a wound that is not healing in the dorsum of the right foot. Will schedule for angiogram. Another office note from 2 months ago, it is noted that the patient has developed osteomyelitis of the fifth metatarsal of the right foot and two additional wounds of the right foot including dorsal and plantar surface. The patient underwent previous fifth metatarsal amputation and was treated with antibiotic. The amputation site has healed. The patient has been scheduled for angiogram in the near future.

The requested health service is not medically necessary.

There is no documentation that the patient has ulceration secondary to severe peripheral arterial disease caused by significant arterial stenosis or occlusion. The patient has not seen by a wound care specialist. The patient has not had vascular imaging such as CTA (Computed Tomographic Angiography) to show occlusion of at least 70% (percent) for either inflow or outflow.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Irritable Bowel Syndrome (IBS)
Treatment: Formulary exception for Ibsrela 50mg Tablet
The insurer denied: Formulary exception for Ibsrela 50mg Tablet
The denial is upheld.

The patient is an adult female with IBS-C (irritable bowel syndrome with constipation). She has failed Miralax, Lactulose and Linzess. The patient's provider is requesting Ibsrela. Ibsrela 
was denied coverage by the health plan, as the patient has not tried and failed lubiprostone. The denial is being appealed.

The health plan should not cover the Formulary exception for Ibsrela.

While the patient has failed the plan preferred Linzess, she has not failed the plan preferred lubiprostone. There is no medical literature to support that the Ibsrela is more effective than or has fewer side effects than the plan preferred lubiprostone. Therefore, the health plan should not cover for formulary exception for Ibsrela.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion
Treatment: Braces, Monthly Visit, and Retainer 
The insurer denied Braces, Monthly Visit, and Retainer 
The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion. She has 4 millimeter (mm) overjet and 2mm overbite. She has moderate maxillary and mandibular crowding. Teeth 4 and 13 are erupted but blocked out of the arch to the lingual. She is treatment planned for Braces, Monthly Visit, and Retainer to correct her malocclusion.

Braces, Monthly Visit, and Retainer are not medically necessary for this patient.
There is no medical reason to correct her malocclusion with braces. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult to correct if not addressed in adolescence. The patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient has a slightly excessive overjet but this amount of overjet does not negatively affect oral health related quality of life. If her teeth were aligned it may provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic Cervical Cancer

Treatment: Y90 radioembolization (outpatient procedure 37242 x1, 37243 x1)

The insurer denied coverage for Y90 radioembolization (outpatient procedure 37242 x1, 37243 x1)

The denial is upheld 

This is a patient with stage IV (4) cervical cancer that has spread to the liver. Y90 radioembolization was requested.

Selective internal radiation therapy (SIRT) was approved for metastatic colorectal cancer to liver. Although it was applied to other metastatic cancers to liver, there is no published data for metastatic cervical cancer. The National Comprehensive Cancer Network (NCCN) guidelines do not suggest the requested treatment for stage 4 cervical cancer. There are newer treatments for metastatic cervical cancer which can be used.

Medically necessary treatment is defined as one which is generally accepted treatment in the United States. The requested treatment is not generally accepted for the patient's clinical condition. Y90 radioembolization (outpatient procedure 37242 x1, 37243 x1) is not considered medically necessary for this patient.

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 Y90 radioembolization (outpatient procedure 37242 x1, 37243 x1) is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes
Treatment: Formulary exception for Ozempic 4mg (milligrams) /3ml (milliliter) Pen
The insurer denied: Formulary exception for Ozempic 4mg (milligrams) /3ml (milliliter) Pen
The denial is upheld.

The patient is an adult female diagnosed with T2DM (type 2 diabetes mellitus). This request is for Ozempic. As reported, the patient has been on Trulicity with no improvement with A1C (glycated hemoglobin). However, there is no documentation of this in the medical records. The medication list includes Fiasp, Ozempic, Dexcom G6 and Lantus. The patient's A1C (glycated hemoglobin) last month was 7.7 %; last year it was 7.9 %; 2 years ago, it was 7.9 %; 3 years ago, it was 9%; 4 years ago, it was 9.1 %; 6 years ago, it was 10.7 %; and 8 years ago, it was 7.8 %.

The health plan should not cover the Formulary exception for Ozempic.

The formulary alternatives Trulicity and Victoza are not documented to have been and are not reasonably expected to be ineffective for this patient. The formulary alternatives Trulicity and 
Victoza are expected to be as effective as the requested medication, as there are no studies that demonstrate the superiority. The formulary alternatives are not documented to have had had adverse effects on this patient. Ozempic is a GLP1R (glucagon-like peptide 1 receptor) agonist (1) that is FDA (United States Food and Drug Administration) approved in the treatment of type II diabetes (2-7). There are no studies showing superiority of the requested medication over the formulary alternatives. The patient can try the formulary alternatives Trulicity and Victoza. Therefore, the health plan should not cover the formulary exception for Ozempic.