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

Diagnosis: Capillary Venous Malformation

Treatment long-pulsed pulsed dye laser therapy

The insurer denied coverage for long-pulsed pulsed dye laser therapy

The denial is overturned

The patient is a child with a diagnosis of capillary venous malformation involving the left mid and upper face, including the periorbital area and lip.  The patient has been treated for many years with pulsed dye laser treatment.  The patient has responded positively to pulse dye laser therapy; however, as she has grown, she is less cooperative with treatment.  The physician is requesting approval for an out-of-network provider to provide pulse dye laser therapy under sedation to allow for the procedure to be performed safely and without psychological trauma to the patient.  

The use of sedation for childhood laser and surgical procedures has been well documented.  Given the age and psychological maturity of the child, it is within the standard of care to offer the possibility of laser treatment with the use of sedation at an appropriate institution. The sensitive location of the treating areas, including the periorbital area and lips which require the patient to not move during the procedure.  

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 long-pulsed pulsed dye laser therapy is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Pharmacy/Prescription Drugs 
The insurer denied Stelara 90 mg/ml. 
The denial is overturned in whole. 

This patient is a female. She has a history of Crohn's disease. She has tried and failed infliximab (Inflectra) despite adequate drug levels. At issue is the medical necessity of Stelara 90 milligrams (mg)/milliliters (ml). 

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

The requested health service/treatment of Stelara 90mg/ml is medically necessary for this patient. 

Stelara is United States Food and Drug Administration (FDA) approved for the treatment of Crohn's disease in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with Crohn's disease. Chavannes M, et al reported a multi-centered cohort study supporting the safety and efficacy of Stelara in pediatric patients with Crohn's disease. A report by Dayan JR, et al showed that ustekinumab (Stelara) is efficacious and safe in pediatric patients with inflammatory bowel disease (IBD). J Rosh, et al recently published a multi-center, double-blind, induction dose-ranging study in pediatric patients with Crohn's disease. The study supported the safety and efficacy of Stelara in this patient population. Finally, the clinical practice guidelines support the use of Stelara in pediatric Crohn's patients who failed tumor necrosis factor (TNF)-alpha inhibitors (van Rheenen, Patrick F., et al). 

Therefore, Stelara use in children with Crohn's disease is appropriate and well supported by peer reviewed evidence. The patient has already failed infliximab and is unlikely to respond to Humira as it has a similar mechanism of action. There are no other FDA approved alternatives. 

Therefore, the requested treatment of Stelara 90mg/ml is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Plaque Psoriasis. 
Treatment: Formulary exception for Taltz. 

The insurer denied the Formulary exception for Taltz. 
The denial is upheld. 

The patient is a male with plaque psoriasis affecting multiple body areas (20% body surface area [BSA]) who has tried and failed topical betamethasone and clobetasol, as well as methotrexate. The request is for Taltz injections.

No, the health plan should not cover the proposed treatment with Taltz. 

The patient has severe psoriasis for which systemic therapy is indicated. He is not a candidate for phototherapy because of the location of psoriasis on the face, which implies ultraviolet light would not be effective. In the era of biologic therapies for psoriasis, the use of methotrexate, cyclosporine, or acitretin is not the most appropriate first-line treatment because their long-term safety and efficacy are inferior to biologic therapies. 

Biologics show superior results to conventional systemic therapies (70% improvement versus 40% improvement) for the treatment of patients with moderate to severe psoriasis, as measured by a decrease in simple-measure for assessing psoriasis activity (S-MAPA) (physician global assessment [PGA] multiplied by body surface area) at week 24. These results were observed despite the fact that patients on biologics had a greater baseline severity and had a greater number of previous treatments. 

There is no documentation that the patient has tried and failed other biologic therapies, which have the potential to provide a similar degree of safety and efficacy as Taltz. The formulary options available [Humira (requires prior authorization), Stelara (requires prior authorization), Skyrizi (requires prior authorization), Tremfya (requires prior authorization), Enbrel (requires prior authorization), Cosentyx (requires prior authorization), Cimzia (requires prior authorization)] include drugs with the same mechanism of action, IL17 (Interleukin 17) inhibition, as Taltz (Cosentyx). Therefore, Taltz is not considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision-ptosis of the left eyelid.
Treatment: Surgical Services. 
The insurer denied repair blepharoptosis. 
The denial is overturned.

The patient is a female with history of ptosis of the left eyelid. She underwent examination, visual field testing and photos for ptosis. The patient underwent surgery for repair of ptosis of her left eye.
The subject under review is the medical necessity for repair of blepharoptosis.

The requested repair is medically necessary for this patient. The patient had documented symptomatic ptosis based on physical exam, visual field testing, and photographs. Ptosis surgery would be warranted to improve visual function in this patient.
The patient had a history of symptomatic ptosis of her left eyelid. She had a documented eye exam noting her marginal reflex distance of 2 millimeter (mm) in her left eye. Visual field demonstrated a 20-degree improvement of her superior field with tapping of the upper eyelid. Photographs demonstrate ptosis of the left upper eyelid.
Ptosis surgery is used to repair a droopy eyelid. A droopy eyelid can cause the patient to experience loss of superior visual field and lead to symptomatic loss of vision. Lifting the droopy eyelid with ptosis surgery can help improve the symptomatic loss of vision and improve visual function in these patients. This patient had documented ptosis of the left upper eyelid on examination with a marginal reflex distance of 2 mm and a superior visual field deficit that improved by 20 degrees with tapping of the upper eyelid on visual field testing. Photographs taken also demonstrate the ptosis on the left eye.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder. 
Treatment:  Surgical placement of implant body endosteal implant for teeth 2, 9, 14, 15 and 30. 

The insurer denied surgical placement of implant body endosteal implant for teeth 2, 9, 14, 15 and 30. 

The determination is upheld. 

The patient presented for evaluation and treatment of teeth #2, 9, 14, 15, 30. Provided for review are previous letters of appeal and denial, full mouth panoramic radiographic images from an unknown date, one page of American Dental Association (ADA) claim forms, a medical history intake form, and clinical notes. 
Previous denials have been on the basis that a letter was not received by the provider to indicate implant placement is the only viable service and that the documentation sent fails to adequately indicate why a fixed or removable prosthesis cannot be placed. 

At issue is the medical necessity of the planned treatment of implant placement (6010) for teeth #2, 9, 14, 15, and 30. 

The notes provided do not show a history of ever having provided any type of denture for the patient, or any specific issue with a partial denture for the maxilla or mandible. Partial dentures utilize the existing dentition and do not extend into the soft palate and can be designed to avoid them altogether. The notes also state there is decay but not for which teeth. Currently, the documentation provided does not support the medical necessity of the requested treatment.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a  male who presented to the emergency department (ED)  with chest pain. The patient also had exertional dyspnea and orthopnea. His dyspnea was present for a long time. The patient reported that he used cocaine on that day.
The patient had a history of hypertension, coronary artery disease (CAD), a fib (atrial fibrillation), and known ejection fraction (EF) 45-50%. The patient also has a history of ethyl alcohol (ETOH), heroin and cocaine abuse. The patient was an every day current smoker. The patient was post tricuspid valve replacement. The patient had known noncompliance with medications, including Lasix and warfarin. The patient was admitted to telemetry bed for management of acute on chronic heart failure and atrial fibrillation.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
 
The patient presented with chest pain and worsened shortness of breath contributed to heart failure. The patient himself was not a reliable historian due to drugs on board. His physical examination revealed crackles and lower extremity edema, but he was not in distress, with stable blood pressure and heart rate. The patient's creatinine was elevated.
However, the patient responded to diuretics quickly and his condition improved. He also became more alert after being in the hospital for two days, due to end of effect narcotics he abused prior to admission. His brain natriuretic peptide (BNP) was elevated and came down, but he might have elevated BNP on chronic basis. His troponin was normal and not followed. His electrocardiography (ECG) was abnormal due to atrial fibrillation, but there was no evidence of acute coronary syndrome. His creatinine was elevated, but not significantly, he might have some baseline renal disease. The patient did not undergo additional imaging beside chest x-ray and ECG.
The patient's previous imaging done with prior admission and outpatient visit were used to manage the patient. The patient's clinical status and his management did not meet criteria for inpatient admission. He could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision. 
Treatment: Pharmacy/Prescription Drug. 
The insurer denied Restasis. 
The denial is overturned.

The patient is a male with dupilumab-associated allergic conjunctivitis for whom coverage of Restasis is the subject of review. Upon appeal, it is identified that the patient has severe atopic dermatitis for which he has being treated with Dupixent  with significant improvement, but the patient has developed severe allergic conjunctivitis secondary to Dupixent treatment. Reportedly, the patient has tried over the counter (OTC) artificial tears, ointments, and topical antihistamines as well as steroids which caused elevation of intraocular pressures. However, topical steroids could not be tapered and have been continued with close monitoring of intraocular pressures. As there is also a concern for long-term steroid use, the provider wanted to start Restasis or Xiidra. The prescriber provided references documenting safety and efficacy of cyclosporine in pediatric patients with allergic and vernal conjunctivitis. Paid claims are identified for Lubrifresh PM ointment, lactulose solution, artificial tears, and fluorometholone. The subject under review is the medical necessity for Restasis.

The health plan's determination is overturned in whole.

Restasis is medically necessary for this patient. It appears that coverage of Restasis was reflexively denied based on the patient's age without consideration of the patient's specific condition or the medical literature reporting the safety and efficacy of Restasis in the pediatric population for similar conditions.
Dupilumab (Dupixent) is a human monoclonal antibody against the interleukin (IL)-4 receptor alpha that is approved for treatment of atopic dermatitis. One of the most common side effects of dupilumab is conjunctivitis, which has been reported in 14-19% of patients. According to Agnihotri et al., moderate, or severe conjunctivitis necessitates anti-inflammatory eye drops or ointments containing corticosteroids, calcineurin inhibitors, or cyclosporine. Shen et al. have reported patients who have been treated effectively with topical cyclosporine 0.05% twice daily (BID). Similarly, Zirwas et al. have also reported such use of topical cyclosporine in the treatment of this patient's condition. Therefore, as topical steroids place the patient at unnecessary risk of cataracts and increased intraocular pressure, and topical cyclosporine has been found to be both effective in the treatment of this patient's specific condition and safe in the pediatric population, the medical necessity of the requested Restasis is established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Clinical Pyelonephritis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of recurrent pyelonephritis who was pregnant during the period under review.  She was admitted with dysuria and flank pain.  The urinalysis was positive for blood and esterase.  Labs were notable for a white blood cell count 10.1 and creatinine 0.7.  A renal ultrasound demonstrated no hydronephrosis.  Intravenous fluids and intravenous antibiotics were provided.  Her transvaginal ultrasound demonstrated a live fetus.  Blood and urine cultures were negative.  The patient was discharged on oral antibiotics.

The prior denial reason was that the patient was not greater than 24 weeks pregnant and that there was no temperature greater than 99.4, based on Interqual Adult Infection: Pyelonephritis subset.  The reason for appeal is that the patient had tachycardia requiring intravenous antibiotics and intravenous fluids for pyelonephritis as well as diagnostic testing and specialist consultations, based on MCG (Milliman Care Guidelines) ORG M-300, Urinary Tract Infection (UTI).

No, the proposed treatment was not medically necessary.
The patient had pyelonephritis and was pregnant but was not at least 24 weeks pregnant.  There was no hydronephrosis or other anatomic abnormality on imaging of the kidneys.  The patient remained hemodynamically stable and afebrile without emesis.  The patient did not have altered mentation, immunocompromised state, bladder outlet obstruction, pyonephrosis, emphysematous pyelonephritis, renal or perinephric abscess, or acute kidney injury.  There was no documentation of bacteremia.  In summary, inpatient admission was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The denial of inpatient admission was appropriate.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female. She presented to the emergency ward with the complaint of dizziness, vomiting and abdominal pain. She had a witnessed seizure and was found to have hyponatremia and alcohol use. She was admitted to the acute inpatient service for evaluation and treatment. Neurological consultation recommended continued treatment with Keppra and outpatient EEG (electroencephalogram).

No, the Inpatient admission was not medically necessary.
The patient presented with acute alcohol use, hyponatremia and a single witnessed seizure. She had returned to her baseline neurological status and definitive treatment with anticonvulsant therapy was established within 24 hours. She did not have any recurrent events, neurological examination abnormalities, evidence of alcohol withdrawal and the degree of hyponatremia did not warrant acute inpatient level of care. Taken together, the diagnostic tests, neurological evaluation, treatment and monitoring could have safely and effectively provided at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain

Treatment: Inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is overturned. 

This female patient has a history of anxiety, congestive heart failure (CHF), non-ischemic cardiomyopathy (NICM), sickle cell trait, obesity, chronic back pain, and polysubstance.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

This patient could not safely be treated in a less restrictive detoxification treatment level of care as she was at risk for severe, complicated, and life-threatening withdrawal due to heavy alcohol use, and she reportedly had multiple comorbid medical issues complicating the management of withdrawal. She had intractable vomiting, sudden onset chest pain, unstable vital signs including elevated blood pressure of 149/91 and a heart rate of 100, agitation, diffuse abdominal pain, and anxiety and was put on a Clinical Institute Withdrawal Assessment (CIWA) protocol with Ativan as needed for detoxification. The patient had cardiac issues including sudden onset chest pain, CHF, and a low ejection fraction of 23% and QTc (interval on EKG [electrocardiogram]) issues.

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 the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: BPH (benign prostatic hyperplasia)
Treatment: Transprostatic Implants
The insurer denied the Transprostatic Implants
The denial is overturned

The patient is male with BPH (benign prostatic hyperplasia). He has requested coverage for treatment with the Urolift procedure. He has tried tamsulosin approximately six months. Cystoscopy demonstrated an obstructing prostate without a median lobe. The prostate volume was 28 cc (cubic centimeters) on ultrasound.

Yes, the Transprostatic Implants are medically necessary.
The patient has persistent or progressive, moderate-to-severe lower urinary tract symptoms despite medical therapy (e.g., alpha blocker, PDE5 [Phosphodiesterase-5] Inhibitor, finasteride/dutasteride) for at least three months or inability to tolerate medical therapy for BPH (benign prostatic hyperplasia). He has estimated prostate volume of less than 80 cc (cubic centimeters). He has no obstructive median lobe of the prostate identified on cystoscopy.

Therefore, given the above, the Transprostatic Implants are medically necessary.

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: Upheld

Diagnosis: overjet, overbite, ectopic eruption, and anterior crowding

Treatment: full braces and monthly braces adjustment visits

The insurer is denied coverage for full braces and monthly braces adjustment visits

The denial is upheld. 

This male patient has no documented history.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer does not concur with the orthodontist. This reviewer HLD index calculation is as follows: 5 points overjet, 4 points overbite, 5 points anterior crowding, 3 points ectopic eruption for a total of 17 points which is below the threshold of 26 points to support orthodontic care.

Further, the orthodontist on progress note dated 1/22/19 clearly indicates that orthodontics is optional: "Patient has fairly straight and aligned teeth - orthodontic treatment is optional (out of pocket) and will not be covered by their insurance (based on HLD index)."
 
Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies.

Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The health plan acted reasonably with sound medical judgment in the best interest of the patient. The clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

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 full braces and monthly braces adjustment visits is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: restricted interests and rigidity in feeding

Treatment: continued feeding service

The insurer denied coverage for continued feeding service.

The denial is overturned. 

This female patient has a history of autism spectrum disorder, attention deficit hyperactivity disorder and restrictive diet.

Since she stopped feeding services, she reportedly regressed and was now refusing preferred solids and had an extremely restricted diet. She reportedly continued with inconsistent intake of chewable foods, had limited acceptance of previously accepted solids, continued with low volumes of food other than preferred foods. She needed these feeding services to try to get an age-appropriate diet and improve independence. This patient had significant developmental delays interfering with her functioning including feeding and eating and without these feeding services she was at increased risk of worsened nutritional status and functioning. She reportedly had past gains with these feeding services and required more time with these services to further progress and sustain previous gains. She reportedly had regression in her feeding and eating due to her developmental delays including her inability to speak verbally and her restricted interests and rigidity in feeding.

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 continued feeding service is overturned.  The medical necessity is substantiated.