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

Diagnosis: Endometriosis

Treatment: Orilissa 150 milligrams (mg) OR (oral route) tabs (tablets)

The insurer denied coverage for Orilissa 150 mg OR tabs.

The denial is upheld. 

The patient is a female who underwent a laparoscopy. According to the provider, a nodule was seen on the left peritoneum compatible with endometriosis (No pathologic confirmation). The patient is complaining of heavy periods and dysmenorrhea. The provider requested coverage for Orilissa.

According to the standard of care, UpToDate (Reference 7) and ASRM (American Society for Reproductive Medicine) recommendations (Reference 1), the treatment of endometriosis-related pain is based on the severity of symptoms. Other causes of pelvic pain should be excluded prior to treatment. 

For women with mild to moderate pain, nonsteroidal anti-inflammatory drugs (NSAIDs) and continuous hormonal contraceptives are recommended rather than either agent alone (Grade 2C). These therapies are low risk, have few side effects, are low-cost, and are generally well-tolerated compared with other medical therapies. 

Women with adequate symptom improvement continue the hormonal therapy/NSAID regimen until pregnancy is desired or the average age of menopause is reached. Women whose symptoms do not improve continue NSAID treatment and are offered an alternate hormonal combination (eg [for example], change to a different estrogen-progestin contraceptive or norethindrone acetate or depo-medroxyprogesterone injection). 

For women with severe symptoms, symptoms that do not respond to the above therapies, or recurrent symptoms, a trial of gonadotropin-releasing hormone (GnRH) agonist with add-back hormonal therapy is recommended (Grade 2C). GnRH agonist treatment has demonstrated efficacy without the risks or negative impact on ovarian reserve of surgery. Orilissa is a GnRH antagonist which also suppresses pituitary gonadotropin hormone production and creates a hypoestrogenic state and is approved as a treatment for endometriosis.

There is no evidence that the patient has failed treatment with NSAIDs, combined oral contraceptives or a progestin. As of now, Orilissa is not medically necessary.

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

Orilissa 150 milligrams (mg) OR (oral route) tabs (tablets) are not considered medically necessary for this patient. 

The insurer's denial of coverage for Orilissa 150 mg OR tabs is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Humira
The insurer denied Humira. The health plan's determination is upheld.

The patient is a male with plaque psoriasis described as severe, and which has been described as being associated with severe rashes, dryness, fissures, flakiness, peeling, small bumps, thickness, and redness. The patient has tried and failed topical ointments.
The requested medication, Humira, is under review for medical necessity.

The health plan determination of Humira coverage is recommended to be upheld, in whole.

Unfortunately, the extent, duration, treatment history, and location of the patient's psoriasis is insufficiently documented to determine whether systemic therapy is even indicated. However, presuming the patient has moderate to severe psoriasis requiring systemic therapy, then it must be emphasized that the patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, and/or phototherapy. Particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, these preferred agents are appropriate for this patient's clinical scenario. Therefore, as per the patient's health plan policy language [1], the requested Humira is not medically necessary.
Modern dermatology literature [2-5] supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Humira, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend the use of these preferred agents as appropriate for this patient's clinical scenario. The patient has been on no documented systemic therapy to date, and therefore the standard, first-line therapies preferred by the health plan are not likely to have any less efficacy, or increased incidence of adverse effects, compared to the requested Humira.
Therefore, as per current medical standards of care, Humira is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Allergic Reaction. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a boy brought to the emergency department (ED) by his mother with bilateral eye swelling and throat pain one hour after taking Motrin for a headache. On arrival, he had normal vital signs and did not have respiratory distress or wheezing, and he did not have a rash or gastrointestinal (GI) symptoms. He did have bilateral eyelid swelling. No uvular edema was noted. He was given epinephrine, Decadron, and Benadryl. On re-evaluation, his eyelid swelling was unchanged, and he was still complaining of a sore throat, so he was admitted to the floor "for monitoring." On admission, he had normal vital signs and exam showed much reduced eyelid swelling. He was discharged shortly thereafter. 

The inpatient hospital admission was not medically necessary. 

The patient arrived with a mild allergic reaction, possibly to Motrin taken an hour previously. The extent of the reaction was eyelid swelling and sore throat. The patient did have eyelid swelling, but the throat did not appear red or swollen and the patient was otherwise completely normal and with normal vital signs. The patient did not meet criteria for anaphylaxis, but was nonetheless treated as if he did, with epinephrine, steroids, and Benadryl. If a period of observation was needed after this therapy, which itself was not clearly indicated, then that could have occurred in the ED. As it happened the patient was discharged very soon after arrival to the pediatric floor. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Stenosis
Treatment: Surgery on bones of the spine 
The insurer denied surgery on bones of the spine. 
The determination is overturned.

The patient has low back and bilateral lower extremity (BLE) pain from spinal stenosis. Her pain is worse with standing and ambulation. The physical exam (PE) was unremarkable. A magnetic resonance imaging (MRI)scan revealed moderate to severe central canal stenosis in part due to ligamentum flavum hypertrophy that measured up to 5 millimeters (mm) bilaterally. The patient has tried physical therapy (PT), pain medications and an epidural injection without adequate pain relief. She was recommended to have a minimally invasive lumbar decompression procedure (MILD) procedure for spinal decompression.
At issue is the medical necessity of the requested procedure.

Yes. The requested procedure is medically necessary.
This patient has moderate to severe spinal stenosis with neurogenic claudication. She had failed conservative treatments including PT, pain medications and epidural injection. Further treatments are necessary to improve her pain and functionality. MILD is a minimally invasive approach to decompress the lumbar spine with no surgical incision for patient with stenosis from ligamentum flavum hypertrophy. It can be done under sedation without general anesthesia. There is strong clinical evidence that proves the efficacy of this intervention. Based on this patient's symptoms, magnetic resonance imaging (MRI) findings, and current clinical evidence, she is a candidate for the MILD procedure. It is medically necessary to consider MILD as the next step treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion; overbite.
Treatment:  D8080 Braces.
The insurer denied the  D8080 Braces.
The denial is overturned.

The patient is a male. The patient has a Class II malocclusion. He has a 100% (percent) overbite.

The request for braces was denied coverage by the health plan, because the patient scored 18 on the handicapping scale.

Yes, the braces are medically necessary.
The patient has a deep, impinging overbite with severe soft tissue damage. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem.

Therefore, given the above, the requested braces are medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. Please see the rationale, above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bowel obstruction.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a female with medical history of recurrent small bowel obstruction status post lysis of adhesions. She presented to the emergency department with severe abdominal pain, nausea, vomiting, and chills. Vital signs were notable for elevated blood pressure 146/92. Physical examination was notable for ill appearance in moderate distress, diffuse abdominal tenderness and guarding, and hypoactive bowel sounds. Labs showed low hemoglobin of 10.8 and hematocrit of 32.7%. Chest x-ray showed no acute infiltrates. X-ray of the abdomen showed persistent small bowel distention with passage of contrast to the colon consistent with residual partial versus resolving complete obstruction. Computed tomography scan of the abdomen and pelvis showed dilated loops of small bowel with gradual transition, trace ascites, and partial obstruction cannot be entirely excluded. She was treated with intravenous fluids, ondansetron, hydromorphone, and promethazine. 

The inpatient hospital admission was not medically necessary.
The care provided could have been provided at a lower level of care. The patient presented with abdominal pain, nausea, and vomiting; she had improvement in symptoms with conservative therapy including brief nasogastric tube suction and then gradual advancement of diet. Imaging did not show definite bowel obstruction or enteritis, and no other gastrointestinal cause for the inpatient level of care, such as gastrointestinal bleeding, peritonitis, toxic megacolon, sepsis, abscess, or other complication was documented. She had return of bowel function with bowel movements soon after presentation. All of the measures that were undertaken, including monitoring, labs, and gradual advancement of diet, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intestinal Obstruction. 
Treatment: Inpatient Admission. 

The insurer denied coverage for an inpatient admission. 

The denial is upheld. 

The patient presented with abdominal pain and vomiting. She had previous abdominal surgeries including a gastric bypass, cholecystectomy, and removal of an infected mesh. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis, A CAT (computed axial tomography) scan showed small bowel obstruction. She was treated with NG (nasogastric) suction and her symptoms resolved. There was minimal fluid suctioned out of the NG tube (NGT). At 6 hours into the admission, the patient was passing flatus and experienced full resolution of her symptoms. The total NGT output was less than 100 cc (cubic centimeters) after clamping the tube for 2 hours and the tube was removed. 

Clinical indications for admission for Intestinal Obstruction (MCG (Milliman Care Guidelines)) include having signs and symptoms of bowel obstruction that are severe or persistent. This includes having NG tube suction that will need to be continued. There also needs to be an imaging study that is consistent with bowel obstruction. 

This patient had adhesions causing intestinal obstruction. She responded rapidly to nasogastric suction. There was only minimal return of gastric contents in the suction. She had initial symptoms that were consistent with bowel obstruction and imaging confirming the obstruction. However, she did not have severe symptoms or suspected perforation and the nasogastric tube did not require long term use. She responded to treatment within 6 hours and could have been managed with observation status. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

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

The insurer's denial of coverage for an inpatient is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gestational hypertension.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a G1 (one pregnancy) female. She presented to the hospital with gestational hypertension and mildly elevated transaminases.

There was no proteinuria or significant symptoms of preeclampsia with severe features. The patient's blood pressures were mildly elevated in the 145/100 range. Initially there was a concern for worsening hypertension and the transaminases, such that the plan was to administer betamethasone for pulmonary maturation and then to induce labor, particularly if the liver functions deteriorated further. However, the blood pressures decreased into the normal range, and the liver functions did not significantly worsen. The patient was discharged to home with close followup.

The health plan contends that and denies coverage for the admission based on the absence of severe problems including chest pain, seizures, or other end organ dysfunction and cites MCG (Milliman Care Guidelines) Hypertensive Disorders of Pregnancy: M-285. The response from the facility does not address this denial, but rather addresses the subsequent delivery admission, during which the patient re-presented to the hospital with a clear diagnosis of preeclampsia with severe features based on marked elevation of transaminases, and labor was induced successfully. The facility contends that this admission was medically necessary based on MCG (Milliman Care Guidelines) 25th edition guidelines for Hypertensive Disorders of Pregnancy due to the elevated lever enzymes and consequent induction of labor and vaginal delivery. However, it does not address the prior admission which is the admission under consideration for this appeal.

No, the Inpatient admission was not medically necessary.
On the dates of service under review, the patient did not meet diagnostic criteria for preeclampsia with severe features. There was elevation of blood pressure into the mild preeclampsia range, slight elevation of the transaminases to less than twice the upper limit of normal, but no clinical or laboratory evidence of preeclampsia with severe features. Hence, in the absence of proteinuria, the patient did not even meet criteria for preeclampsia without severe features, and therefore was appropriately classified as gestational hypertension. The standard of care, consistent with the ACOG (American College of Obstetricians and Gynecologists) practice bulletin for this disease process, does not require hospital admission for gestational hypertension; therefore the care did not require admission level of service.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
The patient did not require admission to the hospital on the dates in question based on the standard of care as set out in the ACOG (American College of Obstetricians and Gynecologists) practice bulletin.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crowding; deep bite.
Treatment:  Braces (insertion and adjustment).
The insurer denied the  Braces (insertion and adjustment).
The denial is upheld.

The patient is a female. The request is for dental benefits for braces insertion and adjustment.

Per the dental clinical summary, the patient has mild upper arch crowding, severe, deep bite, impacted mandibular left premolar, and mild lower incisor intrusion.

The health plan denied coverage for the braces, because the patient did not score a 26, the score necessary to be approved for braces on the Handicapping Labio-Lingual Deviation Index Report. This denial is being appealed.

No, the requested braces insertion and adjustment is not medically necessary.
The patient's severe deep bite is not supported by the information submitted.  It is not evident in the photos that were submitted for review.

Yes, the health plan acted reasonably, with sound medical judgement and in the best interest of the patient.
Braces insertion and adjustments  is not warranted in this case because of the information reviewed does not support the severity as claimed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent.
The insurer denied the Dupixent.
The determination is upheld.

The patient has moderate to severe atopic dermatitis (over 10% body surface area involvement of the arms, and with an associated urticaria-like rash. The patient has tried and failed topical clobetasol and triamcinolone, as well as Prednisone.
At issue is the medical necessity of Dupixent.
The Dupixent is not medically necessary.
The patient has tried and failed topical steroids, but nonsteroidal topical therapies (calcineurin inhibitors and crisaborole) have not yet been tried to date that would limit the need for both systemic steroids and non-steroidal systemic therapies. Systemic therapies (such as Dupixent) which have greater side effects than topical therapies, are not demonstrated to be medically necessary at this time. The patient has no documented treatment failure with, or true medical contraindication to, either the topical calcineurin inhibitors tacrolimus (Protopic) or pimecrolimus (Elidel), or crisaborole (Eucrisa), and/or standard, first-line oral medications used for moderate to severe atopic dermatitis that would obviate the need for further topical therapies . Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with the current medical literature [1-4], the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Watery Diarrhea.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented with fever, abdominal pain and diarrhea. He was hospitalized. The reason for prior denial was that the requested treatment did not meet inpatient level of care.

A brief summary of the patient's hospital stay is as follows:
Per ED (emergency department) note and admission H&P (history and physical): The patient was seen in the ED (emergency department) for abdominal pain and 10 episodes of diarrhea. Abdominal ultrasound was unremarkable, but appendix was not visualized. The patient was suspected of gastroenteritis. He was admitted early morning for IV (intravenous fluids, poor PO (oral) intake and close monitoring.

Per day two progress note: The patient had three loose stools; he still had abdominal pain. The plan was to continue IV (intravenous) fluids and monitoring.

Per day three progress note: The patient slept well. He experienced no more diarrhea. His abdominal CT (computed tomography) was unremarkable. He was discharged to home.

No, the Inpatient admission was not medically necessary.
As documented in admission H&P (history and physical) and progress notes, this patient had abdominal pain and diarrhea, likely due to acute gastroenteritis. He was admitted for IV (intravenous) hydration. During hospital stay, the patient had been stable with no documented acute events. He did not require any acute interventions. There was no documentation for suspected severe infection, severe abdominal tenderness, hemodynamic instability, sever or persistent vomiting, electrolytes or metabolic abnormalities. Therefore, the acute inpatient care was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
As documented in admission H&P (history and physical) and progress notes, this patient had abdominal pain and diarrhea, likely due to acute gastroenteritis. The patient did not require any acute interventions or treatment. The health plan determined that the requested treatment did not meet acute inpatient level of care. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient (1-2)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Memory Loss.
Treatment: Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week.
The insurer denied home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week.
The determination is upheld.

The patient has a past medical history significant for coronary artery disease, paroxysmal atrial fibrillation, heart block type I, thromboangiitis obliterans, peripheral vascular disease, chronic pain syndrome, hyperlipidemia, lymphedema, hepatitis C, venous stasis ulcers, iron deficiency anemia, vitamin D, vitamin B12, and folate deficiency, constipation, osteoarthritis, partial foot amputation, ataxia, poor vision and memory loss.
An increase in personal care assistant (PCA) hours to 84 hours a week is requested. The patient is currently approved for 50 hours a week.  Services were denied by the health plan stating the following: your abilities to perform physical functioning, daily activities stayed the same for personal hygiene, dressing upper and lower body, walking, toilet transfer, toilet use, eating, and medication management. In summary many of your abilities to perform physical functioning stayed the same and therefore your hours stay the same. Additional hours are not medically necessary. This included evaluation and discharge summary from Maimonides Hospital.
At issue is the medical necessity of the personal care services at 84 hours per week.
The requested health service is not medically necessary for this patient.
The Uniform Assessment System (UAS) State of New York was reviewed. The tasking tool noted that 33 hours a week of services were medically necessary. The majority of those services included meal preparation, ordinary housework, shopping, bathing and laundry. This was an increase from 20 hours previously, which included more time for shopping, cleaning, and housework. The prior UAS State of New York was reviewed. The patient lives alone in a 1 bedroom apartment. The physician statement stated that the patient is more confused, forgetful, unsteady on his feet and requires constant assistance and supervision. He is requesting 84 hours with the services.
The patient is an elderly male with multiple medical problems. According to the patient's physician, his clinical status has worsened. The evaluation in September noted that the patient required a total of 33 hours a week of services which was an increase from previous evaluation which showed 20 hours a week as services. The patient is currently approved for 50 hours a week of services and is requesting an additional 34 hours a week of services. The patient is already receiving 17 hours a week of additional services above medical necessity. Documentation does not delineate why the services being provided could not be performed within the 50 hours a week of care which already has been approved. Services beyond 50 hours a week would be considered for safety monitoring and not typically provided under the plan.