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

Diagnosis: Dental Disorder
Treatment:  Braces and monthly visits x 12.
The insurer denied Braces and monthly visits x 12.
The determination is overturned.

The patient has an impacted tooth number (#) 11. This tooth is impacted in a mesioangular inclination and it is in close proximity to the root of tooth 10.
He presented with a skeletal Class III malocclusion and crowding. He is treatment planned for orthodontic treatment to address the malocclusion and impacted tooth. At issue is the medical necessity of braces and monthly visits.

The requested treatment is medically necessary. If left untreated the damage that will likely occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. Studies show that impacted canines with a mesioangular inclination have a less than 15% chance of spontaneous eruption. (2) Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors. (3) Given the position of teeth #10 and #11, tooth #10 would expect to be damaged if tooth #11 is not addressed.
For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aplastic Anemia
Treatment: Promacta
The insurer denied the Promacta.
The denial is overturned.

The patient is a male with a history of Klinefelter syndrome, history of acute liver failure status post liver transplant and rejection followed by recovery of his native liver. He has now developed pancytopenia. He was diagnosed with aplastic anemia and was treated with ATG (anti-thymocyte globulin) and cyclosporine, but developed recurrent pancytopenia. The provided CBC (complete blood count) shows a platelet count of 18,000, hemoglobin 8.5.

Yes, the requested Promacta is medically necessary.

The use of Promacta is medically necessary for the treatment of aplastic anemia if the platelet count is less than 50,000. The submitted medical records document that the member had a platelet count of 18,000. Therefore, the use of Promacta is medically necessary for this patient.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

On the initial review, there was no documentation that the patient had a platelet count of less than 50,000. The more recent medical records document that the patient has a platelet count of 18,000 and therefore meets medical necessity for Promacta.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma flare
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of asthma (no prior intubations), hypertension (HTN), and prior cerebrovascular accident (CVA) presented with 2 days of worsening dyspnea, cough, and wheeze. He was given nebulized albuterol by Emergency Medical Services (EMS) and had some improvement.
In the emergency department (ED), his temperature was 98.6 degrees Fahrenheit, blood pressure (BP) 117/99, heart rate (HR) 107, respiratory rate (RR) 22, peripheral capillary oxygen saturation (SpO2) 97% (percent) on room air (RA). He was not in distress, was breathing comfortably, wheezy, alert and oriented. His sodium (Na) was 138, bicarbonate 24, blood urea nitrogen (BUN)/creatinine (Cr) 14/1.0. A chest x-ray (CXR) showed a subtle left lower lobe (LLL) opacity. He was given nebulized bronchodilators and systemic steroids and continued to improve while in the emergency department (ED) though he still had some wheeze. His CXR findings prompted a consideration of pneumonia, so ceftriaxone and azithromycin were given.
He was diagnosed with an asthma flare possibly due to pneumonia and started on intravenous (IV) methylprednisolone, ceftriaxone, azithromycin, and nebulized bronchodilators.
The next day he was noted to have clear lungs on exam, was saturating well on room air (RA), and treatments continued. He continued to do well, and treatments were continued. He was discharged on Augmentin.
At issue is the medical necessity of inpatient stay. 

An inpatient admission was not medically necessary. The patient presented with pneumonia and an asthma exacerbation. He was not severely ill at presentation with no encephalopathy, hemodynamic instability, respiratory distress or marked gas exchange abnormality, or acute kidney injury or marked electrolyte abnormality. He was not at high risk with no history of severe asthma or prior intubation. From a pneumonia standpoint, as above, he was not severely ill. Routine scoring systems would suggest a low risk of worsening or needing intensive care unit (ICU) care. For both pneumonia and asthma he seemed to improve and by the next day, no wheezing was described on exam; subjective wheezing was described, though his exam was normal. He was not in respiratory distress and was saturating well on room air (RA).
As he was not severely ill, was at low risk of worsening from an asthma or pneumonia standpoint, and improved, an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male who had a two-week history of left hip pain and limp. He was able to walk. A radiograph showed a left slipped capital femoral epiphysis, described as "mild displacement". He was admitted to the hospital and underwent in-situ pinning of the left slipped capital femoral epiphysis. At issue is whether the inpatient stay was medically necessary.

The health plan's determination is upheld.

No, the requested inpatient stay is not medically necessary. A stable slipped capital femoral epiphysis, one in which the patient is able to walk and bear weight, requires fixation in order to prevent the slip from progressing. However, this can be done at a lower level of care status with discharge to home after the patient is able to ambulate with crutches.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-ischemic cardiomyopathy.
Treatment: Wearable Cardioverter Defibrillator (K0606).
The insurer denied the Wearable Cardioverter Defibrillator (K0606).
The denial is upheld.

This patient is a female with a new diagnosis of non-ischemic cardiomyopathy with ejection fraction (EF) of 34% (percent).  She was started on guideline directed medical therapy.  A LifeVest was placed.  This was denied as not medically necessary.  The company appealed the denial.

No, the proposed treatment was not medically necessary.
The typical indication for the use of a LifeVest is in a patient who has an indication for implantation of an implantable cardioverter defibrillator (ICD), but also has a contraindication to its implantation.  This can be an ongoing infection, especially of a pacemaker system, or while a patient is awaiting heart transplantation.  There are no good randomized studies of patients without these indications.  The only data that has been published comes from the company's database.  This demonstrated a low utilization rate for the LifeVest in patients without the typical indications for its use.  The editorial that accompanied this article questioned the role of the LifeVest in the patient without the typical indication for the use of the LIfeVest.  

This patient was just started on heart failure medical therapy and had not reached optimal dosing.  Therefore, there is no indication that the LifeVest is medically necessary in a patient such as this.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The patient does not have an indication for the implantation of an implantable cardioverter defibrillator (ICD).  There is no randomized data that demonstrates that this therapy improves survival in patients with non-ischemic cardiomyopathy.  Therefore, there is no demonstrated medical necessity for this device.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied POEM procedure. 
The denial is overturned.

The patient is a male with achalasia. He has had progressive dysphagia with solids and liquids for years. Esophagogastroduodenoscopy showed dilated esophagus with significant retained secretions and light resistance at the gastroesophageal junction, suspicious for achalasia. Barium esophagogram was consistent with achalasia. Esophageal manometry showed 10/10 failed swallows with pan-esophageal pressurization increased with each subsequent swallow and markedly elevated lower esophageal sphincter pressure, consistent with achalasia type II. The subject under review is peroral endoscopic myotomy for the treatment of achalasia.
Peroral endoscopic myotomy (POEM) is supported as likely to be more beneficial than any standard treatment or treatments for the treatment of the enrollee's type II achalasia. The American Gastroenterological Association best-practice guideline for peroral endoscopic myotomy states that "if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (Kahrilas, et al). The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, recommending POEM as safe and effective for the treatment of type II achalasia (Khashab, et al). Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available (Barbieri, et al; Schlottmann, et al). However, despite comparable efficacy, POEM is significantly less invasive than surgical intervention, resulting in less postoperative pain and a more rapid recovery (Docimo S, et al). In this patient with symptoms including dysphagia, and imaging and manometric evidence of achalasia, the use of POEM is supported by current medical literature and guidelines. For these reasons, POEM should be considered likely to be more beneficial than any standard treatment or treatments for the patient's type II achalasia.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services. 
The insurer denied POEM procedure. 
The denial is overturned.

The patient is a male with a diagnosis of achalasia. The patient has longstanding dysphagia for both solids and liquids. An endoscopy revealed a dilated esophagus and resistance to passage of the endoscope at the gastroesophageal (GE) junction. The patient underwent a high-resolution esophageal manometry and findings were consistent with Type II achalasia - pan esophageal pressurization with a high mean residual lower esophageal sphincter (LES) pressure. Barium esophagogram was also consistent with achalasia.
The patient's provider has recommended approval for the peroral endoscopic myotomy (POEM) procedure as definitive endoscopic treatment. The subject under review is whether the requested procedure is likely to be more beneficial for the patient than any standard treatment for his condition.

The health plan's determination is overturned.

Achalasia results from progressive degeneration of ganglion cells in the myenteric plexus in the esophageal wall. It is characterized by the failure of relaxation of the lower esophageal sphincter (LES), often accompanied by a loss of peristalsis in the distal esophagus. Treatment of achalasia is aimed at decreasing the resting pressure in the LES to allow passage of ingested material. Achalasia can be treated with pneumatic dilatation, botulinum toxin injection, or surgical myotomy. Laparoscopic Heller myotomy (LHM) is the most commonly performed surgical myotomy procedure. Peroral endoscopic myotomy (POEM) is the endoscopic equivalent of surgical myotomy. POEM utilizes submucosal endoscopy to transform the submucosal layer in the esophagus and proximal stomach into a tunnel through which esophageal and gastric myotomy are carried out using an endoscope.
The efficacy and safety of POEM has been compared with that of LHM [1]. In a randomized trial of 221 patients with achalasia, POEM and LHM with fundoplication were equally successful in controlling symptoms (Eckardt symptom score less than or equal to [<=3]) at two years (83 versus 82 %). In a meta-analysis of over 7000 patients in over 70 cohort studies, POEM was more effective than LHM in relieving dysphagia [2]. Predicted probabilities for improvement in dysphagia at 12 months were 93.5% for POEM and 91.0 % for LHM and at 24 months were 92.7 % for POEM and 90.0 % for LHM; both differences were statistically significant. In a trial of 133 treatment-naive patients with achalasia, POEM resulted in a higher rate of treatment success than pneumatic dilation at two years (92 vs 54 %, p< 0.001) [3]
In summary, POEM is now considered the preferred treatment of achalasia based on its safety and long-term efficacy.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: femoral shaft fracture.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a boy who fell while playing basketball and sustained a fracture of the right femoral shaft. This was treated by open reduction and internal fixation using a plate and screws. He was monitored before and after surgery and received analgesics through his intravenous (IV) line and by mouth. He received physical therapy and was able to ambulate with crutches prior to his discharge.

The inpatient hospital admission was medically necessary for this patient. A femur fracture in an adolescent is a major injury, one that usually requires ambulance transportation to the hospital, urgent assessment in the emergency room, temporary stabilization in some fashion and then definitive stabilization with surgery. There is often some blood loss with the potential for hemodynamic instability, and there is always substantial pain that requires treatment with opioids. The surgical procedure done in this patient often requires a long incision with some risk of bleeding. Careful mobilization after surgery with the assistance of physical therapy is required and can be associated with substantial pain. The intensity of the services provided supports inpatient medical care rather than observation or outpatient level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite 
Treatment: Braces 
The insurer denied the braces and monthly visits. 
The denial is overturned. 

The patient is a female requesting orthodontic benefits. 

Yes, the braces and monthly visits are medically necessary. 

The patient has two lower front teeth in crossbite. This means those lower teeth are in front of the upper teeth, and there is attachment loss (gum loss) associated with them. This is an automatic qualifier according to the handicapping index scale. By having these lower canines out of position, there is traumatic meshing of the patient's teeth during the chewing cycle, which will ultimately result in trauma and fracturing of teeth over time. Orthodontic treatment is medically necessary to correct this problem. 

As stated above, the patient definitely needs orthodontic treatment to correct this severe malocclusion.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history significant for HTN (hypertension), obesity, polysubstance abuse, and alcohol abuse. He presented to the ER (emergency room) after having been found unresponsive in his car. 

The patient was given Narcan, with improvement in mental status. His ECG (electrocardiogram) revealed atrial fibrillation at 109 BPM (beats per minute). Chest X-ray was unremarkable. Cardiac troponins were normal. Diltiazem IV (intravenous) x (times) 1 and then PO (oral) was used for heart rate control. Lisinopril was started for BP (blood pressure) control. 

The patient was admitted for monitoring of new onset atrial fibrillation. He remained hemodynamically stable. The echocardiogram revealed preserved LV (left ventricle) function with no significant valvular pathology. The patient converted to sinus rhythm and was discharged home with a plan for outpatient follow-up.

No, the inpatient admission was not medically necessary.

The patient presented with new onset atrial fibrillation. His heart rate was controlled with IV and subsequently oral diltiazem. His CHADS-VASC (congestive heart failure, hypertension, age greater than or equal to 75, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74, sex category) score was low, so no anticoagulation was used. The patient improved clinically with the medical therapy. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia, or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at an observation level of care.

The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient, as the medical necessity of the inpatient admission could not be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II occlusion
Treatment: Braces/monthly visits

The insurer denied braces/monthly visits.

The health plan's determination is upheld. 

The patient in question is a male with a Class II occlusion with 4 millimeter (mm) overjet and 6 mm overbite. The maxillary and mandibular arches have moderate crowding. He is treatment planned for 30-36 months of orthodontics with extraction of a lower incisor to correct his malocclusion.

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 can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. The provided photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 4mm overjet, but research shows this amount of overjet does not affect oral health related quality of life. If his teeth were aligned, it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. Braces are not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atrial Fibrillation.
Treatment: Formulary exception for Eliquis

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

The patient is a female with non-valvular atrial fibrillation. She appropriately required anti-coagulation. She previously had been on Eliquis, but the health plan's preferred DOAC (directly acting oral anticoagulant) is Xarelto. No evidence was provided that showed intolerance or contraindication to the use of Xarelto. Therefore, coverage for the Eliquis request was denied by the health plan. This was appealed.

No, the health plan should not cover the Formulary exception for Eliquis.
While patient had used Eliquis, there is no evidence to suggest that the preferred DOAC (directly acting oral anticoagulant), Xarelto, had failed, or that the patient had a contraindication to the use of the formulary drug. There is no reason to suggest that formulary Xarelto would not be effective and well-tolerated.

It is reasonable to require a trial of Xarelto before any other anti-coagulation therapy is started.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Venous Thromboembolism (VTE)

Treatment: Eliquis (apixaban)

The insurer denied coverage for Eliquis (apixaban)

The denial is overturned.

The patient is a patient with venous thromboembolism (VTE) on Eliquis. The treating provider has requested to continue therapy.  Office visit states the patient has history of bilateral pulmonary embolisms (PEs) during a pregnancy and after several hours' car ride. She was treated with Lovenox at that time.  She was diagnosed with bilateral PEs. The patient continues on Eliquis and is tolerating well.

The patient has been diagnosed with venous thromboembolism (VTE). The patient is currently taking Eliquis (apixaban). This is a continuation request. The patient is stable on current regimen. The patient is free of adverse side effects. The patient is tolerating the treatment regimen well, currently with Eliquis (apixaban). The requested, Eliquis (apixaban) is approved for the treatment of venous thromboembolism (VTE) and cerebral vascular accident (CVA) prevention, in atrial fibrillation (A-FIB). The direct oral anticoagulants (DOACs) differ significantly from vitamin K antagonists in their onset of action, half-life, drug-drug interactions, need for monitoring, ability to monitor should this be called into question, as well as availability of antidotes in the case of excessive bleeding. Overall, all-cause mortality from DOACs appears to be lower than that from warfarin, driven primarily by a decrease in fatal intracranial bleeding risks. This individual with VTE on Eliquis (apixaban), who is stable, ongoing therapy would be warranted versus changing to alternative agents. Switching medications would jeopardize the patient's clinical stability. 

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

The medication Eliquis (apixaban) is considered medically necessary for this patient. 
"Both apixaban and rivaroxaban have been approved for use in acute venous thromboembolism (VTE). Although indirect comparison through network meta-analyses of randomized trials have been performed to compare the efficacy and safety of these agents, further comparison between these agents was lacking until recently. We sought to systematically review and carry out a meta-analysis of studies to further compare apixaban with rivaroxaban from multiple studies done in the real-world settings. Studies comparing rivaroxaban with apixaban in patients with acute VTE were identified through electronic literature searches of Medline, Embase, Scopus, and the Cochrane library ... Study-specific risk ratios (RRs) were calculated and combined using a random-effects model meta-analysis. .... Apixaban shows equivalent efficacy in prevention of recurrent VTE but decreased risk of major and minor bleeding events compared with rivaroxaban." (Aryal, et al 2019).

The insurer's denial of coverage for the medication Eliquis (apixaban) is overturned. Medical Necessity is substantiated.