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

Diagnosis: Dental Problems/Other/Maxillary and Mandibular Crowding
Treatment: Dental/Orthodontic Procedure
The health plan denied the requested orthodontic treatment due to a lack of medical necessity. 
The health plan's determination is upheld.

The patient is a male with mild maxillary and mandibular crowding. Tooth #6 is erupting lingually, within the arch and baby tooth C remains. The patient has a Class I occlusion with a 4-millimeter (mm) overjet and a 4-mm overbite. The patient is treatment planned for 24-30 months of orthodontics to align the teeth and correct the bite, but the plan was denied due to lack of medical necessity.

I uphold, in whole, the health plan's denial of medical necessity.

Tooth #6 is unerupted, but is not impacted since it has room to erupt and is in a favorable position as seen in the patient's panoramic radiograph. At the patient's current age, and given the tooth's position, it is very likely the tooth will erupt if given more time. There are no indications of gingival recession or pathology from the tooth position of #6. It is not as if the tooth is so crowded it is being prevented from erupting, which if left untreated could damage the roots of other permanent teeth, [1] leading to more invasive and expensive procedures than orthodontic treatment.
While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.[2] This patient presents with none of those conditions. If his teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism.
Treatment: Inpatient Hospital Stay.
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a past medical history (PMH) of endometriosis who was admitted with complaints of (c/o) a three-day history of shortness of breath (SOB) associated with left-sided pleuritic chest pain. Vital signs were notable for peripheral capillary oxygen saturation (SpO2) 99%, blood pressure (BP) 128/70, respiratory rate (RR) 19, and pulse 91. Her physical exam was notable for no apparent distress (NAD) and she was non-toxic appearing. Lab work was notable for negative troponins. A computed tomography (CT) scan of the chest showed pulmonary emboli in the left lower lobe branches of the left pulmonary artery. The patient was diagnosed with a pulmonary embolism and treated with low molecular weight heparin (LMWH), hematology/oncology consultation, and cardiac telemetry. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care.

This patient presented to the emergency department (ED) with c/o SOB associated with left-sided pleuritic chest pain and was found to have a left-sided pulmonary embolism. The patient had no history of cancer, heart failure, or chronic lung disease, there was no hypotension, persistent tachycardia, tachypnea, fever, altered mental status (AMS) or hypoxia. The pulmonary embolism severity index (PESI) score was consistent with class I, which is very low risk, with a 0-1.6% 30-day mortality. The PESI was also indicative of low-risk. In addition, there was no respiratory distress, hemodynamic instability, recent bleeding, or serious comorbid conditions. Patients with a PESI score less than 65 are very low risk for 30-day mortality (0%), and those with a score less than 85 are low risk for 30-day mortality (1%); patients in these categories can be considered for outpatient management. This patient was clinically stable, monitored and received anticoagulation, which could have been provided safely at a lower level of care.

Per the Milliman Care Guidelines (MCG) for Pulmonary Embolism, the patient did not have hypoxemia, severe vital sign abnormality, chronic cardiopulmonary disease, hemoptysis, arrhythmias of concern, syncope, right ventricle (RV) dysfunction, positive cardiac markers, was not at high-risk for acute complications, and outpatient anticoagulation was not contraindicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She presented with atypical chest pain and EKG (electrocardiogram) consistent with pericarditis. Her history was significant for hypertension and RA (rheumatoid arthritis).

The patient's cardiac enzymes were negative. Her labs were unremarkable, and echocardiogram showed normal LV (left ventricle) function, no pericardial effusion. She received one dose of beta blocker IV (intravenous) for hypertension. She was prescribed NSAID (nonsteroidal anti-inflammatory drugs) and colchicine for her discharge diagnosis of chest pain, pericarditis.

No, the Inpatient admission was not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome. The patient's exam and cardiac findings were normal; her BP (blood pressure) normalized. Biomarkers and EKG (electrocardiogram) showed no evidence of acute ischemia ("abnormal EKG [electrocardiogram]" consistent with pericarditis). CXR (chest x-ray) was normal. Echocardiogram showed no wall motion abnormality. Treatment did not reflect any serious concern about the patient's cardiac condition as ACS (acute coronary syndrome).  Orders did not include medical therapy for ACS (acute coronary syndrome) such as IV (intravenous) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV (intravenous) NTG (nitroglycerin).

The appropriate level of care is in the patient's best interest and Pericarditis can be safely treated in a lower level of care.

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease) or CHF (congestive heart failure).  While there was always a potential for an adverse event, and in this case a low probability, one did not happen, and no actual treatment was added.

Milliman criteria requirements for inpatient care were not fulfilled.

All testing and therapy that were provided would have been appropriate, safe and guidelines-consistent to be in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, Diabetes Mellitus, Coronary Artery Disease and Peripheral Vascular Disease.
Treatment: Increase in Consumer Directed Personal Assistance Services from 7 Days Per Week (Live-In) to 7 Days Per Week Two 12 Hours Shifts Per Day (Or 'Split Shift').

The insurer denied the Increase in Consumer Directed Personal Assistance Services from 7 Days Per Week (Live-In) to 7 Days Per Week Two 12 Hours Shifts Per Day (Or 'Split Shift').  The denial is overturned. 

The patient is a male with Stroke, Diabetes Mellitus, Coronary Artery Disease and Peripheral Vascular Disease. Due to impairments related to these conditions, he requires assistance for completion of the majority of his/her activities of daily living (ADLs). An appeal review was requested for potential approval of 7 Days Per Week Two 12 Hours Shifts Per Day Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the Increase in Consumer Directed Personal Assistance Services from 7 Days Per Week (Live-In) to 7 Days Per Week Two 12 Hours Shifts Per Day (Or 'Split Shift') is medically necessary.

Recent documentation noted in the patient's medical records indicates that the patient has been experiencing progressive functional decline, including worsening weakness, confusion, gait ataxia and agitation. Specifically, progress reports from the patient's provider indicate that the patient has sustained numerous falls due to dizziness and gait ataxia. Hence, the currently approved plan is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 7 Days Per Week Two 12 Hours Shifts Per Day Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Migraine Headaches (G43.711). 
Treatment: Emgality 120mg/ml (milligrams/milliliter) Pen, Pre-service. 

The insurer denied the Emgality 120mg/ml Pen, Pre-service.  The denial is upheld. 

No, the treatment with Emgality is not medically necessary. 

There are no high-quality clinical studies or standard-of-care guidelines demonstrating that Emgality is safe or effective when used with Botox for migraine prevention. The pivotal trial leading to the FDA (United States Food and Drug Administration) approval of Emgality for migraine prevention excluded persons who were treated with Botox at study commencement. Therefore, the safety and efficacy of Emgality combined with Botox remains undetermined (Pellessi et al.).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inflammatory Spondyloarthropathy.
Treatment: Humira 40 mg (milligrams) Weekly, Pre-service.

The insurer denied the Humira 40 mg (milligrams) weekly, pre-service.  The denial is upheld.

The patient is a female with axial and peripheral spondyloarthropathy (SpA) and fibromyalgia.  She failed treatment with methotrexate, steroids, Celebrex, Cymbalta, gabapentin and cyclobenzaprine.  She has been treated with Humira 40 milligrams (mg) every other week for a few months.  

At the patient's office visit recently, the patient was taking Humira 40 mg every other week and sulfasalazine 500 mg twice daily, but had discontinued prednisone 5 mg daily.  Axial and enthesitis symptoms were improved with Humira, but she remained with active small joint peripheral arthritis.  Humira helped with symptoms until approximately day 8.  The plan was instructed to progressively titrate sulfasalazine up to 1500 mg twice daily, resume prednisone, and increase Humira to 40 mg weekly.  This patient has not tried or failed any other biologic therapies.  Appeal is for Humira 40 mg weekly for the treatment of axial and peripheral spondyloarthropathy.

No, the proposed treatment with Humira 40 mg weekly is not medically necessary.

Humira is FDA (Food and Drug Administration)-approved for the treatment of ankylosing spondylitis at a dose of 40 mg every other week.  Humira is not FDA-approved for this indication at a dose of 40 mg weekly, as requested for this patient.  This patient with spondyloarthropathy had a partial response to Humira dosed every other week in combination with a sub-therapeutic dose of sulfasalazine.  Her dose of sulfasalazine is being progressively increased, and prednisone is being resumed to help with residual peripheral arthritis symptoms.  It is not yet documented whether the patient has responded to this.  

There are multiple other FDA-approved medication regimens that could be used to treat this patient's condition, including various other tumor necrosis factor (TNF) inhibitors in the presence or absence of disease-modifying anti-rheumatic drug (DMARD) therapy, before resorting to off-label dosing of Humira.  Thus, prior to optimizing standard-of-care DMARD and alternate biologic therapy, treatment with weekly Humira for spondyloarthropathy (SpA) is not in accordance with standard of care in the rheumatology community, and not medically necessary for this specific patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces.

The insurer denied the Braces.  The determination is upheld.

The patient has a Class II occlusion and moderate overbite and overjet. The maxillary and mandibular arches are crowded. According to the treatment notes the second molars are blocked out. He is treatment planned for 24-30 months of orthodontics with extraction of four premolars to correct his malocclusion. At issue is whether braces are medically necessary.

There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite; however, that alone is not a medical necessity to treat. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 4 millimeter (mm) overjet, but excessive overjet does not affect oral health related quality of life unless it is greater than 6 mm. (2) If the teeth were aligned, it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, the treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and office visits. 
The denial is overturned.

The patient in question is a male with buccal (reverse) crossbite on tooth number 5 and a deep bite. He presents with a skeletal Class I malocclusion with maxillary spacing and mandibular crowding. He is treatment planned for 30-36 months of orthodontics. The subject under review is the medical necessity for braces and office visits.

The health plan's determination is overturned in whole.

The treatment of braces and office visits is medically necessary for this patient. Because tooth 5 is in buccal crossbite, it has no antagonist. As a result, it is extremely likely that this tooth will overerupt. Overeruption of teeth in buccal crossbite can lead to occlusal interferences and loss of periodontal bone support. [1] Buccal crossbites negatively affect the growth of the mandible and should be corrected as early as possible. [2]

Once this overeruption occurs, it is very difficult to treat. [3] If left untreated, the damage that will occur to the patients teeth will be much more complicated to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Autism Related Treatment (including Applied Behavior Analysis services) 10 hours per week 1:1 service, 1 hour per week supervision). 

The insurer denied mental health services (Applied Behavior Analysis services) 10 hours per week 1:1 service, 1 hour per week supervision).  The denial is overturned in whole.

The patient is a male who has been diagnosed with autism spectrum disorder, level 3, requiring very substantial support. Included for review were a report by his Applied Behavioral Analysis (ABA) provider, board certified behavior analyst (BCBA), and an additional letter by the provider, the treating psychiatrist, the father, and guardianship document.

The BCBA report describes that the patient was first diagnosed with autism spectrum disorder when he was a child. He attends an individual day program through the Department of Developmental Services. Apart from seasonal allergies, his general health is good. He is non-verbal and has very limited receptive language ability. Challenging behaviors include physical and verbal stereotypies, self-injurious behavior (forcefully banging his forehead with his hand, and hair pulling), pushing, elopement and theft. On the Vineland Comprehensive Adaptive Behavior Assessment administered the patient was scored at or below the first centile for all domains. He scored in the Elevated range for both Internalizing and Externalizing Maladaptive Behaviors. At issue in this review is the medical necessity for the additional Mental health services (ABA Services) (10 hours per week 1:1 Service, 1 hour per week Supervision).

The health plan's determination is overturned in whole.

The requested services are medically necessary. Given his increase in aggression and other challenging behaviors during the Covid 19 pandemic, discontinuation of the requested ABA Services (10 hours per week 1:1 Service, 1 hour per week Supervision) previously provided is likely to result in a further increase in maladaptive behaviors.

Muetler et al. [2] published the results of a study investigating the behavioral effects of the Covid 19 pandemic on 87 individuals with autism spectrum disorder aged 3-29 years whose families were administered the Aberrant Behavior Checklist before and after the pandemic. The authors described a "Covid-19-related clinical presentation that resembled Post Traumatic Stress Disorder in individuals with autism spectrum disorder in terms of increased stereotypies, aggression, hypersensitivity, behavioral problems, and sleep and appetite alterations."

The ABA therapist's report indicates that the patient has been making progress in all goals of his ABA therapy, but he is noted to have had increased maladaptive behaviors since the Covid 19 pandemic. His maladaptive behaviors are highly likely to increase if the requested ABA Services (10 hours per week 1:1 Service, 1 hour per week Supervision) are withdrawn.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: small bowel Crohn's disease

Treatment: Humira Starter Pack + Humira 40mg

The insurer is denied coverage for Humira Starter Pack + Humira 40mg

The denial is upheld. 

This female patient has a history of small bowel Crohn's Disease.  At the office visit with pediatric gastroenterologist she was noted to have growth deceleration, poor weight gain and recurrent abdominal pain.  Her weight was 35.1 kilograms (kg).  The physician is requesting coverage for the 80 milligrams (mg) starter kit dosing to provide 160 mg then 80 mg initial doses, followed by 40 mg every other week maintenance.

A publication on consensus guideline of European Crohn's and Colitis Organization (ECCO)/ European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) on the medical management of pediatric Crohn's disease recommended "Adalimumab should be administered as induction therapy at 2.4 mg/kg (maximum 160 mg) at baseline, 1.2 mg/kg (maximum 80 mg) at week 2, followed by 0.6 mg/kg (maximum of 40 mg) every other week. Alternatively, for patients under 40 kg dosing regimens of 80-40-20 mg were proposed, and for patients over 40 kg dosing regimens of 160-80-40 mg. Weekly injections should be considered in patients losing response or with low trough levels". (1)
A pivotal IMAgINE-1 trial was the first double-blind randomized evaluation of adalimumab in 192 children aged 6-17 years with moderate to severe Crohn's disease. Subjects who were <40kg, underwent induction therapy with 80mg on week 0, 40mg at week 2 followed by either 20mg (standard or high dose) or 10mg (low dose) every other week. At week 26, 33.5% in the high dose arm were in clinical remission compared to 23.2% in the low dose arm; P=0.1 (no significant difference between high and low dose groups. (2) 
Another paper looking at the safety, efficacy and pharmacokinetics of adalimumab based on IMAgine-1 trial determined that at week 52, adalimumab trough concentrations (mean  SD) were higher for patients in the standard-dose (9.48  5.61 g/mL [micrograms/milliliters] ) compared with the low-dose (3.51  2.21 g/mL) arm. In patients whose doses were increased from every other week to weekly, higher trough concentrations were observed after dose escalation. Higher body weight, baseline C-reactive protein, and lower baseline albumin levels were associated with greater clearance of adalimumab. An exposure (serum concentration)-efficacy relationship was observed, in which higher concentrations of adalimumab were associated with greater rates of remission. (3)
In clinical practice, as per protocol, adjusting adalimumab maintenance dosing from every other week to weekly administration in the setting of loss of response or inadequate response with the goal of achieving and sustaining continuous clinical remission is routinely employed. (4)

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

The carrier's denial of coverage for the Humira Starter Pack + Humira 40mg is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin Disorders/Other/Tinea Unguium. 
Treatment: Pharmacy/Prescription Drugs. 

The health plan denied the requested prescription drug, Jublia. 

The health plan's determination is upheld. 

The patient is a female. Jublia was prescribed for tinea unguium. 

The health plan's determination is upheld, in whole. 

The patient has not failed or been intolerant to and has no contraindication to formulary alternatives including Itraconazole and Terbinafine. There is not published literature demonstrating Jublia to be more efficacious than or safer than either of these formulary agents. In summary, the formulary drug has not been and will not be ineffective, would be as effective as the non-formulary drug, and would not have adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/ Osteoarthritis. 
Treatment: Home Health Care. 

The health plan denied the requested increase in personal care assistant hours. 
The health plan's determination is overturned, in whole. 

The patient is a female with a past medical history of osteoarthritis, coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus type 2, hearing loss, iron deficiency anemia, bladder incontinence, glaucoma, chronic obstructive pulmonary disease (COPD), and depression who had been assigned personal care assistant (PCA) services 6 hours/day, 7 days/week, to total 42 hours/week based on assessment tool performed, assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, stairs, transportation, bathing, dressing upper/lower body, walking, and locomotion while limited assistance with tasks of phone use, equipment management, personal hygiene, transfer toilet, toilet use, bed mobility, and eating. At issue is the medical necessity of the requested increase in personal care assistant hours. 

The health plan's determination of medical necessity is overturned, in whole. 

Yes. The patient had an injury with left hip fracture with subsequent documented decline in cognitive, physical, and medical status since this fall with fracture. The patient also has chronic progressive medical conditions as documented in the medical records. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, live-in, 7 days/week, to total 168 hours/week 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.