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

Diagnosis: Right hand infection. 
Treatment: Inpatient hospital admission. 

The health plan denied the requested inpatient hospital admission. 
The health plan's determination is overturned. 

This patient is a female with a past medical history of intravenous drug abuse (IVDA) who was sent to the Emergency Department (ED) by her plastic surgeon due to a non-healing wound of her right hand. She complained of pain and occasional bleeding from her right upper extremity wound. She also complained of difficulty with its movement. She had been hospitalized where her wound was debrided, and she was discharged on oral antibiotics. Follow up in the plastic surgeons' office revealed a non-healing wound and she was sent to the ED for further evaluation. Consultation in the ED, by the plastic surgeon noted the patient, who was right hand dominant, had incurred a severe infection to the dorsum of her right hand and wrist after heroin or other drug injections. At that time, she underwent extensive debridement of the non-viable necrotic gangrenous tissues involving multiple extensive tendon mechanism and had undergone intensive local wound care as well as antibiotic treatment. Due to her non-healing wound and failure of oral antibiotics her surgeon recommended inpatient admission for intravenous (IV) antibiotics and possible surgical repair of this wound. Examination of the dorsum of the right hand and wrist by the plastic surgeon revealed an area of 6 x 4 centimeter (cm) somewhat granulating wounds. The patient was admitted into inpatient level of care for the treatment of hand cellulitis with tissue loss and reconstructive surgery required. 

The patient was monitored on a medical unit. Intravenous Unasyn 4 times a day was administered. Home medications were resumed. Infectious disease (ID) was consulted and noted the patient's wound culture grew strep anginosus. Intravenous Unasyn peri-operatively was recommended. 

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

This patient had a complex hand wound. She had previously failed outpatient management and also had recurrent infection after she had been hospitalized where her wound was debrided, and she was discharged on oral antibiotics. While this wound could potentially have been managed an outpatient or observation level of care in a compliant patient, this patient has a history of poor compliance and drug use. She required treatment in a supervised setting. She had acute drug withdrawal while hospitalized, and the treatment with Suboxone, Ativan and Methadone was most appropriately completed in an inpatient setting with psychiatry consultation. Due to the complexity of the patient's situation - significant hand infection that had failed two attempts at outpatient management and significant heroin use history with acute withdrawal, inpatient admission was the most appropriate treatment for this patient. Inpatient admission allowed the best chance to heal this patient's chronic hand wound.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal bleeding
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female with medical history of Ulcerative Colitis, diabetes mellitus, hypertension, hyperlipidemia, and anemia. She presented to the emergency department with three days of rectal bleeding and near-syncope, fatigue, palpitations, and lightheadedness. Vital signs were notable for tachycardia.

The inpatient level of care is not medically necessary. The patient presented with rectal bleeding with symptomatic anemia and was assessed to have an Ulcerative Colitis flare versus hemorrhoidal bleeding. The standard of care for the evaluation and treatment of Ulcerative Colitis was appropriately performed, including intravenous fluids and supportive care, as well as corticosteroids. Imaging did not show colitis or associated complications such as toxic megacolon, and the patient did not have protracted hypotension, peritonitis, bowel obstruction, sepsis, abscess, significant gastrointestinal bleeding or anemia, or perforation to support the inpatient level of care. A Colonoscopy was recommended as an outpatient rather than during the admission. The measures which were undertaken, including observation, monitoring, labs, imaging, Gastroenterology consultation, and corticosteroid therapy, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral mandibular tori
Treatment: Additional General Anesthesia or Intravenous (IV) Sedation (for Dental Services) - 45 Minutes
The insurer denied additional general anesthesia or IV sedation (for dental services) - 45 minutes.
The denial is overturned.

The patient is an adult female. The request is for health benefits for general anesthesia for 90 minutes for bilateral mandibular tori removal. Per the provider's dental clinical summary, x-rays and photos, the existence of bilateral mandibular tori is well supported in these materials.

The health plan is approving 45 minutes of anesthesia only and is denying the additional 45 minutes that the provider requested.

The provider is appealing based on the clinical diagnosis and the time that they feel is necessary to perform the surgery.

The proposed treatment of an additional 45 minutes of general anesthesia for bilateral mandibular tori removal is medically necessary.

In an elderly patient with the stated co-morbidities and the risk of bleeding, the use of general anesthesia is indicated. The health plan agrees with this because they initially approved 45 minutes of anesthesia but denied the additional 45 minutes that the provider requested. This patient's surgery involves two separate sites on both sides of the lower jaw; this surgery is the removal of extra boney growth of the jaw.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: MRI (magnetic resonance imaging) of the lumbar spine
The insurer denied the MRI of the lumbar spine.
The determination is upheld.

This is a patient with a history of obesity, depression, and elevated blood pressure. He is requesting coverage for a magnetic resonance imaging (MRI) scan of the lumbar spine. A review of the records provided documents of treatment with anti-inflammatory medications for low back pain, as well as a referral for physical therapy. The patient reported that there was no improvement with these interventions. However, there are no records documenting an in-office physical therapy evaluation and treatment. At issue is the medical necessity of an MRI of the lumbar spine.
The requested health service/treatment of an MRI lumbar spine without and with contrast was not medically necessary for this patient.
The standard of care for ordering an MRI of the lumbar spine for low back pain includes persistent symptoms despite a 6-8-week period of anti-inflammatory medication and physical therapy. The records support the persistent symptoms and treatment with medication, but there is no medical record evidence that the patient was evaluated and treated by a physical therapist.
Therefore, based on the standard of care, as well as the peer-reviewed literature and clinical guidelines cited in the references, the MRI of the lumbar spine was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is a case of an adult female with a history of ischemic heart disease, hypertension, obstructive sleep apnea (OSA), peripheral vascular disease, and active smoking that presented to the hospital for cardiac catheterization as part of a staged percutaneous intervention. Previous cardiac catheterization revealed triple vessel coronary artery disease and a stent was placed in the proximal and mid right coronary artery (RCA). Percutaneous intervention to treat lesions in the distal left main, proximal left anterior descending and proximal circumflex arteries were planned. Drug eluting stents were successfully placed in the aforementioned arteries as well as in the first obtuse marginal artery. The patient's procedure was performed via a left femoral artery approach. Post procedure, the patient reported severe pain in the left femoral region. Left lower extremity duplex was negative for pseudoaneurysm or occlusion. The patient was kept as an inpatient for an additional night waiting for physical therapy evaluation. Recommendations were made for home physical therapy and the patient was discharged.  

This patient presented for elective percutaneous revascularization. She underwent an uncomplicated procedure and stents were placed in the left anterior descending (LAD) and Circumflex arteries. She remained hospitalized awaiting evaluation for physical therapy. Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (References 1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion, inpatient hospital admission was not medically necessary.  

The health plan acted reasonably, with sound medical judgment, 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: Back Pain.
Treatment: Anterior Lumbar Interbody Fusion of L5/S1 (fifth lumber spine vertebra first sacral vertebra) Lumbar Spine (25558).
The insurer denied: Anterior Lumbar Interbody Fusion of L5/S1 (fifth lumber spine vertebra  first sacral vertebra) Lumbar Spine (25558). 
The denial is upheld.

The patient is an adult female. The patient had surgery for an anterior lumbar interbody fusion of L5-S1 (fifth lumber spine vertebra first sacral vertebra). The patient has a one-year history of lower back pain. The patient has 80% back pain and 20% right lower extremity pain. The pain had significant interference with activities of daily living and was unable to stand, walk or sit for more than five minutes. The patient had previous treatment with NSAIDs (nonsteroidal anti-inflammatory drugs), injections, therapy, and activity modification. The patient had an MRI (magnetic resonance imaging) showing L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) moderate disc degeneration with a right-sided disc herniation and caudal migration. This was abutting the S1 (first sacral vertebra) nerve root sleeve. The request is made for the lumbar fusion surgery with the anterior interbody fusion.

The requested health service was not medically necessary.

The need for this treatment has not been established. The preoperative imaging shows disc degeneration without evidence of instability. Given the lack of documented preoperative instability, the need for surgical intervention for the fusion cannot be supported as medically necessary.

The need for the surgical procedure has not been established, based on the preoperative imaging studies and clinical findings. The patient had disc degeneration causing back pain symptoms. The patient had minimal neurogenic symptoms. There is no evidence that the patient required a fusion since the patient had no instability of the spine such as spondylolisthesis or spondylolysis. Thus, the surgery would not be approved based on the scientific literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic Arthristis.
Treatment: Taltz.
The insurer denied the Taltz.
The denial is overturned.

The patient is a male diagnosed with psoriasis and psoriatic arthritis.  He has tried and failed triamcinolone and was started on Taltz.  The patient has been stabilized on Taltz so the treating provider has requested continuation of treatment with Taltz.  The request was denied by the health plan so the provider is appealing the denial.

Yes, the proposed treatment with Taltz is medically necessary.
The patient 's primary diagnosis is psoriasis but he also has psoriatic arthritis and he has been stabilized on Taltz for three years.  To change the patient's medication puts the patient at risk for destabilization.  The suggested alternatives are not Food and Drug Administrative (FDA) approved for the treatment of both psoriasis and psoriatic arthritis and the patient has both diseases.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The treatment alternatives suggested by the plan are not Food and Drug Administrative approved to treat all of the patient's diagnoses.  Standard of care would be to continue an effective treatment instead of changing to an off-label medication, risking destabilization of one or all of the patient's diagnoses.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite
Treatment: Comprehensive orthodontic treatment of adolescent dentition and visits.
The insurer denied: Comprehensive orthodontic treatment of adolescent dentition and visits.
The denial is upheld.

The patient is a male with a Class I occlusion with 3 millimeter (mm) overbite and 2mm overjet. He has minor maxillary and moderate mandibular crowing. He is treatment planned for orthodontics to correct his malocclusion. The subject under review is the medical necessity for the comprehensive orthodontic treatment of adolescent dentition and visits.

The health plan's determination is upheld.

The requested comprehensive orthodontic treatment of adolescent dentition and visits is not medically necessary. There is no medical reason to correct his malocclusion with braces.
The patient's teeth are crowded but no teeth are impacted. His overbite is 3mm deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There photos and cephalometric radiograph supplied do not support the diagnosis of anterior crossbite with attachment loss of tooth 24. There is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession.
There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.[1] This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a skeletal Class I occlusion.[2] If his teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. The requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 braces and D8670 monthly visits.

The insurer denied coverage for D8080 braces and D8670 monthly visits.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, and two photographic images of study models, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics. 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 on the HLD (Handicapping Labiolingual Deviation) index: attaining 18 points on review by internal reviewers. 

Upon review of the submitted documentation, it is evident that the patient exhibits malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index: 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 provided limited diagnostic information and does not complete an HLD index. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer with a total of 18 points (5 points ove1jet, 5 points overbite, 5 points anterior crowding, 3 points labiolingual spread).

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 needs is a valid approach. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic needs. 


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 visits is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Pulmonary embolism.
Treatment: Eliquis (apixaban).

The insurer denied coverage for Eliquis (apixaban).  The denial is overturned.

This is an adult male who is status post autologous peripheral blood stem cell transplant for acute myeloid leukemia (AML). The patient developed recurrent left lower extremity (LLE) deep vein thrombosis (DVT) and pulmonary embolism (PE) following which he was placed on Enoxaparin. He was switched to Eliquis and was doing well on the medication. He also had signs of graft versus host disease (GVHD).

He was switched to Xarelto as Eliquis was taken out of the formulary. While on Xarelto, the patient developed a left upper extremity (LUE) pericatheter non-obstructing thrombus.

This patient had failed Lovenox and developed a DVT and PE. While on Eliquis, he was doing well, but it was taken out of the formulary, and it was discontinued. Then the patient was placed on Xarelto, and while on it, developed a LUE DVT.

Based on above, Eliquis is necessary for this patient. The patient had failed on the other drugs.  This patient has GVHD for which he is on multiple medications and Warfarin has multiple drug interactions and this patient is at high risk of bleeding due to his underlying medical condition so Warfarin is not suitable. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication. The formulary drug is expected to be ineffective. The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial for Formulary Exception for Eliquis to treat pulmonary embolism is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Obesity.
Treatment:  Wegovy.

The insurer denied coverage for Wegovy.  The denial is overturned.

The patient has a history of obesity. She has been on Wegovy for approximately 6 months. The starting weight was 187 pounds, and current weight is 163 pounds. The treating provider is requesting Wegovy, which is the topic of this review.

The documentation provided indicates that the patient has lost more than five percent of body weight and maintained that loss since starting medication. The documentation shows that this patient started in the obese category with a body mass index (BMI) above 30, and a weight of 187 pounds. Her current BMI is below 30 and a weight of 163 pounds. This is a greater than five percent loss. This supports guidelines from the health plan as well as national guidelines and Food and Drug Administration (FDA) approval for the medication for continuation. As such, the medication is considered medically necessary.

Per Wharton, S. et al. (2020), "Pharmacotherapy: We recommend adjunctive pharmacotherapy for weight loss and weight-loss maintenance for individuals with BMI  30 or BMI  27 with adiposity-related complications, to support medical nutrition therapy, physical activity and psychological interventions. Options include liraglutide 3.0 milligram (mg), naltrexone-bupropion combination and orlistat. Pharmacotherapy augments the magnitude of weight loss beyond that which health behavior changes can achieve alone and is important in the prevention of weight regain."

According to Singh, G. et al. (2020), "There are four FDA-approved medications on the market for weight loss, namely phentermine-topiramate (Qsymia), orlistat (Xenical), naltrexone-bupropion (Contrave), and the glucagon-like peptide-1 receptor agonist (GLP-1 RA) liraglutide (Saxenda). Lorcaserin (Belviq) was previously given FDA approval but was recalled at the beginning of 2020 due to an increased risk of malignancies. Wegovy (semaglutide), the GLP-1 RA discussed in this article, received FDA approval in 2021."

"Guidelines from the American Heart Association/American College of Cardiology/The Obesity Society recommend using a multifactorial approach to manage obesity. This includes initiation of comprehensive lifestyle intervention programs and pharmacotherapy in individuals with BMI 30 or 27 with comorbid conditions like type 2 diabetes, hypertension, dyslipidemia, or obstructive sleep apnea if lifestyle modification alone is not effective." (Mehta, A. et al. 2017)                                                       

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 Wegovy is overturned. Medical Necessity is substantiated.