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

Diagnosis:  Psoriatic arthritis, Psoriasis.
Treatment:  Xeljanz.

The insurer denied coverage for Xeljanz.  The denial is overturned. 

This is a female patient with a history of psoriasis and psoriatic arthritis.  The patient also has a history of depression, anxiety, alcohol related liver disease, obstructive sleep apnea (OSA), gastroesophageal reflux disease (GERD).  She saw her primary doctor for complaints of pain and stiffness and swelling in bilateral hands.  The patient received adalimumab for three months and secukinumab for four months without significant relief in her joint pain.  She had psoriatic patches on the bilateral elbows, which have resolved.  The patient's electromagnetic radiation (x-ray) tests showed evidence of erosive changes at her proximal interphalangeal (PIP) joints bilaterally.  The patient had on-going inflammation at the distal interphalangeal (DIP) joint and prolonged morning stiffness.  The insurer has denied coverage for Xeljanz. 

In terms of non-biologic disease modifying antirheumatic drug (DMARD), the patient cannot be treated with methotrexate or leflunomide, due to her alcoholic liver disease.  Literature also indicated that azathioprine and sulfasalazine can also cause liver side-effects, and are of low benefit in patients with psoriatic arthritis.  According to UpToDate article "Treatment of Psoriatic Arthritis", Xeljanz (tofacitinib), "an oral Janus kinase (JAK), has demonstrated efficacy in the treatment of psoriatic arthritis in several randomized trails, including both patients with an inadequate response to a conventional synthetic DMARD and patients with an inadequate response to tumor necrosis factor (TNF) inhibitor therapy."  In this case, the patient has failed adalimumab and secukinumab and cannot tolerate DMARDs, such as methotrexate, due to her liver disease.  Thus, Xeljanz is considered medically necessary for this patient. 

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

The carrier's denial of coverage for Xeljanz should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: molar occlusion.
Treatment: Braces/monthly visits.
The insurer denied the braces/monthly visits. The health plan's determination is overturned. 

The patient in question is a male with a Class II molar occlusion. He has a buccal (reverse) crossbite on tooth #5, and a crossbite on #4. Tooth #4 does not have the space to fit into the dental arch. He is treatment planned for 36 months of orthodontics with extraction of tooth #4 but treatment was denied due to lack of medical necessity.

Braces and Monthly Visit are medically necessary for this patient.
Because tooth #4 is in buccal crossbite, it has no antagonist. As a result, it is extremely likely that tooth #4 will over erupt. Once this overeruption occurs, it is very difficult to treat.

If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)
Treatment: Trelegy Ellipta
The insurer denied the Trelegy Ellipta.
The denial is overturned. 

The patient is a female with severe COPD (chronic obstructive pulmonary disease) who is being treated with Trelegy Ellipta. The patient has tried and failed Breo and Incruse Ellipta. The patient has been on Trelegy Ellipta with good symptoms control and reduction in COPD exacerbations as well as improved quality of life. 

The health plan denied Trelegy Ellipta, since the patient has not tried and failed two separate prescriptions for Arnuity Ellipta in combination with Anoro Ellipta, the components of Trelegy Ellipta.

Yes, the treatment with Trelegy Ellipta is medically necessary.

The health plan denied Trelegy Ellipta since the patient has not tried and failed two separate prescriptions for Arnuity Ellipta in combination with Anoro Ellipta, the components of Trelegy Ellipta. The patient has tried and failed Breo in combination with Incruse Ellipta, which is similar to Arnuity Ellipta in combination with Anoro Ellipta. Thus, the Arnuity Ellipta in combination with Anoro Ellipta is not likely to improve the patient's symptoms as well as single triple therapy. The single triple therapy inhaler is also likely to improve compliance as compared to using two different inhalers.

In patients with symptomatic COPD at risk of exacerbations, once-daily FF (fluticasone furoate)/UMEC (umeclidinium)/VI (vilanterol) (Trelegy Ellipta), compared with FF/VI or UMEC/VI, improved patient-perceived HRQoL (health-related quality of life) and symptoms. Triple therapy showed improvements in lung function, health status using the St. George's Respiratory Questionnaire, and exacerbations when compared to single or double therapies. The current literate data suggest that the triple therapy (Trelegy Ellipta) is likely superior to single or double therapy. The continued use is medically necessary in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hepatitis C.
Treatment: Pharmacy/Prescription Drugs (Epclusa).
The health plan denied the request for Epclusa. 
The health plan's determination is overturned.

This is a review for the use of Epclusa (Sofosbuvir/Velpatasvir) to treat acute hepatitis C virus (HCV) genotype 2b infection. This female was diagnosed with HCV infection. She is treatment naive. Her HCV viral load is just 30,500 IU (international units) / milliliter. She has stage F0-F1 fibrosis on an HCV Fibrosure test. Her attending physician would like to use Epclusa for 12 weeks to treat this patient's HCV genotype (an individual's collection of genes) 2b infection.

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

Yes, the requested health service/treatment of Sofosbuvir/Velpatasvir 400/100 MG (Epclusa) is medically necessary for this patient. Based on current guidelines and standard of care. Patients with acute HCV infection who have a detectable viral load should be treated.
According to the current updated guidelines by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) in collaboration with the International Antiviral Society-USA (IAS-USA) for management of chronic HCV: After the initial diagnosis of acute HCV with viremia (defined as quantifiable ribonucleic acid (RNA), HCV treatment should be initiated without awaiting spontaneous resolution.
Patients with acute HCV infection should be treated upon initial diagnosis without awaiting spontaneous resolution, using a "test and treat" strategy. Real-world data have demonstrated a reduction in HCV viremia prevalence and incidence with unrestricted access to HCV therapy. In addition, mathematical modeling suggests that direct-acting antiviral (DAA) treatment scale-up, especially among those at highest risk of transmission, can reduce HCV incidence and prevalence. Moreover, delay introduced by waiting for spontaneous clearance may be associated with loss to follow up. Owing to high efficacy and safety, the same regimens that are recommended for chronic HCV infection are recommended for acute infection.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal
Pharmacy/Prescription Drugs

Diagnosis: Osteoarthritis
Treatment: Euflexxa injections
The insurer denied Euflexxa injections. The health plan's determination is upheld. 

This case describes a male patient with a complaint of left knee pain. This patient has a known history of bilateral knee osteoarthritis and has been treated with viscosupplementation injections in the past. The supplied records document that the last series of Euflexxa injections were completed. The records contain an office note in which the patient expressed a desire to proceed with a repeat course of Euflexxa for both knees. The note states that the patient was not seen in person and there was therefore no physical examination completed due to Covid 19 restrictions. The provider planned to seek authorization for bilateral knee Euflexxa injections. 

The requested bilateral knee Euflexxa Injections are not medically necessary for this patient. This determination is based upon the conclusions of recent articles published by Tammachote and colleagues in the Journal of Bone and Joint Surgery in 2016 and by Jevsevar and associates in the Journal of Bone and Joint Surgery in 2015. These articles found that injections such as the Euflexxa requested in this case are no more effective than a corticosteroid injection or a placebo for the treatment of knee osteoarthritis. Furthermore, the American Academy of Orthopedic Surgeons does not endorse the use of viscosupplementation injections for the treatment of knee osteoarthritis based on the most recent evidence-based treatment guideline for the treatment of osteoarthritis of the knee.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Stelara. 
The denial is upheld in whole.

The patient is a female with hidradenitis suppurativa that involves her stomach; the clinic notes report cysts of the chest, back, arms, abdomen, thighs, and axillae. The patient has tried and failed topical clindamycin gel, 10% body wash, and oral spironolactone. The patient has had a gastric sleeve surgery less than a year ago, so antibiotics are being avoided. Humira was being used with success for four years, but the patient was diagnosed with a systemic drug rash six months ago and was forced to cease treatment. The COVID-19 pandemic has led the provider to avoid restarting Humira because it is immunosuppressive. A sample of Stelara was tried, and signs of improvement have occurred since then.
Medical necessity for treatment with Stelara is the subject under review.

The health plan's determination is upheld in whole.

All current medical literature [1-5] supports the use of tumor necrosis factor inhibitors over Stelara as proven treatments with greater time-tested experience and literature support. Stelara has a potential role to be used as a fourth-line treatment, if tumor necrosis factor inhibitors have, as a class, failed or been proven intolerable to patients with severe hidradenitis suppurativa. Otherwise alternative tumor necrosis factor inhibitors are the medically necessary course of action to most appropriately and reliably treat this patient as supported by the medical literature. Therefore, in accordance with the peer reviewed literature and the standard of care, the use of Stelara for this particular clinical scenario is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned


Diagnosis: Asthma
Treatment: ASMANEX
The insurer denied ASMANEX. 
The health plan's determination is overturned. 

The patient is a male with chronic asthma and chronic rhinitis who was using ASMANEX 200 micrograms (mcg) and the asthma was well controlled. The ASMANEX was stopped briefly during the summertime and the pediatric pulmonologist is requesting to restart the treatment for the winter. As per the note, the time when patient was on ASMANEX, the asthma was well controlled.

A formulary exception is indicated in this case. ASMANEX 200 mcg once a day is needed for the adequate control of the asthma. The pediatric pulmonologist tried the Flovent before without adequate control of the patient's asthma. Given the patient is a young child and the comorbidity of chronic allergic rhinitis, ASMANEX is better than the formulary alternatives.
While the patient is on ASMANEX, the exacerbation of asthma was almost nil with no requirement for intermittent steroids. Also, ASMANEX has a favorable systemic absorption profile better than other inhaled corticosteroids. Flovent has almost 17 percent systemic absorption, however, the ASMANEX has only less than 1 percent systemic absorption.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Pes cavus, Plantar fasciitis

Treatment: Custom-molded foot orthotics

The insurer denied coverage for custom-molded foot orthotics.

The denial is overturned.

This is a female child diagnosed with bilateral Pes cavus and plantar fasciitis. An office visit indicated that the provider was requesting custom-molded foot orthotics as the patient was unable to wear normal foot care without pain. The functional orthotics were medically necessary to control or eliminate many path of mechanical problems arising from foot or leg deformities. The provider noted that she was pain free while wearing orthotics. The patient experienced pain when not using orthotics. The patient had undergone a virtual visit and was still presenting with a bilateral high arch. The patient was doing some foot exercises regularly that did not help with the pain unless she was wearing orthotics. The patient had outgrown her current orthotics and they were worn out and torn and did not support a high arch. The patient was in need of a replacement pair. The provider noted the patient could not use nonsteroidal anti-inflammatory drugs to alleviate the pain because she had irritable bowel disease. Medications to treat the patient's ailments were not advised given the patient's age and the potential for liver damage.

The use of foot orthotics has been proven and studied in literature for many years and is generally accepted as a standard of care for conservative treatment for Pes cavus foot structure and plantar fasciitis. The health policy stated that the custom-molded foot orthotics were denied due to the child not having "unequal legs, ankles that are bent, and part of foot removed": in a Pes cavus foot structure, the ankles are inherently structurally "bent" due to limited rearfoot motion and excessive supination biomechanically. The criteria also stated that the patient has not "tried conventional treatments like exercises, therapy, or over the counter pain medications," which is also not correct. The notes from the referring physician clearly state that the patient has done exercises and is unable to take medications due to gastrointestinal comorbidity. Therefore, custom orthotics are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for custom-molded foot orthotics is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: shortness of breath.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a man with history of asthma who presented to the hospital. He presented with a chief complaint of shortness of breath. He denied fevers, chills, nausea and vomiting. Other past history included bipolar disorder, heroin abuse and personality disorder. Vital signs showed Blood pressure 132/68, heart rate 80, temperature 97.9 Fahrenheit, and respiratory rate 20. On physical examination, heart was regular, breath sounds had wheezes but no crackles, abdomen was soft, and there was no cranial nerve deficit. Chest x-ray was negative for pneumonia. Labs showed white blood cell count (WBC) 12.4, hemoglobin 14.2, platelets 159, creatinine 0.73, sodium 139, and potassium 4.8. The patient was admitted for acute asthma exacerbation in the setting of drug use. The plan of care included bronchodilators, azithromycin, prednisone, pulmonary function testing, brain (or B-type) natriuretic peptide (BNP) testing, D dimer, consider chest computed tomography (CT), COVID-19 testing, and outpatient pulmonary consult. 

The inpatient hospital admission was not medically necessary. The patient presented with shortness of breath but he was hemodynamically stable, had a normal oxygen saturation, had a negative chest x-ray with no evidence of acute pneumonia, did not have evidence of sepsis, and overall was stable. Inpatient care was not needed to evaluate his symptoms.

The patient did have risk factors for a potentially adverse outcome, particularly because of his history of heroin use. However, he demonstrated improvement within the first 24 hours, with a reduction in dyspnea and overall symptoms. In addition, he did not have hypoxemia. Given rapid improvement in 24 hours, albeit still in a state requiring additional medical care, he could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

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

The patient is a man who presented to his provider's office with 3 days of exertional chest pain. He had had stenting 2 weeks earlier after sustaining a non-ST elevation myocardial infarction (NSTEMI). The patient had a history of hypertension and hyperlipidemia. He was taken to the emergency department (ED). The electrocardiogram (ECG) showed no ischemic changes. The patient was admitted, myocardial infarction (MI) ruled out by serial troponins, and treated medically. The patient was discharged in stable condition. Under review is the inpatient stay.

The inpatient stay was not medically necessary. The patient had chest pain which may have been an acute coronary syndrome, although this was unlikely. It was reasonable to observe the patient to rule out myocardial infarction. This could have been performed at a lower level of care. Further, it was reasonable to consider stress testing or catheterization, but these could have been performed at a lower level. In fact, neither of these tests were performed. There was no medical necessity requiring an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental or orthodontic procedure. 
The insurer denied braces and monthly visits x 12. 
The denial is upheld in whole.  

The patient is a male with Skeletal Class I dental arches with Class II cuspid malocclusion. The patient has mild maxillary crowding and moderate mandibular crowding. There is moderate overjet and severe overbite.
The subject to be determined is the medical necessity for braces and 12 monthly visits.

Braces and monthly visits x 12 is not medically necessary for this patient. Using the Handicapping Labio-Lingual Deviation (HLD) index, which is the standard guideline for determination of medical necessity, the malocclusion would score a 19 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeter (mm) or greater and underbite 3.5mm or greater. Using the standard guideline, a score of 26 or more is required for treatment to be considered medically necessary. The malocclusion in question does not meet the standard guideline to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces and the 12 month visits are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Orthodontic Treatment and Periodic Treatment Visits.
The insurer denied the Orthodontic Treatment and Periodic Treatment Visits.
The determination is upheld.

The patient has a Skeletal Class I dental arches with Class II cuspid malocclusion, mild maxillary crowding, and moderate mandibular crowding with bimaxillary protrusion and proclination of incisors. The issue for review is the medical necessity for braces and periodic office visits.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 12 with no auto qualifiers. Auto qualifiers include a cleft palate deformity or craniofacial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater, and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. There is no anterior crossbite at the mandibular right lateral incisor when viewing the right buccal intra-oral photo; there is actually an overjet. In addition, there is no evidence of gingival recession on the mandibular right lateral incisor, again per the right buccal intra-oral photo. The malocclusion in question does not meet the criteria to be classified as handicapping, and the treatment would not be considered medically necessary. Thus, braces and periodic office visits are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thyroid nodule.
Treatment: BRAF genetic testing and molecular pathology.
The insurer denied the BRAF genetic testing and molecular pathology.
The denial is upheld. 

The patient is a male who underwent ultrasound and biopsy of a thyroid nodule. "For the purpose of determining malignancy, of which the results came back suspicious for malignancy," the patient and his physicians requested approval for BRAF genetic testing and molecular pathology. 

No, the proposed treatment, BRAF genetic testing and molecular pathology, was not medically necessary. 

According to guidelines from the National Comprehensive Cancer Network (NCCN), "Molecular diagnostics may be useful to allow reclassification of follicular lesions as either more or less likely to be benign or malignant based on the genetic profile." However, molecular testing in-and-of-itself is of limited utility, for "Molecular markers should be interpreted with caution and in the context of clinical, radiographic, and cytologic features of each individual patient." Therefore, in the absence of "clinical, radiographic, and cytologic features," BRAF genetic testing and molecular pathology was not medically necessary. [NCCN]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied treatment with Lupron. The denial is upheld in whole. 

The patient is a male diagnosed with central precocious puberty (CPP). This request is for Lupron Depot. As reported, he has been on Lupron Depot (approved last year) and he is tolerating it well. He began developing pubic hair between age two years ago with a growth spurt noted beginning three years ago. His 4th injection was in the beginning of the year. His testes are 6 milliliters (ml) bilaterally with tanner 2-3 and pubic hair is at Tanner III. 

The subject under review is the medical necessity for treatment with Lupron. 

The health plan's determination is upheld in whole. 

The definition of precocious puberty is children who have the onset of secondary sexual characteristics younger than age 8 in girls and younger than age 9.5 in boys.[1-3] Central precocious puberty (CPP) is diagnosed using a basal luteinizing hormone (LH) of greater than (>) 0.3 or stimulation testing with a gonadotropin-releasing hormone (GnRH) analog such as leuprolide showing a pubertal response defined as an LH >5 and estradiol greater than 40. [4] CPP is treated with GnRH agonists[5-10] such as Lupron[11] and supprelin.[12] The Food and Drug Administration (FDA) indication for GnRH agonists is for use in central precocious puberty (CPP). In addition, when used for CPP the FDA recommends discontinuation of GnRH agonists before age 11 for females and before age 12 for males.[11] This is consistent with accepted recommendations for discontinuation of GnRH agonist therapy at a bone age of 12 in girls and 13 in boys. [2, 4-7] 
The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.