Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Odactra. 
The denial is upheld.

The patient is a female  The request is for Odactra 12 standardized quality-house dust mite sublingual (SQ-HDM SUB). She has tried Dymista, mometasone and olopatadine and Flonase. The subject under review is whether the requested non-formulary drug would be more effective than the formulary alternatives.

The health plan's determination is upheld.

The alternatives nasal steroids [e.g., flunisolide nasal solution, fluticasone nasal spray, Omnaris spray, triamcinolone acetonide nasal aerosol suspension], ipratropium bromide nasal solution 0.03%, montelukast, oral antihistamines [cetirizine, fexofenadine, loratadine]) will not be and has not been ineffective and would not be less effective as the non-formulary drug (Odactra) and would not have adverse effects.
There are no head to head studies which have compared Odactra to the alternatives.
Odactra is indicated for the treatment of allergic rhinitis due to house dust mite (HDM) and is indicated as immunotherapy in adults 18-65 years old for HDM-induced allergic rhinitis, with or without conjunctivitis, in patients with confirmed in vitro immunoglobulin E (IgE) antibodies to Dermatophagoides farina or Dermatophagoides pteronyssinus HDM or confirmed skin testing to licensed HDM allergen extracts. In 2 randomized clinical field efficacy studies there was a small improvement in mean total combined rhinitis score with HDM allergen extract compared with placebo in the final 8 weeks of up to 12 months study treatment duration. In a randomized environmental exposure chamber study, mean total nasal symptom score was significantly reduced with HDM allergen extract compared with placebo after 24 weeks of study treatment. Another trial of the same product showed that the treatment effect was evident after 14 weeks of therapy. 
The studies on Odactra were compared to the placebo.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type II Diabetes Mellitus. 
Treatment: Formulary exception for Humalog Kwikpen, Pre-service. 

The insurer denied the Formulary exception for Humalog Kwikpen, Pre-service. 
The denial is overturned. 

The patient is a male with type 2 diabetes and stage 4 chronic kidney disease. He has tried and failed generic lispro and Novolog due to hyperglycemia. The request for Humalog Kwikpen is under review. The prior request was denied, as the patient has not tried both of the formulary alternatives, namely Fiasp and Novolog. 

Yes, the health plan should cover the Formulary exception for Humalog Kwikpen.
This patient has type 2 diabetes. He is on multiple daily insulin injections. He has been stable on Humalog insulin. He has tried and failed multiple other insulin formulations, including Novolog, which resulted in hyperglycemia. Novolog and Fiasp are both forms of aspart insulin, and result in similar A1C (glycated hemoglobin) lowering [1]. Given he has tried and failed Novolog, he can be reasonably expected to fail Fiasp insulin. Without Humalog Kwikpen, this patient will be at risk of uncontrolled hyperglycemia, which can cause retinopathy. Therefore, yes, the health plan should cover the Formulary exception for Humalog Kwikpen.
Appeal type: Medical necessity
Decision: Upheld

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

Treatment: D8080 braces.

The insurer denied coverage for D8080 braces.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images letters from orthodontist as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The Orthodontist identified several clinical findings including severe overjet, overbite, ectopic eruption, and anterior crowding and has recommended orthodontics. The Orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 29 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 20 points on the HLD index. The patient's mother is appealing the decision on behalf of the patient. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating Orthodontist completes the second portion of the index arriving at 29 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 20 points on the HLD index (3 overjet, 3 overbite, 10 anterior crowding and 4 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.	

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 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 healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for D8080 braces is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity. 

Treatment: Bariatric laparoscopic surgery with an inpatient facility stay. 

The insurer denied coverage for bariatric laparoscopic surgery with an inpatient facility stay. 

The denial is overturned. 

This is a female patient with a past medical history of anxiety, gallbladder disorder, morbid obesity, osteoarthritis, peripheral edema, and snoring and stress incontinence. The patient was seen and referred by her primary care physician (PCP) for bariatric surgical evaluation and was seen by a Physician Assistant (PA) where it was noted that her body mass index (BMI) was 51.2 and the obesity had been present for more than 5 years. The patient was felt to be an appropriate candidate for weight loss surgery. She was seen by a Bariatric Surgeon for surgical visit where it was noted that the patient's BMI was 50.66 and that her obesity had been present for more than 5 years. She failed medical treatment and was interested in laparoscopic gastric bypass. The Bariatric Surgeon did review the required letter of support from the patient's primary care physician (PCP). He noted that she did undergo a psych evaluation and was deemed to be a good candidate. He also personally reviewed the registered dietitian (who is under his supervision) note and agreed with the nutritional assessment of the dietitian that this patient has satisfied all pre surgery requirements including nutrition education on the bariatric lifestyle meal plan, an exercise regimen and behavior modification techniques.

Based upon the records provided and Milliman Care Guidelines (MCG), the patient does meet the criteria and indications for bariatric surgery. The patient has a BMI of greater than 50 with sleep apnea. She did have psych clearance as well as tried weight loss in the past as well as being followed by nutrition for multiple visits. She therefore does meet the criteria set forth by MCG guidelines.

The denial is overturned, and coverage should be provided for bariatric surgery in this patient given her BMI of greater than 50. The patient does meet MCG criteria for bariatric surgery. The patient did meet with the nutritionist at least 7 times. She did have a referral from her PCP and psych clearance, and she therefore meets the criteria for bariatric surgery as well as inpatient stay as lap Roux-en-Y gastric bypass is performed as an inpatient procedure.

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

The insurer's denial of coverage for bariatric laparoscopic surgery with an inpatient facility stay is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is upheld.

The patient is a female with a history of hypertension, diabetes, coronary artery disease (CAD), chronic headaches, osteoarthritis, and arteritis (being treated with corticosteroids). She presented to the emergency room with bleeding from a recent temporal artery biopsy site. The biopsy occurred earlier that day. Vital signs were notable for an initial blood pressure of 210/90 that quickly dropped down to 186/77. Physical exam revealed some oozing from a biopsy site on the left temporal. Labs were notable for a white blood cell (WBC) count of 12,700, hemoglobin 10.7 grams per deciliter (g/dl), creatinine 1.36 milligrams per deciliter (mg/dl), and a glucose of 158. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.

No, the requested health service/treatment of inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The elevated WBC and blood pressure were likely related to stress and the corticosteroids, and the blood pressure improved considerably in the emergency room. The elevated creatinine also improved quickly with intravenous fluids. None of the noted findings, including the bleeding from the biopsy site, required acute inpatient care. Therefore, based on the standard of care, and the peer reviewed literature cited. The acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autoimmune neuropathy secondary to Sjogren's Syndrome. 

Treatment: Procedure code J1561, immunoglobulin for a possible problem with the immune system, 48 visits. 

The insurer denied coverage for the procedure code J1561, immunoglobulin for a possible problem with the immune system, 48 visits. 

The denial is overturned. 

This is a male patient who has a history of Sjogren's disease with small fiber neuropathy. The patient was seen for a follow-up. The documentation indicated he reported ongoing symptoms that were frustrating. He reported anxiety and frustration as well as difficulty with memory and thinking. He also reported ongoing fatigue and complaints of dry eyes. He also complained of blurry vision and heat sensitivity. The physician indicated Magnetic Resonance Imaging (MRI) of the brain previously documented frontal lobe atrophy. The patient does have a history of an abnormal sweat test with positive antibodies. The physical examination did not reveal any significant findings. The physician detailed the patient should begin intravenous immunoglobulin (IVIG) to address autoimmune neuropathy. 

The patient has a defined clinical history of small fiber, peripheral neuropathy with a defined, documented history of Sjogren's Syndrome. Sjogren's Syndrome is an autoimmune illness with difficult to treat small fiber neuropathy. Treatment with small fiber neuropathy is typically performed with immune modulating agents, and IVIG has demonstrated efficacy in the treatment of small fiber neuropathy in the context of Sjogren's Syndrome. The use of IVIG is standard of care in the treatment of autoimmune neuropathy secondary to Sjogren's Syndrome. Therefore, the requested IVIG is medically necessary in this case. 

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 the procedure code J1561, immunoglobulin for a possible problem with the immune system, 48 visits is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post-traumatic lumbo-sacral musculoskeletal and radicular pain syndrome.
Treatment: Consumer Directed Personal Assistance Services of 40 hours per week. 
The insurer denied coverage for Consumer Directed Personal Assistance Services of 40 hours per week. 

The denial is upheld. 

This is a male patient with a past medical history of bilateral laminotomy/medial facetectomy at lumbar vertebra (L)4 and L5, polyosteoarthritis, hypertension, depression, anxiety, insomnia and chronic pain to the lower back and bilateral knees.  Per a letter from the patient's Nurse Practitioner, the patient received treatment due to post-traumatic lumbo-sacral musculoskeletal and radicular pain syndrome, and he is moderately disabled.  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient has impairments. The patient's apartment building has an elevator and is handicapped accessible.  He lives on the second floor of a two bedroom apartment with a roommate/friend.  The patient's roommate and sister assist him as needed when there is no aide available.

Needs are: 

-	Maximal assistance for meal preparation, ordinary housework and shopping;
-	Extensive Assistance for managing stairs, transportation and bathing;
-	Limited assistance for managing finances, managing medications, personal hygiene, dressing his upper and lower body, walking, toilet transfer and locomotion;
Supervision/Independence for bed mobility and is independent and needs setup help only with eating and toilet use.
-	Cognition:  No impairment. 
-	Continence: There is no incontinence. 

The patient uses an assistive device for locomotion indoors. 

An increase of Consumer Directed Personal Assistance Services to 40 hours per week is being requested.

The insurer has partially denied coverage for the Consumer Directed Personal Assistance Services of 40 hours per week.  They stated the clinical information supported a partial increase in hours from the previous approval of 17.5 hours per week.   The insurer approved a total of 22 hours per week.  They stated the new hours are enough to support the patient's activities of daily living. 

The patient needs limited assistance with activities of daily living (ADLs) and is continent.  He currently receives 3 hours/day of personal care services.  He has informal caregivers.  The available documentation does not support the need for an additional 212 hours/day. 
      
The health plan acted reasonably with sound medical judgment in the best interest of the patient.          

The insurer's Partial denial of coverage for the requested Consumer Directed Personal Assistance Services of 40 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical chest pain. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with a history of panic attacks who presented to the hospital complaining of dyspnea, chest tightness and loss of consciousness with a fall four days prior to presentation. He walked into the Emergency Department (ED) noting that he had suffered from worsening panic attacks over the past week. Vital signs on arrival were stable (blood pressure 134/68, pulse 97 beats per minute) and physical examination was unremarkable. Electrocardiogram (ECG) demonstrated no ST or T wave changes and high sensitivity troponin was mildly elevated but trended downward to normal at 39.4 (first result), 18.3 (second result), 7.7 (third result). Computed tomography (CT) of the head was normal and neurology work up was within normal limits. Creatine phosphokinase (CPK) was 949 and the patient was diagnosed with mild rhabdomyolysis and subsequently discharged. 

This patient presented with atypical chest pain following a panic attack. His pretest probability of coronary artery disease is low.(1) Utilizing the HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score he was considered low risk.(2) Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days.(3) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Heydayati et al.(3)  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Elevated troponin level was likely false positive in the setting of rhabdomyolysis. 

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. The patient did not require acute inpatient hospital admission and could have been treated at a lower level of care. The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epistaxis. 
Treatment: Inpatient admission. 

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

The patient is a female.  At the time of admission to the hospital, she had a past medical history significant for hypertension (HTN), dyslipidemia, coronary artery disease (CAD), atrial fibrillation, asthma, chronic obstructive pulmonary disease (COPD), peripheral vascular disease and diabetes mellitus. 

The patient presented to the emergency room with epistaxis. The bleeding subsided while in the emergency room. Vital signs were stable. Labs were done with no evidence of significant blood loss. The patient was discharged, however the patient developed repeat nose bleeding while in the parking lot and returned to the emergency room. The emergency room physician applied direct pressure and the bleeding stopped. The patient was admitted for monitoring. Her anticoagulation was held. She remained stable and was discharged home the next day with a plan for outpatient follow-up. 

No, the proposed inpatient admission was not medically necessary. 
The medical necessity of the requested treatment could not be established. 

This patient with multiple cardiac comorbidities presented for evaluation of epistaxis. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability.  There was no evidence of respiratory distress, significant anemia, need for transfusion, etc. The bleeding was controlled in the emergency room. Although it was prudent to monitor the patient after bleeding was controlled to rule out recurrence, it could have been performed in a lower than inpatient level of care. Therefore, the clinical information provided in the records submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care in the emergency department.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-seizures. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a male with a history of seizures, asthma, hypertension, tobacco use, and polysubstance abuse. He presented to the emergency room following two witnessed seizures that both resolved without intervention. Vital signs were notable for a blood pressure of 136/99. He was awake and alert. The physical exam was normal. Labs were notable for very low phenytoin and levetiracetam levels, as well as opioids and tetrahydrocannabinol (THC) in the urine drug screen. The head computed tomography (CT) scan was normal. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. While in the emergency room (ER) the patient had another generalized seizure, which was treated with intravenous lorazepam and levetiracetam. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with phenytoin. The hospital stay was clinically uneventful, and the patient left against medical advice later in the day.

The health plan's determination is upheld.

The requested inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. It was extremely likely that the patient's presenting seizures were due to noncompliance with his anti-seizure medication regimen. There was no evidence of head trauma, infection, intracranial lesions, or severe metabolic disarray. The services provided - reloading anti-seizure medication - was not at the acute inpatient level of intensity. Therefore, based on the standard of care, and the peer reviewed literature cited below, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation.
Treatment: Hospital Admission.

The insurer denied coverage for hospital admission.  The denial is upheld.

At issue is the case of a gentleman that presented to the hospital for elective left atrial catheter ablation to treat atrial fibrillation. Past medical history was significant for hypertension and symptomatic atrial fibrillation. He underwent electrophysiologic (EP) study with pulmonary vein electrical isolation and cavotricuspid isthmus ablation. The intraoperative and postoperative course were uncomplicated, and the patient was discharged the following day. 

In this case, there were no clinical reasons for hospital admission, and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity.(1) Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day.(2) The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care. In conclusion, hospital admission was not medically necessary.

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

The insurer's denial of coverage for the hospital admission is upheld. Medical necessity is not substantiated.