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

Diagnosis: Paroxysmal Atrial Fibrillation. 
Treatment: Formulary exception for Eliquis. 

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

The patient is a female with history of atrial fibrillation. A request was made for use of Eliquis, while the formulary includes warfarin and Xarelto. In the request for exception, it was stated that the patient had tried Xarelto and it was not tolerated or had failed treatment (there was no documentation seen in the records). 

Yes, the health plan should cover the proposed treatment with Eliquis. 

Non-valvular atrial fibrillation is a Class I indication for anti-coagulation. Warfarin and direct oral anticoagulants (DOACs) are accepted anti-coagulants. However, recent data as noted below have shown a superiority of Eliquis over Xarelto in preventing ischemic events. It is reasonable for a treating physician to prescribe based on the landmark studies. 

In addition, per the American College of Cardiology recent recommendation: direct oral anticoagulants (DOACs), compared with warfarin, were associated with lower risks for ischemic stroke or systemic embolism and major bleeding events in patients with valvular atrial fibrillation (AF). Therefore, Eliquis is preferred over warfarin. 

The health plan should cover the proposed treatment with Eliquis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.

Treatment D8080 braces and D8670 monthly visit.

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical t1ndings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth (mandibular left canine) when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. 

Upon review of the submitted documentation, 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer score on the HLD index attains 17 points (5 overjet, 4 overbite, 5 anterior crowding, 3 labiolingual spread) which is below the required 26 points.

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 medical/dental necessity of orthodontic care.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End Stage Renal Disease (ESRD).
Treatment: Inpatient admission.

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

This is the case of a male with end stage renal disease (ESRD) on hemodialysis who was admitted for missing dialysis treatment as an outpatient. He left against medical advice (AMA) the same day after he received routine hemodialysis.

The patient was admitted for missing dialysis treatment, he was treated with hemodialysis on admission, his condition responded to dialysis. He did not have persistent severe hyperkalemia, no signs of severe volume overload or hypoxia, no documentation of severe uremia such as encephalopathy or uremic bleeding. He had established dialysis access and did not require emergent vascular intervention. His condition could have been treated safely under lower level of care.

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

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


Diagnosis; atrial fibrillation
Treatment: Eliquis (apixaban)
The insurer denied Eliquis (apixaban). The health plan's determination is upheld.

The patient is a male with history of a cardiomyopathy, left ventricular ejection fraction (LVEF) 40% (percent), atrial fibrillation, and cardioversion's as well as ablations. The use of Eliquis is under review.

A formulary exception is not indicated in this case. Xarelto (which is a plan formulary drug) would be as effective without adverse effects.

Those with atrial fibrillation can be at elevated risk of an associated cerebrovascular accident (CVA) and in some individuals anticoagulation is indicated. Warfarin has been proven effective for atrial fibrillation (afib) stroke prevention. The new generation of anticoagulants, including Eliquis and Xarelto have been developed for afib stroke prevention. All agents have an associated increased risk of both major and minor bleeding. The newer medications have generally been demonstrated more effective than Warfarin for stroke prevention and are generally safer. However, there is no definitive evidence such as a large blinded randomized control trial directly comparing Eliquis to Xarelto establishing it as definitive standard of care towards improved atrial fibrillation stroke prevention outcomes. Also, there was no contraindication to Xarelto in this case. Therefore, Eliquis is not indicated in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infect (UTI)

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This case involves a female diagnosed with diabetes mellitus and hypertension. The patient was seen in the emergency department (ED) regarding acute onset of dizziness, blurry vision, and tingling to the left side of the face. Symptoms lasted 20 minutes and had resolved. There was also a history of chronic left facial droop from several years prior. There were also reports of a weird sensation in the tongue with difficulty with speech. Symptoms had improved when she arrived at the ED and she felt better. Blood pressure at that time was 90/60. The patient was also noted to have urinary tract infection (UTI) and was admitted to the hospital for work-up for possible stroke. Magnetic resonance imaging (MRI) was negative for stroke and the patient was discharged home to follow-up with neurology for further work-up.

The patient presented for a discrete episode of transient acute onset of dizziness with blurred vision and left-sided facial tingling. Additional history reported an atypical sensation involving the tongue with difficulty with speech. She was evaluated in the ED and admitted to the hospital. She was found to have a UTI and was treated from this vantage point. MRI of the brain was negative for acute stroke, hemorrhage, or acute intracranial process. She was discharged home with outpatient follow up with neurology. Care provided, including diagnostic imaging study with MRI, medical management and specialty consultation could have been performed in the ED and at an observation level of care. Care provided did not warrant inpatient admission. 

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: Upheld

Diagnosis: Possible Infertility. 
Treatment: In-vitro fertilization (IVF). 

The insurer denied IVF. The health plan's determination is upheld. 

The patient is a female who has no history of infertility. Per reports, she initially presented inquiring about freezing her eggs for fertility preservation. Recently, the patient presented wanting to pursue an in vitro fertilization (IVF) cycle with preimplantation genetic testing (PGT-M). Her husband is a carrier for both BRCA (breast cancer) 1 and 2. Her work-up shown includes: AMH (Anti-Mullerian hormone) 2.09, AFC (antral follicle count) 10-14. Normal karyotypes for both patient and spouse are noted. Genetic carrier screening showed the patient as being negative for all mutations tested. The Spouse is positive carrier for congenital adrenal hyperplasia and Tay-Sachs. The Spouse has a normal semen analysis. 

An In-Vitro Fertilization (IVF) Cycle is not medically necessary for this patient. The only reason for this patient to do IVF is to do perform PGT-M. She has no medical reason (ie no infertility diagnosis) that would require her to do IVF. She also does not meet the criteria for coverage for PGT-M. Therefore, there is no medical necessity for IVF. The presence of either BRCA1 or BRCA2 or both does not guarantee with 100% (percent) certainty that the person with these mutations will have cancer. They do significantly increase that person's risk of developing multiple cancers in the future, but that is not for certain. Many people with these mutations do not ever get diagnosed with cancer despite their increased predisposition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epigastric Pain. 
Treatment: CT scan of abdomen. 

The insurer denied the CT scan of abdomen. 
The determination is overturned. 

The patient has persistent epigastric pain and regurgitation. He has been on pantoprazole and famotidine. An ultrasound of the abdomen showed a newly echogenic liver. An esophagogastroduodenoscopy showed Grade A esophagitis, mild gastritis, and normal duodenum. Lab results showed an elevated bilirubin of 1.3 milligrams per deciliter (mg/dL). He has had an esophagogastroduodenoscopy and ultrasound of the abdomen without findings to explain his pain. At issue is the medical necessity of a computed tomography scan of the abdomen for the evaluation of abdominal pain. 

Yes, the computed tomography scan of the abdomen is medically necessary. 
The patient has had abdominal pain, which has not responded to acid suppression medication; no etiology is apparent on more limited examinations such as an ultrasound and esophagogastroduodenoscopy. A computed tomography (CT) scan is beneficial in diagnosing adult patients with abdominal pain, and is considered the first-line imaging modality for this indication in this population [1]. It is broadly used in clinical practice for the evaluation of abdominal pain. There are a number of medical diseases with nonspecific symptoms which cannot be diagnosed using physical examination alone. One example is adult intussusception, which presents with non-specific abdominal pain; a CT scan is the most sensitive diagnostic method for diagnosis [2,3]. CT has become a primary imaging test for evaluation of the small bowel, and is especially useful in diagnosis of Crohn's disease; it is also effective in the diagnosis of the extra-enteric manifestations of the disease, including fistulae, sinus tracts, and abscesses [4]. CT is the imaging test of choice for diagnosis of vascular compression syndromes, such as median arcuate ligament syndrome, which may present with abdominal pain and nonspecific and obscure symptoms, causing delayed or erroneous diagnoses [5]. Internal hernia may also present with abdominal pain, and may result in small bowel obstruction, or strangulation with infarction [6]. Establishing a correct diagnosis of internal hernia with physical examination alone is very difficult, although a CT is a sensitive test. Given that a cause for ongoing abdominal pain has not been determined in the patient, and a CT scan has a high sensitivity for several serious etiologies for abdominal pain that cannot be discovered by physical examination or more limited examinations such as ultrasound or esophagogastroduodenoscopy, a CT scan would be medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara. 

The health plan denied Stelara. The health plan's determination is overturned. 

The patient is a male diagnosed with Crohn's Disease (CD). The patient has moderately to severely active disease. He had an ileocolic resection. The patient started on Stelara and the dose was increased to every 6 weeks. The patient was without gastrointestinal (GI) symptoms. Blood tests demonstrate a normal complete blood count (CBC) and comprehensive metabolic panel (CMP) with a low Vitamin D. Prior to this, the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were normal. An upper endoscopy showed minor findings. There is an Ustekinumab level of 7.6 ug/ml (micrograms/milliliter) on the chart, but there is no associated date. There were no drug antibodies. On another occasion the level was 19. Later his Ustekinumab level was 4.8.ug/ml. At that time the CRP was elevated. 

The patient's provider has recommended therapy with Stelara subcutaneous (SQ) 90 mg (milligrams). 

I recommend overturning, in whole, the health plan's determination of medical necessity. 

Yes, the patient has aggressive disease and has already required a major surgery for the active disease. There is no guarantee that any of the biologics will work for this patient; some patients cycle through all of the classes of drugs without finding a beneficial agent. Unfortunately, it is not like switching statins for cholesterol or proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD). In this case he is doing very well on Stelara. He has been on this therapy for nearly 4 years and has a good response. Although not fully reflected in the chart, he apparently required dose escalation and responded to that change in medication. There is ample data as referenced below that some patients do find benefit with dose escalation above every 8-week dosing. There is a very good chance that if switched to the preferred formulary drug, Humira, the patient could experience a severe flare of his disease requiring steroids, hospitalization, and potential future surgery. In the best interest in the care of this patient it is medically necessary to continue Stelara 90 mg every 6 weeks.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, knee/hips osteoarthritis. 
Treatment: Wheelchair Ramp. 

The insurer denied the Wheelchair Ramp. 
The denial is overturned. 

The patient is a female with a history of Alzheimer's disease, knee/hips osteoarthritis, using a wheelchair. The request is for a wheelchair ramp due to difficulty in entering and exiting the house, as this requires the assistance of two people to lift her over the steps. 

The daughter made the request toward enabling the patient to be able to enter and exit the house. At the moment, patient receives Consumer Directed Personal Assistance Service (CDPAS) 24 hours a day and 7 days a week, but requires a huge effort by at least two people to do the lifting. 

Yes, the Wheelchair Ramp is medically necessary. 

The wheelchair ramp is medically necessary, as it is not mainly for the convenience of the patient. She currently requires heavy lifting by two people to enter and exit the house, and the law allows such modification as this will also help her independence. 

The patient's primary care physician endorsed this appeal and therefore prescribed the wheelchair ramp. 

In addition, the requested ramp is medically necessary because it is In accordance with Generally Accepted Standards of Medical Practice; Clinically appropriate, in terms of type, frequency, extent, service site and duration, and considered effective for the patient's Sickness, Injury, Mental Illness, substance-related and addictive disorders disease or its symptoms; Not mainly for the patient's convenience or that of the patient's doctor or other health care provider; Not more intensive than an alternative drug, service(s), service site or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's Sickness, Injury, disease or symptoms. 

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

There is a need for a wheelchair ramp in this case. The request was made by the daughter, and later endorsed by her primary care physician. 

The daughter made the request toward enabling the patient to be able to enter and exit the house. At the moment, the patient receives Consumer Directed Personal Assistance Service (CDPAS) 24 hours a day and 7 days a week, but requires a huge effort by at least two people to do the lifting, making this an accident waiting to happen or more difficulty in entering and exiting the house.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pelvic pain and dysmenorrhea.
Treatment: Lo Loestrin Fe.
The insurer denied Lo Loestrin Fe. 
The health plan's determination is overturned.

The patient is a female with pelvic pain and dysmenorrhea. She had complained of pain and was prescribed Lo Loestrin. This was denied by the health plan. Under review is the medical necessity of Lo Loestrin Fe.

The requested Lo Loestrin Fe is medically necessary for this patient.
The patient has dysmenorrhea/pelvic pain and combined oral contraceptives are an appropriate treatment for dysmenorrhea. Lo Loestrin is a combined oral contraceptive and would be appropriate for this patient's dysmenorrhea. She can use this particular medication for dysmenorrhea as all combined oral contraceptives are a treatment for dysmenorrhea. It is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease. 
Treatment: Inpatient admission. 

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

The patient is a male. He was hospitalized. He presented for elective cardiac catheterization with coronary angiography after OP (outpatient) coronary CCTA (coronary computed tomography angiography) performed to evaluate DOE (dyspnea on exertion) showed significant CAD (coronary artery disease). 

The patient's treatment included successful PCI (percutaneous coronary intervention) with DES (drug eluting stent) to the LAD (left anterior descending artery) on the same day. Staged PCI (percutaneous coronary intervention) to the left circumflex was done the following day. There were no procedural-related complications, and he was and he was discharged later on the same day. 

This is an appeal of the denied claim the requested Acute Inpatient Hospital stay was medically necessary for this patient. 

No, the Inpatient admission was not medically necessary. 

In this particular case, criteria for admission are not met. The goal length of stay is Ambulatory. Inpatient stay may be needed for PCI (percutaneous coronary intervention) for unstable angina after acute MI (myocardial infarction), but none was documented. In this particular case, the patient underwent cardiac catheterization followed by successful and uncomplicated staged PCIs (percutaneous coronary intervention) on back to back days. 

The information provided does not support the medical necessity for admission after the patient's successful and uncomplicated coronary interventions. PCI (percutaneous coronary intervention) procedures are routinely performed in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like AMI (acute myocardial infarction), CVA (cerebrovascular accident), contrast nephropathy, acutely decompensated CHF (congestive heart failure), life-threatening cardiac arrhythmia, procedural complications like acute coronary perforation or vascular access complication requiring surgery or retroperitoneal hematoma, extravascular procedural complications such as, pericardial effusion, or cardiac tamponade requiring pericardiocentesis or surgery, urgent or emergent CABG (coronary artery bypass graft) surgery, patient requiring IV (intravenous) glycoprotein receptor inhibitors for use including complex lesions and threatened or actual vessel closure or other medical instability or acute care needs that would require acute inpatient management. Therefore, the Inpatient admission was not medically necessary, based on the submitted information and the current standards evidence-based medical care. 

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

Diagnosis: Mild gingivitis, mild to moderate localized bone loss. 
Treatment: D2751 white glass with metal crown tooth 20. 

The insurer denied coverage for D2751 white glass with metal crown tooth 20. 

The denial is upheld. 

Upon review of the documentation provided which includes copy of full mouth series radiographs and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended full coverage crown for tooth #20. The insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this service and therefore the service does not meet medical necessity criteria. The patient is appealing. 

The objective documentation provided for review is a copy of full mouth series radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting #20 based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental service as enumerated above and therefore the crown is deemed not medically necessary. 

The documentation is insufficient to justify or substantiate the treatment. 

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

The insurer's denial of coverage for D2751 white glass with metal crown tooth 20 is upheld. Medical Necessity is not substantiated.