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

Diagnosis: Substance abuse

Treatment is inpatient substance abuse rehabilitation stay

The insurer denied coverage for inpatient substance abuse rehabilitation stay

The denial is upheld

According to his initial assessment, the patient reported history of nicotine and cannabis use without potentially harmful behaviors associated with it. The patient denied history of overdose, history of blackouts or withdrawal and denied "other addictive behaviors." According to the individual clinical session: "the patient's substance use disorder reflects cocaine and cannabis use and progress to daily use to manage stressors". This information does not correlate with information from the initial assessment. 

The patient had moderate functional impairment. He is homeless with severe deficits in the ability to engage in socially constructive activities and the ability to maintain responsibilities. He does odd jobs. At the same time, on assessment of the patient's self-sufficiency of activities of daily living (ADLs), he reported "10" (very easy) for all ADLs, reported minor past, current or pending legal issues and denied mandatory treatment. 

The patient has minor co-morbidity with regards to medical and psychiatric disorders. The patient has diagnosis of Post-Traumatic Stress Disorder (PTSD), he is not taking psychiatric medications and does not have a history of psychiatric hospitalizations. On initial assessment psychiatric evaluation was recommended. The patient denied having medical diagnoses. His vital signs were within normal limits and continued to be normal throughout his stay at the center. 

He has a moderately stressful environment. The patient is doing add jobs, he does not have significant decline in his health or recent onset of severely disabling or life-threatening illness. The patient does not have overwhelming demands to meet immediate obligations, does not have legal issues causing severe disruption of his life.

The patient has a limited support system. On admission assessment, he reports that his family is supportive of the recovery process. In the letter written by the LMSW (licensed medical social worker), utilization review specialist,: "He admitted that he does have support from his immediate family, but his immediate family only, which he stated are estranged". 

The reviewer utilized Level of Care Utilization System (LOCUS) assessment tools. The patient met criteria for Level 3 Level of Care (LOC) based on a total score. However, due to having a combined score for level of stress and support system as being above 5, it puts the patient in level 4 LOC, which correlates to Medically monitored non-residential services.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient substance abuse rehabilitation stay, is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Syncytial Virus (RSV). 
Treatment: Full Hospital Admission. 

The insurer denied coverage for full hospital admission. 

The denial is overturned. 

This is a male child with a history of asthma who had been sick for 3 days with a cough, congestion and post tussive vomiting. He had a fever of 105 degrees F (Fahrenheit) and a decreased appetite. When he developed difficulty breathing his mother brought him to the pediatrician for an evaluation. The pediatrician treated the child with albuterol and obtained a urine test which was positive for ketones. The pediatrician recommended that the child be taken to the ER (emergency room) for additional treatment. 

In the emergency room he was noted to be in respiratory distress with increased work of breathing with accessory muscle retractions and belly breathing. The temperature in the ER was 101 degrees F. On physical exam he was noted to have a pulse oximeter reading of 88% (percent) on room air. On physical examination he had bilateral crackles and wheezing in the right base. He was treated with an intravenous (IV) bolus of normal saline, solumedrol, 10 puffs of albuterol and solumedrol. He was started on oxygen via a high flow nasal canula. His chest X-ray was unremarkable, and a respiratory viral panel was positive for Respiratory Syncytial Virus (RSV). Blood testing was significant for a low serum sodium (131) and an elevated anion gap (15). Following treatment in the ER he also was treated with IV Ringers Lactate and the decision was made to admit him to the PICU (pediatric care unit) for ongoing treatment with albuterol every 1 hour with a diagnosis of status asthmaticus. 

The patient was treated appropriately in the ER for an acute episode of wheezing, hypoxemia and difficulty breathing. The child has a history of previous treatment at home with albuterol for asthma. The child had evidence of dehydration and he needed to be treated with a bolus of normal saline followed by ringer's lactate. He had hypoxemia and needed to be treated with oxygen and albuterol every hour when admitted. When he did not respond to treatment in the ER it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing treatment with oxygen and albuterol every hour. He was not stable enough to be safely discharged. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Squamous Cells of Undetermined Significance.

Treatment: Current procedural terminology (CPT) code 58571, laparoscopy, surgical, with total hysterectomy, for uterus 250 grams (g) or less; with removal of tubes and/or ovaries.

The insurer denied coverage for CPT code 58571, laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tubes and/or ovaries.

The denial is upheld.

The patient is an adult with a history of abnormal Pap (Papanicolaou) smears. The patient has undergone 2 LEEP (loop electrosurgical excision procedure) both showing Cervical intraepithelial neoplasia (CIN)-1.  

The last Pap smear showed Atypical Squamous Cells of Undetermined Significance (ASCUS) positive for high-risk HPV (human papillomavirus).  

The provider and the patient are requesting coverage for a hysterectomy: CPT code 58571, laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tubes and/or ovaries.

In 2019, the American Society for Colposcopy and Cervical Pathology (ASCCP), in collaboration with multiple professional societies and government organizations in the United States and Canada, published practice-changing consensus guidelines regarding the evaluation and management of cervical dysplasia.

This patient's results show ASCUS and positive high risk HPV. The risk of developing CIN 3+ is 4.4 percent.

According to the standard of care, and societies recommendation including consensus guidelines, for nonpregnant patients greater than or equal to ( >=) 25 years old with an immediate risk of CIN 3+ between 4 and 24 percent, colposcopy is the preferred management option. Treatment with excision may be avoided in those patients in whom colposcopic biopsies demonstrate CIN 2 or less.

So based on the standard of care, the next step for this patient is to undergo a colposcopy. As of now there is no indication for a hysterectomy and the requested procedure is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for current procedural terminology (CPT) code 58571, laparoscopy, surgical, with total hysterectomy, for uterus 250 grams (g) or less; with removal of tubes and/or ovaries is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eosinophilic Esophagitis. 
Treatment: Dupixent. 

The insurer denied Dupixent. 
The denial is overturned. 

The patient is an adult male with eosinophilic esophagitis, status post food impactions and esophageal perforation. He has failed H2 (histamine H2-receptor) blockers and fluticisone with ongoing evidence of eosinophilic esophagitis on EGD (esophagogastroduodenoscopy) after 1 month of Flovent. His provider is requesting treatment with Dupixent. Dupixent was denied coverage by the health plan, as the patient has not failed budesonide suspension, as well as esomeprazole, omeprazole, rabeprazole, lansoprazole and pantoprazole. The denial is being appealed. 

The requested Dupixent is clinically appropriate, accepted standard of medical care, and is medically necessary. 

The patient has biopsy-proven eosinophilic esophagitis (EoE) with recurrent food impactions and esophageal perforation. The patient has evidence of ongoing EoE (eosinophilic esophagitis) on the most recent upper GI (gastrointestinal) endoscopy. Dupixent is the only FDA (United States Food and Drugs Administration)-approved drug used to treat EoE (eosinophilic esophagitis). Current medical literature and standard of care supports the use of Dupixent at this time as being clinically appropriate and accepted standard of care. Therefore, the requested Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: amyotrophic lateral sclerosis (ALS)

Treatment: Relyvrio 3GM - 1GM Powder PKT

The insurer denied coverage for Relyvrio 3GM - 1GM Powder PKT

The denial is overturned.

This case involves an adult diagnosed with an amyotrophic lateral sclerosis (ALS) who was assessed after she voiced progression of her symptoms.  At the time of the assessment, the patient was found to have stable breathing with slow vital capacity (SVC) at 78% (percent).  The patient was being recommended for Relyvrio powder packet to treat her condition.  

For abortive disease management, the patient was taking riluzole, which is 1 of only 2 other currently approved Food and Drug Administration (FDA) medications indicated for ALS.  The denial of coverage indicates that the patient is not a candidate for the use of Relyvrio because she has had ALS symptoms for more than 18 months.  The FDA did not stipulate follow-up for this medication nor were there any requirements concerning symptom onset.  Amrix (the manufacturer of Relyvrio) and the FDA intended this drug to be available for all patients with ALS.  The medication will continue to be prescribed in the ALS population regardless of disease duration.  There is no evidence to suggest that it is not as effective in the broader cohort of ALS patients.  The physician wanted to state that because ALS does not have a standard course of progression for every patient, and due to the this, disease duration, functional rating scores, and respiratory status are not qualifying factors for patient eligibility for this medication.  The physician stated that relatively it was meant to slow progression, stop, or reverse it.  This medication has been shown to slow disease progression with a goal to enhance the quality of life and patient outcomes.  The intention for the use of this medication is to preserve the patient's physical function so that she can lead a more productive life and delay a more rapid and irreversible loss of function.  

The Food and Drug Administration states that Relyvrio is indicated for the treatment of any amyotrophic lateral sclerosis (ALS) in adults.  The recommended dosage is 1 packet (3 grams (g) sodium phenylbutyrate and 1 g taurursodiol) administered orally or via feeding tube.  The initial dosage is 1 packet daily for the first 3 weeks with a maintenance dosage of 1 packet twice daily thereafter.  The prior determination claimed that Relyvrio was denied because the patient did not have documented symptom onset less than 18 months at the time of therapy initiation.  However, given that the intention for the use of Relyvrio set forth by the FDA was to treat all patients with ALS, the rationale for the denial of coverage was inappropriate and not within the standard of care.  Given the limited number of medications approved for treating ALS, the requested medication is medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Relyvrio 3GM - 1GM Powder PKT is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease.
Treatment: Lab Work/Blood Tests- therapeutic drug monitoring.
The insurer denied Lab Work/Blood Tests- therapeutic drug monitoring.
The determination is overturned.

This patient has a past medical history significant for fistulizing ileocolonic Crohn's disease status/post (s/p) end-to-end anastomosis, currently on a weekly dose of Humira and low-dose methotrexate therapy. They were recently admitted for suspected Crohn's flare characterized by diarrhea, requiring hospitalization. Subsequent work-up revealed computed tomography (CT) scan findings of ileocolitis, colonic infection by Shigella and Cryptosporidium in the setting of chronic immunosuppression, elevated liver function test (LFT), which led to discontinuation of the methotrexate. In addition, the patient's inflammatory bowel disease (IBD) history is noted for history failure of Mercaptopurine (6-MP) monotherapy and of autoantibody formation to Humira, which led to increased dosing of Humira with combination therapy with methotrexate. The patient is currently on Humira monotherapy. The gastrointestinal (GI) provider is currently requesting rechecking Humira drug levels. At issue is the proposed health service or treatment laboratory services.

The proposed health service/treatment laboratory service is likely to be more beneficial than any standard treatment for the insured life threatening or disabling condition or disease.

Unfortunately, this patient is at a high risk for complication based on prior history of failure of multiple immunosuppressive agents. Furthermore, they have experienced repeat Crohn's flare, secondary to pharmacokinetics failure of Humira secondary to autoantibody formation to Humira resulting in loss of response of Humira. It is clinically significant to determine (the presence and concentration of autoantibody formation). This clinical information is necessary to continue with Humira or switch in-class or out-class anti-tumor necrosis factor (TNF) agents. Failure to determine autoantibody formation may lead to the selection of suboptimal immunosuppression and increase complications, leading to increased mortality and morbidity.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease.
Treatment: Lab Work/Blood Tests- therapeutic drug monitoring.
The insurer denied Lab Work/Blood Tests- therapeutic drug monitoring.
The determination is overturned.

The patient is diagnosed with Crohn's Disease and is status/post (s/p) ileocolectomy. They are on Adalimumab (ADA) therapy. The patient initially was on adalimumab (ADA) 40 milligrams (mg) every 2 weeks but due to disease activity required escalation to every week. The patient was found to have antibodies to adalimumab (ADA) and methotrexate was added which decreased antibody production. Recently due to an infection, methotrexate had to be discontinued. The provider is concerned the patient may again be developing antibodies. The patient underwent drug level and antibody testing for adalimumab (ADA). At issue is the proposed health service or treatment of laboratory services.

In Crohn's disease, higher adalimumab trough levels and negative anti-adalimumab-antibodies are associated with better clinical and endoscopic outcomes. Generation of anti-drug antibodies is recognized as one important mechanism of treatment failure and adverse events. The current approach to managing the loss of response to adalimumab is empirical. In this specific case, the patient developed antibodies before starting methotrexate. The patient had to come off this therapy and there were appropriate concern antibodies would develop again. Testing at this time was appropriate as there was no guarantee methotrexate would again show this beneficial effect.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Mental Health/Depression/MDD (Major Depressive Disorder)
Treatment: Outpatient/Transcranial Magnetic Stimulation (TMS)
The health plan denied the requested Transcranial Magnetic Stimulation (TMS) as experimental/investigational. 
The health plan's determination is upheld.

The patient is a female whose physician is requesting transcranial magnetic stimulation (TMS). The office visit indicates the patient stated she had been depressed for a year with worsening for the past three months. She indicated she had researched TMS and did not want to go from medication to medication. She indicated she had histories of bipolar disorder and generalized anxiety disorder and had experienced depression on and off. She reported that her symptoms were debilitating and that she had difficulty with getting out of bed. She endorsed associated symptoms of decreased appetite, loss of interest in doing things, hypersomnia, low energy, psychomotor retardation, and suicidal ideation without plan or intent. She reported anxiety symptoms consisting of feeling anxious and on edge with excessive worry and difficulty with controlling or stopping worry. She reported that her current regimen was ineffective. She reported past trials of Prozac, Zoloft, Celexa, Lexapro, Wellbutrin, Effexor, Cymbalta, Vraylar, Abilify, Ativan, Tegretol, Neurontin, Ritalin, and Lithium. The patient reported three previous inpatient hospitalizations for manic episodes. She denied any history of substance abuse. The assessed diagnoses are listed as severe depressed bipolar I disorder and generalized anxiety disorder, and the plan was to start treatment with TMS.

The health plan's determination regarding the proposed health service is upheld, in whole.

No, the proposed TMS is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.
Health plan policy indicates that TMS is covered only for the treatment of treatment-resistant major depressive disorder, and that treatment of all other conditions with TMS is considered investigational and experimental because there is a lack of evidence from peer-reviewed literature demonstrating safety, efficacy, or substantially improved outcomes. These conditions include bipolar disorder and generalized anxiety disorder. The patient's history is consistent with a diagnosis of bipolar disorder in that she reports having been hospitalized three times in the past for manic episodes. 
As such, health plan criteria for TMS are not met. Additionally, review of the medical literature indicates that the evidence for the effectiveness of TMS in the treatment of bipolar disorder is limited and that there is a need for further studies. For this reason, TMS is not likely to be more beneficial than any standard treatment or treatments for the insured's condition. The use of TMS in the treatment of bipolar disorder is not supported by health plan policy or the medical literature.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Mental Health/Depression/MDD (Major Depressive Disorder)
Treatment: Outpatient/Transcranial Magnetic Stimulation (TMS)
The health plan denied the requested Transcranial Magnetic Stimulation (TMS) as experimental/investigational. 
The health plan's determination is overturned.


The patient is a female with a history of treatment resistant major depression. Her symptoms are uncontrolled. She has failed numerous trials of medications including Trintellix, Zyprexa, Risperdal, Rexulti, Lamictal, Prozac, Zoloft, Celexa, Lexapro, Cymbalta, Wellbutrin, and Abilify. She has shown evidence of severe depression and her physician has recommended transcranial magnetic stimulation (TMS) which was previously denied.

I overturn, in whole, the health plan's determination regarding the proposed service and treatment.

Transcranial magnetic stimulation (TMS) is an Food and Drug Administration (FDA) approved treatment for treatment resistant depression. The patient clearly has evidence of severe depression that is refractory to antidepressants both alone and in combination with atypical antipsychotics. There is significant evidence that TMS is both a safe and effective treatment for individuals with treatment resistant depression (Perera et al., 2016, Norred et al., 2021, and Iriarte and George, 2018). Given the above, the proposed TMS is more beneficial than any standard treatment or treatments for the insured's life threatening or disabling mental health condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Raspy voice, Reflux
Treatment: Speech Therapy
The insurer denied Speech Therapy.
The determination is upheld.

This is a male patient who is diagnosed with a raspy voice and reflux. The patient was seen for a vocal assessment. He presented with a mild dysphonia that was characterized by huskiness secondary to true vocal fold (TVF) pre-nodular edema, erythema, and laryngopharyngeal reflux disease (LPRD). Treatment was recommended at a frequency of 2-6 sessions/90 days to decrease dysphonia in speaking and singing voice and well as decrease vocal fatigue. Long-term goals include vocal hygiene, acid reflux management and adequate breath support. The patient received speech therapy. The issue for review is whether the speech therapy visits are medically necessary.

Based on the presented information, the specified voice therapy sessions for this patient are not medically necessary. Based on a videostroboscopic evaluation, there was some edema noted and amplitude values were within functional limits, complete glottic closure, and thickened mucous. At that point, the patient was placed on medication for acid reflux. The therapy notes indicate a focus (as well as progress) on vocal hygiene, acid reflux management, and breath support. The provided documentation does not support a medical necessity justification of the speech/voice therapy. Although therapy provided by a qualified speech-language pathologist was likely beneficial for the patient in teaching him to learn and incorporate useful vocal strategies for managing his overall voice usage, there is not enough evidence provided to deem this therapy medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

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

This is a female patient who presented with a skeletal Class I malocclusion. She has maxillary and mandibular crowding. Teeth 7 and 10 are in anterior crossbite. She is treatment planned for 24-36 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to correct her malocclusion. At issue is the medical necessity of braces and monthly visits.

This patient presented with an anterior crossbite, crowding, and a skeletal jaw imbalance. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) These problems are much more time consuming to correct than the patient's existing orthodontic problem.
Teeth 7 and 10 are at high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time (4), which will make treating this occlusion at a later time more difficult. Further movement of teeth 22 or 27 will likely lead to the need for future for periodontal grafting on these teeth. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, the orthodontic treatment is medically necessary.