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

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Surgical Services. 

The insurer denied outpatient surgery. 
The denial is upheld. 

The patient is a female who complains of chafing, rashes, infections and irritation on her upper arms due to excess skin from weight loss. Her surgeon recommends brachioplasty to treat her symptoms. Photos show excoriations. The subject under review is the medical necessity for the requested surgery. 

The health plan's determination is upheld. 

The records do not establish medical necessity for the proposed brachioplasties. The patient's condition does not meet the American Society of Plastic Surgery criteria for third party coverage of skin resection following massive weight loss. According to the American Society of Plastic Surgery Position Paper "Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients," (1) "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. 
The records do not indicate any rare circumstances that mandate treatment with brachioplasties. According to a 2010 outcome analysis of brachioplasty surgery, "Patients report improvement in contour and self-esteem, and a high level of satisfaction with this procedure, despite the potential for an unfavorable scar." This study found improvements in self-esteem and contour but did not describe functional benefits from brachioplasty surgery. According to Sergesketter et al.: "Brachioplasty has become one of the fastest-growing aesthetic surgery procedures, paralleling rising rates of weight loss surgery nationally." 
The records do not document any attempts at medical treatment for her rashes with topical barrier creams or anti-fungal medications. Based on the standard of care, physician supervised treatment is the simplest, and safest method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is certainly not the case for this patient.
Appeal type: Medical necessity
Decision: Upheld

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

This case describes a male patient who injured his left ankle after slipping and falling on some ice. He was evaluated in the emergency department. The patient suffered a left ankle bimalleolar ankle fracture dislocation. The patient was subsequently admitted for definitive care. Surgery was performed without complications. The patient was deemed stable for discharge home. 

The inpatient hospital admission was not medically necessary for this patient. First, the provided medical records comment that the patient sustained an acute bimalleolar ankle fracture after slipping on some ice. The patient was admitted for further work up and definitive care. The patient was taken to the operating room for surgical fixation of the ankle fracture but there is no documentation in the patient's chart as to why the surgery was delayed for 2 days. The surgery was completed without complications. The patient's lab values and vital signs remained normal during the entire hospital stay. There was no documentation of any post-operative complications to include infection, blood clots or any other medical issue that would necessitate the inpatient hospital admission. Thus, based upon the provided documentation in the medical records, the inpatient stay is not indicated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Diabetes, hypertension, congestive heart failure and chronic obstructive pulmonary disease (COPD)

Treatment: Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 40 hours per week

The denial is modified

The patient has chronic medical problems including diabetes, hypertension, congestive heart failure and chronic obstructive pulmonary disease (COPD). She lives with her son in a 2-bedroom apartment. She was approved for CDPAS 14 hours/week. Under review is the requested increase Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's cognitive skills are described as "modified independent." She is fully alert and oriented. She "can describe emergency event and able to dial 911 in emergency event." The patient requires extensive assistance for bathing and lower body dressing. Otherwise, personal hygiene, upper body dressing and toilet transfer/use requires only limited assistance. She is continent of bowel and bladder. She is able to walk with a cane and contact guard assistance. The clinical records do not substantiate a level of physical/cognitive impairment, debility or significant functional decline to warrant the medical necessity of an increase in CDPAP hours to 40 per week. However, increasing CDPAP to 28 hours/week is clinically appropriate; allowing the patient to continue living safely at home.  

The healthcare plan acted reasonably in part, with sound medical judgment and in the best interest of the patient. From a physical medicine and rehabilitation perspective, Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week is not considered medically necessary. However, 28 hours per week is considered medically necessary.

The insurer's denial of coverage for consumer directed personal assistance services (CDPAS) 40 hours per week is modified. Medical Necessity for increasing CDPAP to 28 hours/week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque Psoriasis.
Treatment: Otezla 30 mg.
The insurer denied the Otezla 30 mg.
The determination is upheld.

The patient has a diagnosis of psoriasis. The body surface area affected is 5% at baseline. He has failed Taclonex suspension, betamethasone and clobetasol solution. The medication under review is Otezla 30 milligrams (mg).


The requested health treatment of Otezla 30 mg is not medically necessary for this patient. According to the "National physician specialty society recommendations" for psoriasis- the American Academy of Dermatology Psoriasis Guidelines- and dermatology literature, systemic therapies such as methotrexate, cyclosporine and actiretin are effective treatments for the management of psoriasis (1, 2).
The request for Otezla is not medically necessary because the submitted records do not indicate that the patient has failed or has a contraindication or had an inadequate response to conventional systemic therapy.
Within the peer-reviewed literature, West et al 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve PASI75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (3).
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not necessary. It is noted that the patient has failed numerous topical steroids. However, there is no documentation provided that the patient has tried and/or failed methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Otezla medically more appropriate than the other options.
Therefore, the administration of Otezla is not strongly supported for this patient, and Otezla is not medically necessary for this patient based on the current evidence-based medical literature.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hypertrophied Turbinates.

Treatment: VivAer nasal airway reconstruction procedure.

The insurer denied coverage for VivAer nasal airway reconstruction procedure.

The denial is overturned.

This case involves a male who has previously been diagnosed with obstructive sleep apnea and chronic rhinitis. The documentation indicated he was seen for a follow-up and it was noted he would benefit from myofunctional exercises. It is noted he has 3-4 episodes of ethmoidal sinusitis typically treated with antibiotics. Per provided documentation he has had a trial of positive airway pressure (Pap) therapy however he was not able to maintain.  He has also undergone uvulopalatopharyngoplasty (UPPP) surgery and utilized an oral appliance. He did have moderate hypertrophy bilaterally on prior examination. He did have a diagnosis of obstruction of nasal valve and has utilize nasal sprays and Latera implants. The documentation indicated he underwent the requested procedure due to ongoing symptoms.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

The VivAer nasal airway reconstruction procedure has final approval from the appropriate regulatory bodies for this diagnosis. 

He was a good candidate based on pathology, symptoms and a failure of multiple medications and treatment.

VivAer nasal airway reconstruction procedure is the best available treatment for this patient at this time. The adverse risks do not increase over standard treatment/services.

According to peer-reviewed literature, temperature-controlled radiofrequency treatment of nasal valve collapse is safe and effective in reducing symptoms of nasal airway obstruction (NAO). The literature does indicate nasal valve collapse is 1 of several causes of nasal obstruction. The safety and efficacy of the requested procedure to treat the above has been established. The documentation indicated this patient was diagnosed with rhinitis in addition to nasal valve collapse and obstructive sleep apnea. The documentation indicated he has had a trial of multiple treatments to include surgical intervention, the use of an oral appliance, medication management, and Pap therapy. He did have evidence of moderate hypertrophy bilaterally in addition to obstruction of nasal valve. He exhausted other conservative treatment and therefore, given the requested procedure is noted to be safe and effective, the prior denial is overturned.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of VivAer nasal airway reconstruction procedure should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hypertrophied Turbinates.
Treatment: VivAer nasal airway reconstruction procedure.
The insurer denied coverage for VivAer nasal airway reconstruction procedure.
The denial is overturned.

This was a male with a documented history of hypertrophied turbinates and obstructive sleep apnea. He continued to have some symptoms and was found to have both nasal valves compromised. 

The patient underwent reduction of his hypertrophied turbinates using the VivAer radio frequency to improve his nasal airflow. An at home sleep study found that his AHI (Apnea-Hypopnea Index) was 3.9/hour with the normal standard being =<(less than or equal to) 5. This was an improvement from his prior study which found an AHI of 21.1.

The peer reviewed literature has shown that the VivAer is efficacious for improving the nasal airway1-8. The Food and Drug Administration (FDA) ruled that the VivAer stylus was "Substantially Equivalent (SESE)" and did not require further evaluation.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome using the VivAer1-8.

The VivAer nasal airway reconstruction procedure does not need final approval from the appropriate regulatory bodies for this diagnosis as the FDA ruled that the VivAer ARC stylus was SESE and did not require further evaluation. 

The patient was a good candidate for VivAer nasal airway reconstruction procedure. The efficacy of the procedure is evidenced by the improvement of his AHI from preoperative of 21.1 to 3.9 which is in the normal rage. 

The VivAer nasal airway reconstruction procedure provided was the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of VivAer nasal airway reconstruction procedure should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pleomorphic Liposarcoma of L (left) Forearm. 
Treatment: Current procedural terminology (CPT) code 71250, CT (computed tomography) of the chest without contrast. 

The insurer denied coverage for current procedural terminology (CPT) code 71250, CT of the chest without contrast. 

The denial is overturned. 

Patient is a male with history of soft tissue sarcoma.  The patient had a diagnosis (Dx) of Pleomorphic Liposarcoma of L (left) Forearm.  The patient had a computed tomography (CT) of chest for evaluation for metastatic disease which was unremarkable. The patient underwent surgery for removal of the cancerous lesion.  His surgeon is requesting a follow up chest CT for surveillance. 

Lung is the most common site for metastasis for soft tissue sarcomas.  NCCN (National Comprehensive Cancer Network) Guidelines for Soft Tissue sarcomas recommend follow up CT to detect metastasis every 3 to 6 months for the first 2 to 3 years and subsequently every 6 months for up to 5 years. 

Based on above it is reasonable to do the CT of the chest. 

Prior Denial is overturned. 

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

The insurer's denial of coverage for current procedural terminology (CPT) code 71250, computed tomography (CT) of the chest without contrast is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type I Diabetes Mellitus.
Treatment: Formulary exception for Lyumjev.
The insurer denied the Formulary exception for Lyumjev.
The denial is overturned.

The patient is a male with type 1 diabetes on insulin pump therapy. The request for Lyumjev is under review.

The prior request was denied coverage by the health plan, as the formulary requires trial and failure or intolerance or contraindication to Fiasp and Novolog. The physician is appealing this determination as the patient has tried and failed Novolog (due to uncontrolled glucose levels) and Fiasp (pump occlusions). Lyumjev has improved glucose control and has not occluded pump.

Yes, the health plan should cover the formulary exception for Lyumjev.
This request is for Luymjev for the treatment of type 1 diabetes. This patient has tried and failed the formulary alternatives Novolog (due to uncontrolled glucose levels) and Fiasp (pump occlusions). This patient's glucose levels have improved on Lyumjev. Without Lyumjev, this patient will be at increased risk of uncontrolled hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the health plan should cover the formulary exception for Lyumjev.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the hospital after a seizure at home. Her family called emergency medical services and she was transported to the hospital. Her seizure aborted spontaneously at home. She was briefly postictal. On arrival to the emergency room, she was treated with levetiracetam. The patient was admitted to the hospital for further evaluation. She had a negative computed tomography (CT) scan of the head and a negative magnetic resonance imaging (MRI) scan of the brain for an acute ischemic process. The patient underwent an electroencephalogram (EEG) that showed occasional left mid to posterior temporal sharp waves and occasional burst of generalized sharp and slow waves. Given the abnormality on the EEG, continuation of levetiracetam was recommended. She was discharged with outpatient neurology follow-up.
At issue is the medical necessity of an inpatient stay.

The requested inpatient admission is not medically necessary. The patient presented to the hospital after one seizure. She did not have any further seizures in the emergency room or during the hospitalization. While the patient did have a postictal state, the period was brief and resolved within the observation time frame. The patient did not have persistent altered mental status or a new neurologic deficit such as motor weakness in an arm or leg. Additionally, there were no significant cardiac, imaging, or laboratory findings suggesting an underlying cause of the seizures that required correction or intervention during hospitalization. The patient did have epileptiform activity on EEG suggesting a diagnosis of epilepsy. The patient was treated with levetiracetam and discharged on this medication for outpatient follow-up. None of the services required an acute inpatient admission due to rapid improvement during the observation period, lack of multiple seizures, and lack of a malignant etiology (cerebral hemorrhage, increased intracranial pressure, etc) that would benefit from hospitalization.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/cryptogenic stroke.
Treatment: Eliquis.
The insurer denied Eliquis. 
The denial is overturned.

The patient is a male with cryptogenic stroke. The patient was prescribed treatment with the non-formulary drug Eliquis. The plan denied Eliquis because the patient has not tried and failed the formulary alternatives of warfarin and Xarelto. The patient failed Xarelto due to rectal bleeding. The patient used Xarelto, but it caused rectal bleeding. The subject under review is whether the formulary drug will be less effective or have more adverse effects than the non-formulary drug requested.

The health plan's determination is overturned.

The patient has tried and failed Xarelto due to drug side effects that caused rectal bleeding. As such, the only drug that the patient has not tried and failed is warfarin. The literature clearly demonstrates that Eliquis is superior to warfarin for prevention of stroke and prevention of major bleeding complications. The Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial compared apixaban (a novel oral direct factor Xa inhibitor) with warfarin for the prevention of stroke or systemic embolism in patients with atrial fibrillation (AF) and at least one additional risk factor for stroke. The study demonstrated that apixaban 5 milligrams (mg) twice daily compared with warfarin was associated with a lower risk of stroke or systemic embolism, caused less bleeding including intracerebral hemorrhage (ICH), and resulted in lower mortality.
In summary the non-formulary drug Eliquis will be more effective for this patient and is the most appropriate choice in this case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: chronic migraine.
Treatment: Qulipta.
The insurer denied Qulipta. 
The health plan's determination is upheld.

The patient is a woman with chronic migraines. Treatment with Qulipta is the subject of this review. The patient has tried and failed Emgality, Nurtec ODT (oral disintegrating tablet), and topiramate. Qulipta was denied because the patient has not tried and failed the formulary alternatives of Ajovy and Aimovig. 

The requested formulary drug of Aimovig and Ajovy has not been ineffective and would not have adverse effects. Aimovig and Ajovy are anti- CGRP (calcitonin gene related peptide) injectable monoclonal antibodies. These drugs are Food and Drug Administration (FDA) approved for prevention of chronic migraine. These drugs have been shown to be safe and effective in randomized controlled trials. Qulipta is not FDA approved for prevention of chronic migraine. Qulipta is only FDA approved for prevention of episodic migraine. The patient does not have episodic migraine. Data are lacking to show that Qulipta is safe and effective for treatment of the patient's condition. Further studies are needed. A formulary exception is not indicated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atrial fibrillation.
Treatment: Eliquis.
The insurer denied the Eliquis.
The determination is overturned.

The patient has a history of hypertension, diabetes mellitus type 2, hyperlipidemia, and paroxysmal atrial fibrillation. A review of the patient records provided for this case demonstrates that the patient was initially anticoagulated with Xarelto, but due to drug intolerance, she was switched to the non-formulary apixaban for the prevention of a stroke. The patient's health plan has denied coverage for the non-formulary medication, apixaban. The patient's treating physician is appealing this denial.

At issue whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

Yes, based on records provided for review of this case, both formulary anticoagulants, Xarelto and warfarin, are medically inappropriate for this patient for this patient.
The patient has already failed treatment with Xarelto due to drug intolerance. Furthermore, based on published medical literature comparing warfarin to the direct oral anticoagulants for the prevention of stroke and systemic embolism, the direct oral anticoagulants are believed to be superior to warfarin for preventing stroke and systemic embolism with a lower risk of serious bleeding (1). For these reasons, the non-formulary anticoagulant, apixaban, is the most medically appropriate treatment to prevent stroke for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding; overjet; crossbite. 
Treatment: D8080 Braces and D8670 Monthly Visit. 

The insurer denied the D8080 Braces and D8670 Monthly Visit. 
The denial is overturned. 

The patient is a male. The request is for orthodontic treatment (braces) and monthly visits. 

Per the dental clinical summary, the patient presents with class I skeletal relationship, Class II canines, severe maxillary crowding, moderate mandibular crowding, moderately excessive overjet, anterior crossbite with gingival attachment loss (mandibular right canine). 

The health plan denied coverage for the braces, because the patient did not score a 26, the score needed on the Handicapping Labio-Lingual Deviation (HLD) Index report for orthodontic treatment approval. 

The provider appealed the case based on the diagnoses. 

Yes, the requested braces and monthly visits are medically necessary. 

As evident in the photos and x-rays, the patient has an excessive overjet of greater than 4mm (millimeters). Normal overjet is 1-3 mm (millimeters). 

Any significant overjet beyond normal puts the patient at risk for increased trauma due to the protrusion, sleep apnea, speech impediments and possible damage to the soft tissue (gums) from the position of the lower teeth coming in contact with the upper gums. 

Therefore, given the above, the requested braces and monthly visits are medically necessary. 

No, the health plan did not act reasonably , with sound medical judgement and in the best interest of the patient. 
Cases of severe overjet that are not corrected can have severe long term negative effect on the patient's ability to have normal chewing function and speech.