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

Diagnosis: Foot Wound.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with history of type 2 diabetes and neuropathy. He was referred due to failure of outpatient treatment. The issue was a burn from a few months earlier that failed to heal. It had been worsening over the last few days prior to his admission.

The patient had wound cultures positive for MRSA (methicillin-resistant Staphylococcus aureus). The patient experienced chills. Lab work was drawn. He had abated inflammatory markers. He received IV (intravenous) morphine for pain. He received IV (intravenous) vancomycin. Vascular workup was performed showing decreased perfusion. He improved a few days after admission. He was transitioned to oral antibiotics, and he was then deemed stable for discharge.

Yes, the Inpatient admission was medically necessary.
The treatment that the patient underwent is in keeping with standard of community standard of care. A diabetic with poor circulation who had worsening ulceration with infection and systemic changes should be admitted and undergo IV (intravenous) antibiotics and workup by a multidisciplinary team, which is exactly what was done in this case.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Erythema

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is the case of a girl born full term with 1-2 days history of bilateral left breast swelling, left greater than right, also was fussy and crying inconsolably when lifted up especially when held with arms around her chest. No fever. Exclusively breastfed. Vital signs were normal, and the patient was well-appearing. Pediatric History and Physical (H&P) notes left breast with surrounding erythema and warmth, assessed as bilateral gynecomastia left greater than right, no fluctuance or drainage, most likely has mastitis secondary to infectious spread to physiologically hypertrophied tissue, although no clinical evidence of involvement of underlying tissue that would suggest necrotizing fasciitis.  Infectious Disease (ID) consult's note on day 2 of admission states clinically well appearing with improvement in swelling and erythema bilaterally, notes swelling erythema and tenderness and agrees with diagnosis of acute mastitis. She had no other clinical signs to suggest an invasive bacterial infection.

It was clinically appropriate to treat with intravenous (IV) antibiotics. It is recommended that for treatment for mastitis in infants younger than two months treatment be initiated parenterally because of the potential for progression to abscess with oral treatment and the risk of the etiology being community acquired methicillin-resistant staphylococcus aureus (MRSA) (UpToDate). In one study quoted in the UpToDate reference, all five babies who were treated orally developed breast abscess despite the organism being susceptible. 50% (percent) of babies with mastitis develop abscess, which may require drainage and further antibiotic management. Moreover, leukocytosis is common, and a blood culture should be performed, which means that parenteral antibiotics be continued pending culture results, and a lumbar puncture (LP) if clinically indicated. The patient's white blood cell (WBC) count was 19,000, which by itself correlates with a high risk of bacteremia, which is another reason this baby needed inpatient admission level of care period and parenteral antibiotics.

The inpatient admission is considered medically necessary for this patient.

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 an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Migraine. 
Treatment: Botox Injection. 

The insurer denied the Botox injection. 
The determination is upheld. 

The patient has chronic migraine and has tried and failed antihypertensive drugs and antidepressant drugs. Botox was denied because there was not documentation of certain headache features. The provider appealed the determination. 
At issue is the medical necessity of a Botox injection. 

The requested health service/treatment of Botox Injection is not medically necessary for this patient. While Botox is Food and Drug Administration (FDA) approved for the prevention of chronic migraine, the submitted documentation does not show that the patient has undergone an adequate trial of preventative agents. The documentation indicates that the member has tried and failed antidepressants and antihypertensive agents. Not all hypertensive agents or antidepressants are effective for prevention of migraine. There is no specification of what drugs were tried and failed or the duration of therapy. 

Additionally, there is documentation that the patient has a headache on 15 days of the month. Chronic migraine is defined as 15 or more headache days per month with 8 or more of those days meeting migraine criteria for at least 3 months. There is inadequate documentation of chronic migraine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines. 
Treatment: Botox 200 Unit IJ SOLR. 

The insurer denied the Botox 200 Unit IJ SOLR. 
The denial is upheld. 

The patient is a female with chronic migraines. She has approximately six to seven headaches per week. She has failed treatment with topiramate, amitriptyline, Aimovig and candesartan. Her neurologist requested Botox for preventative treatment of her migraines. This request was denied due to the patient being below the age recommendation. The patient's neurologist appealed the decision stating she has failed multiple treatments including those listed above, thus making Botox medically necessary. This review is in regard to Botox use. 

No, the proposed treatment with Botox is not medically necessary. 

The plan denied Botox use based on the patient's age being below the recommended age. The available literature on Botox use in patients below the recommended age is reviewed below. 

A review of recent studies on Botox in pediatric patients includes a small randomized controlled trial with 15 patients. Botox administration was associated with a clinical significant benefit when compared to placebo (Shah). 

There is another recent randomized clinical trial of adolescents with chronic migraine. This was a double blind controlled study with 125 patients, randomized to Botox or placebo. The results failed to show Botox superiority over placebo (Winner). Per the authors, both the Botox treatment and placebo control groups had an improvement in headaches, but there was no significant difference among the two groups. 

A review of past retrospective studies and case series provided support for some benefit for Botox, but these provided low level support (Shah). However, overall, the level of evidence supporting Botox use was low (Marcelo). Per review of the American Academy of Neurology guidelines for chronic migraine preventative care in the pediatric age group did not recommend Botox due to lack of sufficient supporting data (Oskoui). 

In summary, there is low level anecdotal and uncontrolled evidence supporting Botox use for adolescents with chronic migraine. However, higher level data from controlled studies is conflicting, with the larger studies failing to show a benefit of Botox over placebo. Of these study types, controlled study data is by far the most important and carries the most weight, as there is a very high rate of placebo response to headache preventative treatments in the pediatric age group. 

Therefore, there is a lack of sufficient data from well-constructed clinical studies to permit a scientific conclusion regarding durable benefits of Botox for the treatment of chronic migraine in pediatric patients with chronic migraine. Thus, Botox is not medically necessary. 

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

The plan denied Botox based on the patient's age being below the recommend age. As discussed above, there is a lack of sufficient evidence to support Botox use as safe and effective for treatment of chronic migraine in patients below the recommended age.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Other/Occlusion
Treatment: Dental/Orthodontic Procedure
The health plan denied the requested orthodontic treatment as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a Skeletal Class I occlusion. He has moderate mandibular crowding and moderate maxillary crowding, mild overjet, and mild overbite with an anterior crossbite at tooth # (number)10.
The subject to be determined is the medical necessity for braces.

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 20 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 9mm (millimeters) or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, braces are not medically necessary for this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Knee Pain
Treatment: intra-articular lidocaine in combination with corticosteroids
The insurer denied intra-articular lidocaine in combination with corticosteroids.
The determination is overturned.

The patient has a complaint of bilateral knee pain. The provided medical records document that this patient attempted oral medications and physical therapy without relief of his knee pain. The patient did have prior corticosteroid injections in both knees with improvement in his knee pain. The patient underwent diagnostic ultrasound imaging of both knees which revealed bilateral knee effusions and evidence of osteoarthritis in each knee. Bilateral knee injections were then performed with lidocaine and 40 milligrams (mg) of Kenalog. The patient's health plan denied coverage for this care. At issue in this case is whether the intra-articular lidocaine injection in combination with corticosteroids is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed treatment of an intra-articular lidocaine injection in combination with corticosteroids is likely to be more beneficial than any standard treatment or treatments for the insured's knee osteoarthritis.
This patient has painful bilateral knee osteoarthritis and has attempted the se of oral medications and physical therapy without relief of his pain. Thus, the medical necessity of the bilateral lidocaine and Kenalog injections is established based upon the documentation in the medical records. In addition, the current, peer-reviewed literature does support the use of corticosteroid injections to provide pain relief for patient's suffering from painful knee osteoarthritis. A recent article published by Phillips and colleagues in the Orthopedic Journal of Sports Medicine concluded that "Available clinical practice guidelines provide recommendations on injectables for knee osteoarthritis (OA) treatment. General guidance from a global perspective concluded that intra-articular corticosteroids and intra-articular hyaluronic acid are favored for different needed responses and can be utilized within the knee osteoarthritis (OA) treatment paradigm, while platelet-rich plasma (PRP) currently has insufficient evidence to make a conclusive recommendation for or against its use." Additional articles published by Pavone and colleagues and by Blankenstein and associates in the peer-reviewed literature have documented that corticosteroid injections are both safe and effective for the treatment of knee osteoarthritis in patients with symptomatic pain from this pathology. This determination is based upon the provided documentation in the medical records and the recommendations of the current, peer-reviewed literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health. 
Treatment: Mental Health -Residential. 

The insurer denied Residential Mental Health Treatment. 
The denial is upheld. 

The patient is a female, who has a complex past psychiatric history of bipolar disorder, gender dysphoria, attention deficit hyperactivity disorder (ADHD), substance use disorder, obsessive compulsive disorder, prominent borderline personality traits and a history of chronic suicidality. She reported that suicidal thoughts have occurred since 5th grade and per records never disappears but changes in intensity. The patient has been hospitalized 5 times in 3 years and has completed intensive outpatient treatment on multiple occasions during that time span. The patient was admitted to Residential treatment. 

At issue is the medical necessity of Residential Mental Health Treatment. 

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

The requested health service/treatment of Residential Mental Health Treatment was not medically necessary for this patient. 
At the time of admission to the residential treatment center, the member was not suicidal, agitated or showing signs of distress. The patient was noted to have stability in weight and improvement in anxiety. In addition, the patient noted that suicidal ideation was "manageable", and she had no suicidal intent or plan. The patient was willing to participate in treatment. Given the above, the determination of medical necessity was reasonable and based on sound medical judgement. 

The patient was willing to engage in treatment and was able to be redirected. The patient was willing to attend treatment and participated in most treatment groups. The patient did have mood lability and irritability demonstrated by group notes but was able to process these emotions in groups and identify maladaptive emotional responses. The patient was able to process chronic suicidal thoughts and able to work on goals of treatment. Per the American Academy of Child and Adolescent Psychiatry (AACAP) residential treatment guidelines (2010) and Kober and Martin (2017), it is widely accepted that adolescent treatment is best served in the home with the patient's family and the least restrictive treatment setting should be used to deliver treatment. The patient has a supportive family and was not an imminent danger to herself or others and could have safely been treated in a less restrictive setting. There was no evidence of any acute safety concerns, inability to complete daily activities or otherwise disruptive behaviors during the dates in questions. Given this, the requested health service is not medically necessary. 

Therefore, the requested health service/treatment of Residential Mental Health Treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has sickle cell disease (SCD) presenting with fever and URI (upper respiratory infection) symptoms concerning for sinusitis. The medical record indicates that the patient was non-toxic appearing, labs were "otherwise reassuring" and vital signs were unremarkable except for fever, and chest x-ray was clear.

Empiric antibiotic coverage for sickle cell patients with fever is standard of care based on their relative immune-compromised state. However, indications for hospitalization instead of ambulatory management include very young age, very high fever, high white blood cell count (WBC) or toxic appearance.  The patient did not meet these criteria for high risk of sepsis, and therefore, it is unclear from the medical record why hospitalization rather than ambulatory management was deemed necessary.  As such, denial from the health care plan was reasonable.

As indicated above, the patient does not appear to have met high risk criteria to support the need for inpatient management rather than ambulatory management. Reference 2 notes, "Admission Criteria Consideration for admission should be a dynamic process taking into account reassessment of patient over time and in response to intervention. However, there are some instances in which admission is necessary or strongly encouraged: 1. Toxic, ill appearing or clinically suspected ACS [acute coronary syndrome] 2. Child is under six months old or not up to date on vaccinations 3. Hemoglobin and /or reticulocyte count well below baseline or WBC (white blood cell) > 30,000."

As indicated in Reference 3, "A well-appearing febrile child with SCD may be managed as an outpatient after blood is obtained for bacterial culture and parenteral antibiotics are administered, provided there are no other reasons for admission and the patient is able to return promptly for worsening condition or for growth of a pathogen from their blood culture."

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Atopic Dermatitis.  
Treatment: Dupixent.  

The insurer denied coverage for the medication Dupixent.  

The denial is overturned.  

The patient has a diagnosis of severe atopic dermatitis affecting 50% (percent) total body surface area (TBSA).  The patient has failed topical therapy with steroids and tacrolimus ointment, but requires systemic therapy.  The health care plan recommends light therapy; however, due to the patient's school schedule, this is not feasible.  The requested medication is Dupixent.  

The patient has severe atopic dermatitis that involves a large surface area, requiring systemic therapy.  Light therapy would not be an ideal treatment option, as it would require the patient to miss school 3 times per week for treatments.  The patient requires systemic therapy given the extent of involvement and the use of Dupixent would appear to be reasonable, given that it is FDA (Food and Drug Administration) approved for the treatment of atopic dermatitis (AD) and the impracticality of light therapy.  The request for Dupixent is supported by the medical literature and specialty society guidelines.  Dupixent is the only systemic therapy approved by the FDA for the management of atopic dermatitis.  The FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments (1-3).  According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment... with moderate-to-severe AD who are uncontrolled with topical therapies" (1).  

As such, the decision is overturned and Dupixent is approved at the medical discretion of the physician based on the standard of care and the provided medical documentation.  

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

The insurer's denial of coverage for the medication Dupixent is overturned.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis

Treatment: Entyvio

The insurer denied coverage for Entyvio.

The denial is overturned.

The patient was diagnosed with ulcerative colitis. She was treated with mesalamine enemas and oral mesalamine. However, she has had increased symptoms and her doctor is now recommending Entyvio.

An article titled "More UC [ulcerative colitis] patients achieve remission with Entyvio vs anti-TNF [tumor necrosis factor]" notes data was analyzed from a multicenter cohort of 334 patients treated for ulcerative colitis. It was found that vedolizumab had higher rates of clinical remission and endoscopic healing compared with the anti-TNF group after 12 months of treatment.

An article titled "Comparative Safety and Effectiveness of Vedolizumab to Tumor Necrosis Factor Antagonist Therapy for Ulcerative Colitis" noted a total of 772 patients were included. The conclusion was that treatment of ulcerative colitis with vedolizumab is associated with higher rates of remission than treatment with TNF-antagonist therapy. Vedolizumab also had lower rates of side effects in TNF antagonist-naive patients.

The American College of Gastroenterology has published a clinical guideline: Ulcerative Colitis in Adults, which discusses management of moderate to severe active ulcerative colitis. One of the recommendations for treatment is to give vedolizumab for induction of treatment.

This patient requires biologic therapy. The American College of Gastroenterology supports the use of Entyvio as induction therapy. The scientific literature has shown that there is some benefit in achieving higher remission rates with Entyvio as compared to anti-TNF agents. The health care plan did not act reasonably or in the best interest of the patient. Entyvio is medically necessary for this patient.

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

The insurer's denial of coverage for Entyvio is overturned. Medical necessity is substantiated.