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

Diagnosis: Type II Diabetes
Treatment: Dexcom G6 Mis Sensor, Pre-service
The insurer denied the Dexcom G6 Mis Sensor, Pre-service
The denial is upheld

This is a male with type II diabetes treated with metformin and Ozempic. The request for Dexcom G6 is under review. 

The prior request was denied as approval criteria requires a diagnosis of type 1 diabetes, intensive insulin regimen, and that the patient is monitoring glucose four times daily. The physician is appealing this determination.

No, the proposed Dexcom G6 is not medically necessary.

This request is for Dexcom G6 for management of type II diabetes. Continuous glucose monitoring has been shown to be safe and effective for patients with type II diabetes on basal insulin therapy [1] and multiple daily insulin injections. It is unknown if continuous glucose monitoring is effective in this clinical situation of a patient with type II diabetes on metformin and Ozempic. The American Diabetes Association clinical guidelines [2] do not support the use of continuous glucose monitoring in this clinical situation. Therefore, no, proposed Dexcom G6 is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The health plan appropriately denied the requested Dexcom G6 which was not medically necessary as outlined above.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Class II subdivision left malocclusion and moderate overbite
Treatment: braces
The insurer denied braces. The health plan's determination is upheld. 

The patient in question is a female with a Class II subdivision left malocclusion and moderate overbite. The maxillary and mandibular arches are both crowded. She is treatment planned for braces. 

Braces are not medically necessary for this patient. The patient's bite is deep but there is no indication of damage to the incisors or the palate in the photographs, and her cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided that there is severe soft tissue damage (or any soft tissue damage) on this patient.
There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another. Furthermore, deep bites may be corrected in adulthood, so it is not as if she will lose the ability to correct her malocclusion should she choose to do so as an adult.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis

Treatment Taltz 80 mg/ml (milligram per milliliter)

The insurer denied coverage for Taltz 80mg/ml

The denial is upheld

The patient is a teenaged patient with a past medical history of significant for hypertension and obesity who has a diagnosis of psoriasis.  The patient has failed therapy with topical steroids (halobetasol, clobetasol, hydrocortisone OTC [over the counter]) and calcipotriene.  The requested medication is Taltz.

Based on the provided documentation Taltz is not medically necessary for treatment of this patient's psoriasis.  Although conventional therapies, such as methotrexate and cyclosporine, may be contraindicated, there is no contraindications to systemic therapies such as Enbrel and humira which have been used with success in treatment of psoriasis.  

There is no comparative, controlled studies showing that Taltz would be more appropriate than alternative therapies.  There is no medical and scientific literature and/or evidence based clinical practice guidelines that specifically supports the administration of Taltz for this patient's condition as an accepted standard of practice over alternative insurer preferred medications.   

According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient.   Multiple alternative biologics are available, and FDA (Food and Drug Administrative) approved for this patient, including Humira, Enbrel, and Stelara (5).  The preferred agents are effective therapies for the treatment of the patient's psoriasis.  The provided medical notes do not provide any evidence of an absolute contraindication for the use of these available alternatives.  

Therefore, Taltz is not medically necessary for this patient based on the medical documentation provided. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Taltz 80 mg/ml is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.
Treatment: Inpatient Hospital Stay.

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

The patient presented to the hospital emergency department (ED) with a history of progressively worsening abdominal pain of 3-days duration. Her evaluation included a physical exam, computed tomography (CT) scan, and labs. She was afebrile at the time of presentation. The heart rate was normal at 68 beats/minute at presentation. The abdomen was tender in the right lower quadrant. Lab data identified a normal white blood cell (WBC) count of 10.7 thousand (K). A CT scan showed findings consistent with early appendicitis. Her evaluation yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested. She was admitted to the hospital.
The patient was provided intravenous (IV) fluid and antibiotics. She underwent a laparoscopic appendectomy with findings of acute appendicitis. The surgery was performed without complication. Her diet was advanced and pain management was converted to oral medications. She was discharged home.
At issue is the medical necessity of an inpatient stay.
Acute inpatient admission was not medically necessary for this patient as the care provided could have been rendered with a lower level of care.
This patient presented to the ED and underwent an uncomplicated appendectomy procedure. The post-surgical course was without adverse incident. The patient responded favorably to treatment and the hospitalization was uncomplicated. The patient was previously healthy and the vital signs were consistently normal. The progress notes document clinical stability without complication during this period of monitoring.
The submitted clinical documentation does not support the need for inpatient admission for this patient. A lower level of care would have satisfactorily allowed for the care provided and would have been consistent with the accepted standard of medical care.
Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the treatment of appendicitis can be provided without an inpatient level of care. In this case, the patient tolerated oral hydration, diet/medication and surgical treatment. A lower level of care would have appropriately provided for surgical treatment and overnight monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pain Management. 

The health plan denied the treatment of basivertebral nerve ablation as not medically necessary. 

The reviewer has upheld in whole the health plan's determination. 

The patient has complaints of back and neck pain. It is noted the patient had undergone prior electromyography (EMG) testing which is noted to show lumbar radiculopathy. Patient has undergone conservative treatment with no relief. A magnetic resonance imaging (MRI) study of the lumbar spine demonstrates Lumbar (L)5-Sacral (S)1 degenerative changes. Back pain interferes with her work tolerance, and she has limitations. Patient is also noted to have left leg pain and numbness. Pain is rated 6 out of 10. Patient's diagnoses include lumbar radiculopathy and lumbar spondylosis. MRI of the lumbar spine indicated multilevel degenerative changes. There is a request for intraosseous basivertebral nerve ablation. 

The requested health service/treatment of Basivertebral Nerve Ablation is not medically necessary for this patient There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. As such, the requested health service/treatment of Basivertebral Nerve Ablation is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, type 2 diabetes mellitus, coronary artery disease with a stent, chronic back pain, osteoarthritis and hypoparathyroidism.

Treatment: Personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week: 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The insurer denied coverage for personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week: 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The denial is upheld.

The patient has chronic medical problems including hypertension, diabetes and coronary artery disease.  She developed right leg gangrene resulting in a right above knee amputation and uses a prosthesis for ambulation.  The patient lives in a private home with her husband.  Her daughter is reportedly involved in all aspects of her care.  The patient is currently receiving PCA level 2; 12 hours/day-7 days/week, for a total of 84 hours/week.  She is requesting an increase to 12 hours/day, 7 days/week: 12 hours/day, 7 days/week (split shift) for a total of 168 hours/week.

According to the Uniform Assessment System (UAS) report, the patient requires extensive to maximal assistance for activities of daily living including bathing, personal hygiene, dressing and toilet transfers/use.  She is frequently incontinent of bladder and continent of bowel.  The patient's functional ability is much the same as was documented in the UAS prior report.  In addition, there has been no significant functional or cognitive decline over the prior months.  The patient is able to plan a meal and can eat independently.  She is fully alert and oriented with cognitive ability described as "modified independent."  The patient's PCA level 2; 12 hours/day-7 days/week, for a total of 84 hours/week is sufficient; allowing her to continue living safely at home.  Since additional hours are not provided for stand-alone safety supervision, companionship or when the aide is not performing tasks, the requested increase to 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift) for a total of 168 hours/week is not medically necessary.  

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

The insurer's denial of coverage for the Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: OA (osteoarthritis), peripheral neuropathy, and DM (diabetes mellitus), respiratory insufficiency. 
Treatment: Personal Care Services 10-12 Hours A Day, 7 Days A Week For A Total of 70-84 Hours Per Week. 

The insurer denied the Personal Care Services 10-12 Hours A Day, 7 Days A Week For A Total of 70-84 Hours Per Week. 
The denial is overturned. 

The patient is a female. She has PMH (past medical history) of OA (osteoarthritis), peripheral neuropathy, and DM (diabetes mellitus). She reportedly has respiratory insufficiency. 

The patient's respiratory insufficiency has progressed, and she needs continuous oxygen. The patient has increased difficulty with ambulation and ADLs (activities of daily living). 

The request is for increase in personal care services from 8 hours/day to 12 hours/day, 7 days a week. 

Yes, the Personal Care Services 10-12 Hours A Day, 7 Days A Week For A Total of 70-84 Hours Per Week is medically necessary. 

The patient's respiratory insufficiency has progressed. She needs continuous oxygen. The patient will need longer aide assistance. The patient has difficulty performing her ADLs (activities of daily living). She needs help with all her tasks. She has a history of falls. 

The patient currently receives Personal Care Services 8 Hours A Day, 7 Days A Week For a total of 56 hours per week. She needs 10-12 Hours A Day, 7 Days A Week For A Total of 70-84 Hours Per Week. 

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

Diagnosis: Tibial Plateau fracture
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female. She had sustained a Tibial Plateau fracture. She was seen and evaluated, and the recommended surgery was performed.

The patient's admission and surgery completed. She met discharge criteria from PACU (post anesthesia care unit). The patient's pertinent co-morbidities directly impacting her inpatient cycle of care included breast cancer, history of DVT (deep venous thrombosis) without pulmonary embolism.

Postoperatively, the patient developed transient hyponatremia. Post-operative clinical co-management was completed by the combined services of Hospitalist, Acute Pain Service and Physical Therapy-Rehabilitation. The patient participated in Physical Therapy and met criteria for safe discharge home the next day. Her medical problem being hyponatremia was reversed and met criteria for discharge home.

Yes, the Inpatient admission was medically necessary.
Intra-articular fracture (tibial plateau) have improved short and long term outcomes with surgical restoration of the joint congruency and repair of associated menisci-ligamentous injuries should that be identified.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Hospital length of stay is determined by a predetermined set of criteria for safe discharge based on suitable pain control, correction of any impacting derangements in lab indices: blood loss anemia, hyponatremia as in this case.

The time line for the patient's cycle of care indicates that the index procedure concluded on the day of admission, and she met safe discharge criteria from a medical (Hospitalist and Acute Pain Service) and Therapy standpoint.

The intent for scheduled outpatient surgery for ORIF (open reduction internal fixation) of plateau fracture is certainly laudable, but with surgery concluding far after access to Therapy, and her ability to safely progress to the discharge criteria physically not met the next day despite her complete participation, this exceeded the initial goal of inpatient stay. In addition impacting variables being adequate oral multi-modal pain relief and correction of hyponatremia did not occur until the next day.

Therefore, as the patient did not meet discharge criteria initially, the Inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis (OA)

Treatment: Zilretta 32 mg (milligrams) to treat OA

The insurer denied coverage for Zilretta 32 mg to treat OA.

The denial is upheld.

This is a male with a history of obstructive sleep apnea (OSA), opioid abuse, osteoarthritis (OA), and spondylolisthesis of the lumbar region. He presented to the Orthopedic Surgeon's office with complaints of a three-week history of right knee pain. He received a Euflexxa injection which gave him significant relief. Cortisone therapy provided mild relief. Right knee pain is related to degenerative OA. The physician recommended continuing conservative management with rest, ice, and pain medications. He recommended Zilretta 32 milligrams (mg) injection to treat OA.

Zilretta is an extended-release type of corticosteroid injection. A review of literature supports use if other agents have not been effective. 

The Official Disability Guidelines reports:

Triamcinolone acetonide is a synthetic corticosteroid that provides an anti-inflammatory response. The extended-release formulation consists of poly (lactic-co-glycolic acid) (PLGA) microspheres that slowly release triamcinolone acetonide after intra-articular injection. (2)

In a double-blind study, adults or older with symptomatic knee osteoarthritis were randomized to treatment with a single intra-articular injection of extended-release triamcinolone, saline (placebo), or triamcinolone crystalline suspension (active control). Extended-release triamcinolone reduced the average daily pain intensity score at 12 weeks compared with placebo; there was no difference compared with control. (1) A review article notes that there is no role for extended-release triamcinolone injection based on current evidence. (2) Adverse effects include local post-injection inflammatory reactions. (1)

It is important to note the patient had received two prior corticosteroid injections which did not provide long term benefit. (Methylprednisolone). There is no documentation that a formulary agent was utilized nor ineffective. For example, Kenalog or Betamethasone. 

Kenalog is triamcinolone. It should be utilized first before trying a special long-acting preparation. There is no literature supporting Zilretta as a first line medication. 

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

The insurer's denial of coverage for Zilretta 32 milligram (mg) injection to treat osteoarthritis (OA) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Areata

Treatment: Xeljanz 10 milligram (mg) tablet

The insurer denied coverage for Xeljanz 10 milligram (mg) tablet.

The denial is overturned.

The patient has a diagnosis of alopecia areata.  He has failed therapy with ILK (intralesional Kenalog) and topical as well as oral steroids.  He has been on Xeljanz therapy without any noted complications and with excellent clinical response.  The requested medication is continuation of Xeljanz.  

The patient has extensive disease involvement of alopecia which necessitates systemic therapy.  According to the submitted documentation, the patient has been on Xeljanz with excellent results.  The patient had previously failed ILK and topical as well as oral steroids.  The use of Xeljanz and its continuation is within the standard of care.  It would be unreasonable to discontinue a medication shown to treat the patient's condition after failure of standard therapies and with no FDA (Food and Drug Administration) approved alternative.  In this clinical situation, continuation of Xeljanz is an appropriate treatment option for treatment of alopecia areata.  As a result, the denial is reversed and the use of Xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment. 

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

The insurer's denial of coverage for the Xeljanz 10 milligram (mg) tablet is overturned.  Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Hives, Irritable Bowel Syndrome.
Treatment: Gastrointestinal pathogen panel.
The insurer denied the gastrointestinal pathogen panel.
The determination is overturned.

The patient had the onset of consistent diarrhea 1-2 weeks before presenting to her primary care physician (with hives). A gastrointestinal pathogen panel was negative. At issue is whether a gastrointestinal pathogen panel is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes, the testing at issue is likely to be more beneficial than any standard treatment or treatments for evaluation of the insured's diarrhea in this case. In this case with protracted diarrhea, the use of gastrointestinal polymerase chain reaction pathogen panel is supported. According to the 2017 Infectious Diseases Society of America guidelines for acute diarrhea, there are pathogens (such as Cyclospora cayetanensis) which can cause protracted diarrhea (as in this case) and cannot be detected with commonly used tests, but can be found with nucleic acid amplification tests (NAATs) [1]. According to the American College of Gastroenterology guidelines for the management of acute diarrhea, "traditional methods of diagnosis (bacterial culture, microscopy with and without special stains and immunofluorescence, and antigen testing) fail to reveal the etiology of the majority of cases of acute diarrheal infection. If available, the use of Food and Drug Administration (FDA)-approved culture-independent methods of diagnosis can be recommended at least as an adjunct to traditional methods"; the guidelines state that the polymerase chain reaction testing at issue in this case was 22 times more sensitive in clinical testing for the detection of parasite such as the Cyclospora found in this case [2]. Other literature also supports evaluation in patients with protracted diarrhea [3,4]. For these reasons, the testing at issue is supported as likely to be more beneficial than any standard treatment or treatments for evaluation of the insured's diarrhea in this case.