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

Diagnosis:  Migraine Headache.
Treatment:  Aimovig 70mg (milligrams)/ml (milliliter) SC (subcutaneous) SOAJ (solution auto injector).

The insurer denied:  Aimovig 70mg (milligrams)/ml (milliliter) SC (subcutaneous) SOAJ (solution auto injector).  The denial is overturned.

The patient is a teenage female with chronic migraines. She has daily headaches. Her headaches worsen 7 times per month. She has previously used topiramate, amitriptyline and gabapentin to prevent headaches. She also tried propranolol without benefit. She currently receives nortriptyline as headache prevention treatment. Her neurologist requested Aimovig. The request was denied coverage by the health plan due to a minimum age requirement of 18 years old. Her treating physician wrote an appeal letter that notes that the patient tried other treatments without sufficient benefit and that per professional opinion, Aimovig is necessary. This review is in regard to Aimovig use.

The requested Aimovig is medically necessary.

The patient has chronic migraines and needs further improvement in headache control. The patient has tried and failed several migraine preventative treatment options. There are limited treatment options available. There is some efficacy and safety data for CGRP (calcitonin gene-related peptide) inhibitors in the patient's age group. There is a retrospective study of CGRP (calcitonin gene-related peptide) inhibitors used for 
prevention of migraine in adolescent patients, which showed an improvement in the number of headache days and functioning compared to their baseline (Greene). Another retrospective study specific to Vyepti (Eptinezumab) showed a reduction in headaches and good tolerability in 11 patients (Zorrilla). Vyepti is analogous to the other CGRP (calcitonin gene-related peptide) monoclonal antibodies medications, including Aimovig, so the results are pertinent. A third retrospective study of 10 adolescents found evidence of efficacy and safety (no adverse events) (Katsuki). This patient has special circumstances for which CGRP (calcitonin gene-related peptide) inhibitors would be appropriate, as the patient has failed multiple first- and second-line preventative treatments for migraine. The patient should be considered as having special circumstances where CGRP (calcitonin gene-related peptide) inhibitors could be considered (Szperka). Therefore, CGRP (calcitonin gene-related peptide) inhibitor use is supported in this specific case based on current medical literature. Aimovig is medically necessary per current standards of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity

Treatment: Wegovy 1 milligram (mg)/0.5 milliliter (ml) injection

The insurer denied coverage for Wegovy 1 milligram (mg)/0.5 milliliter (ml) injection

The denial is upheld 

This is a patient diagnosed with obesity. This request is for Wegovy. As per a visit note, the patient is on Ozempic.

As per a recent letter, the patient has Hashimoto's disease and Attention Deficit Disorder (ADD); the patient has had abnormal weight gain recently increasing their body mass index (BMI) to 24.68 with a current weight of 172 pounds. Just a few years ago the patient used to weigh 135 pounds. The patient presents with fatigue and long standing difficulty losing weight despite changes in lifestyle (very restrictive diet and exercise). 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The request is not medically necessary.

Semaglutide is a glucagon-like peptide-1 receptor (GLP1R) agonist[1] that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity [2-4]. Recent studies published in major peer reviewed medical journals have shown safety and efficacy of Semaglutide for the treatment of obesity [5-7]. This medication is now available for the treatment of obesity in the form of Wegovy. 

The standard of care based on multiple societal guidelines [8-13] requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension, and hyperlipidemia. The patient has a BMI of 27 with no documentation of a weight related comorbidity. The request does not meet the standard of care and is therefore not medically necessary.

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 Wegovy 1 milligram (mg)/0.5 milliliter (ml) injection services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atopic neurodermatitis.
Treatment:  Dupixent.

The insurer denied Dupixent.  The health plan's determination is upheld. 

The patient is a male with atopic neurodermatitis. Body surface area affected is 8% (percent). He has tried and failed triamcinolone ointment. The medication under review is Dupixent.

Dupixent is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan, such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis.

It is noted that the patient has tried and failed the topical steroid triamcinolone. However, the patient has no true contraindications to the other preferred, formulary medications, which have been shown to be effective for the treatment of atopic dermatitis. The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents, such as tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Neck Pain

Treatment: Pain injection (20553 x 1)

The insurer denied coverage for pain injection (20553 x 1)

The denial is overturned

This patient has chronic neck pain following an Anterior Cervical Discectomy Fusion (ACDF) from C (cervical) 5 to C7. Also of note is a C4-C5 small disc protrusion.  The patient has done Physical Therapy (PT) and is doing a Home Exercise Program.  The patient is using Methocarbamol for spasm and pain.  The patient had previously tried Flexeril and Robaxin. The patient has had trigger point injections and also acupuncture. The documentation does specify that the patient had 50% pain relief achieved (see progress notes) and the duration of the pain relief was 6 weeks as documented, but subsequent visits show a decline in pain relief (down to 25%). 

Centers for Medicare and Medicaid Services (CMS) guidelines (L35010) on frequency of trigger point injections states: "It is expected that trigger point injections would not usually be performed more often than three sessions in a three month period." Basic pain management principles considers 50% pain relief the standard for a successful block. This was achieved and the duration was 6 weeks.  Therefore, the request meets the Health Plan criteria. The request is medically reasonable and necessary.

Based on the above, the insurer's denial must be reversed. 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 pain injection (20553 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis
Treatment: Rinvoq
The insurer denied Rinvoq. The health plan's determination is upheld.

This is a female patient who has a history of ulcerative colitis (UC). She has tried and failed numerous therapies, including infliximab and Xeljanz. The requested service is for Rinvoq, in addition to Stelara.
Rinvoq is a selective Janus kinase (JAK) inhibitor that is being used in several immune-mediated inflammatory diseases. Rinvoq is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease and ulcerative colitis in adults. The safety and efficacy of Rinvoq are well established.
According to Sandborn, William J., et al., "8 weeks of treatment with upadacitinib was more effective than placebo for inducing remission in patients with moderately to severely active UC."
None of the JAK inhibitors are currently FDA-approved for pediatric patients with ulcerative colitis or Crohn's disease. The off-label use of this class of medications in refractory cases of inflammatory bowel disease in children is reasonable.
According to Legeret, Corinne et al., "Currently, there are a wide range of different subtype-selective JAK inhibitors under development, not only for the treatment of inflammatory bowel disease (IBD), but also for other inflammatory conditions. In the CELEST trial, for example, in adult CD (Crohns disease) patients receiving Upadacitinib (selective to JAK1), clinical remission was achieved in 21 percent (%). So far, only very small observational cohort studies in children with IBD receiving Tofacitinib are available: of 21 patients (UC and IBD-U), 43% showed a good clinical response at the end of the 12-week induction, and at 52 weeks, 33% were still on Tofacitinib and steroid-free, whereas the others showed a refractory disease."
However, there is no literature supporting the safety of the combination of Rinvoq and Stelara in pediatric patients. The intended dual therapy is not well supported by the current literature.
Per Ribaldone, Davide Giuseppe, et al., "The use of dual biological therapy is an attractive therapeutic option and may be an opportunity to better tailor and personalize the therapies for patients. Further studies, such as randomized control trials, to provide comparative efficacy and safety endpoints of combination therapies and to clarify potential advantages of combined biological therapies, are needed."
The patient has not tried and failed monotherapy with Stelara or Rinvoq. Therefore, medical necessity for dual therapy with Rinvoq and Stelara cannot be established.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Severe persistent asthma and chronic lung disease
Treatment: Formulary Exception for Dulera (mometasone 
furoate-formoterol fumarate)
The insurer denied: Formulary Exception for Dulera (mometasone furoate-formoterol fumarate)
The denial is upheld.

The patient is a school aged male with a diagnosis of persistent asthma. Dulera (mometasone furoate-formoterol fumarate) has been requested. The prior denial reason was due to the formulary alternative requirements not being met.

The health plan should not cover the proposed treatment.

The treating physician intends for the patient to use Single Maintenance and Reliever Therapy (SMART) as outlined by the Global Initiative for Asthma (GINA) 2020 asthma guidelines and Expert Panel Report 4 (EPR-4) 2020 guidelines. As Symbicort contains formoterol which has a fast onset of action, Symbicort is suitable as a reliever therapy as demonstrated in O'Bryne et al. 2018. This as-needed use of Symbicort is acceptable per medical literature. However, the patient has trialed high-dose Symbicort without adequate control of his asthma. The patient has also used Advair without adequate control. The patient's forced expiratory volume in one second (FEV1) was only 66% predicted. The provider would like to use Dulera which also contains formoterol for Single Maintenance and Reliever Therapy (SMART). However, the use of Dulera as Single Maintenance and Reliever Therapy (SMART) has not been demonstrated in high quality studies. There is no high-quality study demonstrating that the requested medication as Single Maintenance and Reliever Therapy (SMART) is more effective and safer than all formulary medications used as a daily controller therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's
Treatment: Inpatient Rehabilitation Hospital Admission 
The insurer denied Inpatient Rehabilitation Hospital Admission 
The health plan's determination is overturned. 

The patient is a male with a history of weakness secondary to a recent pneumonia infection. He has a medical history of Parkinson's disease, stroke, polio, congestive heart failure (CHF), hypertension (HTN), aortic stenosis, chronic atrial fibrillation and chronic right hemiparesis. A request was made for inpatient rehabilitation admission. The patient is weaning off of oxygen and needs close cardiac monitoring.

The requested Inpatient Rehabilitation Hospital Admission is medically necessary for this patient.
The setting for inpatient rehabilitation is principally determined by the individual's medical and functional status and the ability of the rehabilitation facility to provide the necessary level of care. Acute inpatient rehabilitation is required when an individual's medical status is such that the intensity of services required could not reasonably be provided in an alternative setting (subacute facility or outpatient rehabilitation department). Examples of conditions requiring acute inpatient rehabilitation include, but are not limited to, individuals with significant functional disabilities associated with stroke, spinal cord injuries, acquired brain injuries, major trauma and burns. The patient should be able to tolerate 3 hours of therapy per day for 15 hours a week and require physician evaluation 3 times a week.
Considering the patient's extensive medical history and recent infection, the requested inpatient rehabilitation treatment is appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week 
The health plan's determination is overturned. 

The patient is a female with past medical history of bipolar disorder, ovarian cancer, osteoarthritis, urinary incontinence, and hyperlipidemia who had been assigned PCA (personal care aide) services based on an assessment that assessed the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing medication, and transportation. With tasks of managing finances, stairs, shopping, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with task of phone use. The patient was assessed at supervision with task of eating and independent with task of bed mobility. 

Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week are medically necessary for this patient.
There is documentation of the medical necessity of increased PCA services from the patient's PCP (primary care provider). The patient's family noted they are unable to provide informal help at the level they were able to and the patient's son is only home in the night hours. The patient requires at least maximum assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet the patient's unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient requires assistance outside of any informal support provided by her family. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autistic disorder. 

Treatment: four units of therapeutic activities (97530). 

The insurer denied coverage for four units of therapeutic activities (97530). 

The denial is upheld. 
 

This is a pre teen age male with "motor dysfunction." His reported diagnosis is "F84.0 (Autistic disorder)". Under review are the 4 units of therapeutic activities (97530) provided by the therapist that was denied by the insurer; leading to an external review. 

The occupational therapy (OT) treatment notes made available for review are inadequate and do not provide sufficient objective clinical information to support the medical necessity of the 4 units of therapeutic activities (97530) provided by the therapist. The initial evaluation does list "the long-term goals to be worked on during the therapy sessions." However, the submitted notes do not provide sufficient details and/or do not demonstrate a skilled level of care was necessary to perform these services. The clinical records do not establish the medical necessity of continuing a structured outpatient OT treatment program for the time period under review. There are no specific quantitative assessments or documented measurable responses to prior treatment. There remains a lack of credible documented quantitative functional improvement to support the medical necessity of the 4 units of therapeutic activities (97530) provided by The therapist. 

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 four units of therapeutic activities (97530) provided by The therapist is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arteriovenous malformations, anemia, coronary artery disease. 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This is an elderly male with hypertension, hyperlipidemia, coronary artery disease, cerebrovascular accident, arteriovenous malformations (AVMs), and anemia. He was sent to the emergency department for a hemoglobin of 5.8. In the emergency department, the hemoglobin was 5.1. His stool was heme positive. His creatinine was 1.2, white blood cell count was 13, and glomerular filtration rate (GFR) was 55. Previous esophagogastroduodenoscopy (EGD) and colonoscopy 4 years ago showed non-bleeding arteriovenous malformations, diverticulosis, colon polyps, and hemorrhoids. The patient received one unit packed red blood cells and was treated with intravenous proton pump inhibitor therapy. The next day, the patient's hemoglobin was 7.8. The patient received another unit of packed red blood cells. Esophagogastroduodenoscopy (EGD) showed a duodenal arteriovenous malformation, gastritis, and no active bleeding. On day #3, computed tomography (CT) was negative for retroperitoneal hemorrhage. Hemoglobin was 8.4. The plan was for an outpatient capsule endoscopy. Gastroenterology signed off. On day number (#) 4, there were no new complaints. The patient was awaiting authorization to return to rehab. Hemoglobin was 9. On day #5, the patient was comfortable. The patient was awaiting authorization to return to rehab. On day #6, there were no new complaints. The patient was discharged. 

The requested health service was not medically necessary. 

The patient did not have hemodynamic instability, active / ongoing gastrointestinal bleeding, high-risk lesion for re-bleeding seen on esophagogastroduodenoscopy, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding; or evaluation requiring the patient to not eat or drink for an extended period (for example (e.g.), more than 24 hours). The patient did not have inability to maintain oral hydration (e.g., needs intravenous fluid support) that persisted; and did not have suspected toxic megacolon. The patient did not have bacteremia. Additionally, from day #4 to discharge, the patient was awaiting placement to rehab. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood clot
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult female. She has a history of lupus, antiphospholipid syndrome, rheumatoid arthritis, and deep vein thrombosis (DVT). She presented with a complaint of left calf pain for two days. Duplex showed acute left superior vena cava (SVC) DVT. International normalized ratio (INR) was 10.7. The patient was treated with vitamin K, Lovenox, and holding of Warfarin. She was seen by vascular surgery with no intervention recommended. The patient was seen by hematology with recommendation for anticoagulation with Lovenox alone. Inpatient admission for patient's hospitalization was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient hospital admission was not medically necessary.

Criteria for inpatient level of care is not met based on MCG (Milliman Care Guidelines) guidelines. The patient does have underlying thrombophilia but did not have subtherapeutic anticoagulation on Warfarin (INR was supratherapeutic). She was treated with Lovenox anticoagulation, which does not require inpatient level of care for its management. She was not deemed to require vascular intervention by vascular surgery. Therefore, the inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
Treatment: C8080 Braces, D8670 Monthly Visits
The insurer denied: C8080 Braces, D8670 Monthly Visits
The denial is overturned.

The patient is a teenage male. The request is for orthodontic treatment with monthly visits. The patient has a Class I malocclusion with a deep bite and a posterior crossbite on the left side. The patient has severe upper and lower jaw crowding. The prior denial was due to a score of 21 on the handicapping index scale.

The requested health service is medically necessary.

The patient's upper front teeth are severely protruded and subject to trauma over time due to this. Over time, fracturing and/or loosening can occur due to their being positioned so far forwards. Also, the upper and lower left first premolars are in crossbite (reverse bite). This means that during the chewing cycle, they will not glide over each other smoothly, but rather bang into each other traumatically. Over time this can lead to fractures and/or loosening of these teeth. For these reasons, orthodontic treatment is medically necessary. The monthly visits are needed to make sure the treatment is progressing properly.