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

Diagnosis: Class I occlusion 
Treatment: braces/monthly visit 
The insurer denied braces/monthly visit 
The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion. She has 3 millimeter (mm) overbite and 4 mm overjet. She has moderate maxillary and mandibular crowing. She is in the late mixed dentition stage of dental development with three remaining primary teeth. The second molars are still far from eruption. 

Braces and monthly visits are not medically necessary. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the mandibular teeth or palatal soft tissue damage from their current position. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient has a slightly excessive overjet but this amount of overjet does not negatively affect oral health related quality of life. If her 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 Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal bleed. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 
 
The patient has a history of alcohol abuse and presented after vomiting coffee grounds. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The hemoglobin was 12.9. The international normalized ratio (INR) was normal. The platelet count was 88,000. The alcohol level was 307. Intravenous (IV) Protonix was started. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was 0. The liver enzymes were elevated consistent with alcoholic liver disease. 

Medical necessity was determined based on Milliman Care Guideline (MCG) M-180 for Upper GI (gastrointestinal) Bleeding. Clinical indications for admission include hemodynamic instability, ongoing active bleeding, peptic ulcer with high risk endoscopic features, severe coagulopathy, anemia with sign of cardiac ischemia, gastric outlet obstruction, peritoneal signs, or an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

The patient was consuming alcohol and vomited coffee grounds. He was not actively bleeding in the hospital. IV hydration, Proton pump inhibitor (PPI) therapy, and antiemetics could have been given with observation care. He was not in acute withdrawal. He had alcoholic liver disease but was not in acute liver failure. He did not meet MCG criteria for admission for Upper GI Bleeding. 

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

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion. 
Treatment: D8080 braces. 
The insurer denied D8080 braces. 
The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 7. She presents with a skeletal Class I malocclusion with minor crowding in the maxilla and mandible. She is treatment planned for braces. 

Braces are medically necessary for this patient. This patient presents with an anterior crossbite on tooth 7. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. 
Tooth 26 is already being pushed labially in the dental arch and showing signs of recession. If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal 
Pain Management

Diagnosis:  back pain
Treatment: Epidural Injection Procedure for Back Pain Management

The insurer denied injections for pain management.
The denial is overturned.

This is a female patient with a history of chronic low back and radicular pain. A magnetic resonance imaging (MRI) of the lumbar (L) spine revealed L4 and L5 disc protrusion with severe spinal stenosis. The documentation indicates that the patient has been treated with lumbar facet radiofrequency ablation (RFA) and a caudal epidural steroid injection that did not provide relief; however, the caudal injection may not have spread enough to the L4 and L5 level to provide the patient with relief. A request was made for a bilateral L4 and L5 transforaminal epidural injection.
The requested health service and treatment of an epidural injection procedure for back pain management is medically necessary for this patient.
The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Injections of steroids directly into the epidural space are used for treatment of radicular back or neck pain after failure with conservative management. The steroids are given with or without anesthetic agents for relief of pain. Epidural steroid injections have been considered a generally accepted standard of medical practice for many years. The results of clinical trials have been mixed. Although short-term relief of radicular pain may occur, long-term outcomes vary. No more than three to four injections should be given in a six-month period. Injections are usually given at least a week apart.
There is a risk of bleeding, infection, or spinal cord injury with this invasive procedure. Some practitioners may give epidural steroid injections blindly; however, the use of fluoroscopy for visualization of needle placement has been shown to reduce the risk and complications of the procedure.
In this case the patient had persisting complaints despite conservative treatment therefore the injection would be indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression
Treatment: Vagus Nerve Stimulation
The insurer denied Vagus Nerve Stimulation
The determination is overturned.

The patient is an adult female diagnosed with severe and recurrent major depressive disorder and treatment refractory depression. The patient has received multiple medication trials without a substantial clinical response or remission. The patient also failed treatments with esketamine, ketamine, and electroconvulsive therapy (ECT) including 45 ECT treatments with partial benefit and no sustained therapeutic benefit. 
The patient's most recently submitted documentation reveals a mental status examination with severe symptoms of depression with normal appearance and behavior, clear speech, and linear thought processing, thought content which is devoid of suicidal ideation or morbid thought content, and no severe symptoms of depression including anhedonia, guilt, and low self-worth. 
At issue is the medical necessity of Vagus Nerve Stimulation.

Yes, the requested health service/treatment of vagus nerve stimulation (VNS) is medically necessary for this patient.
The existing literature does clearly support the use of VNS therapy as an augmentation strategy for the treatment of refractory depression. The procedure and use of VNS therapy being requested is consistent with existing reports or trials that have evaluated the efficacy or effectiveness of VNS therapy in patients with major depressive disorder and treatment refractory depression. The use of VNS therapy for initial treatment and for maintenance treatment is an appropriate augmentation strategy for depressive disorder in this patient, especially in view of the clinical history and the treatment refractory nature of the case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes. 
Treatment: Januvia (sitagliptin). 
The insurer denied coverage for Januvia (sitagliptin). 
The denial is upheld. 
 
This is an adult diagnosed with Type 2 diabetes mellitus. As reported, the patient is unable to tolerate metformin or Glipizide. The patient has been taking Januvia and is stable on it, showing improvement in fasting glucose and A1c (glycated hemoglobin). A formulary exception for Januvia is requested. 

Januvia, a dipeptidyl peptidase-4 (DPP-4) inhibitor, is Food and Drug Administration (FDA)-approved for type II diabetes. DPP-4 inhibitors have similar efficacy. There are no trials showing superiority of one DPP-4 inhibitor over another including linagliptin (Tradjenta), saxagliptin (Onglyza), vildagliptin (Galvus), alogliptin (Nesina) or sitagliptin (Januvia). The American Association of Clinical Endocrinologists' consensus statement regarding treatment of patients with Type two diabetes recommends the use of metformin followed by the use of a DPP-4 inhibitor or a glucagon-like peptide-1 (GLP-1) agonist. There are no studies demonstrating the superiority of the requested therapy over the preferred formulary alternative Tradjenta. 

There is no documentation that the patient tried the formulary alternative Tradjenta, or that Tradjenta would be contraindicated for the patient. 

The formulary drug is not expected to cause adverse effects. 

The formulary drug was not tried, and the patient did not have an adverse reaction or contraindication. 

The formulary drug is not expected to be ineffective. 

The non- formulary drug is not expected to be more effective than the formulary alternative. 

The carrier's denial of a request for a Formulary Exception for Januvia (sitagliptin) to treat diabetes mellitus with hyperglycemia is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ehlers-Danlos, C (cervical) 1-C2 instability. 
Treatment: Bone Marrow Aspiration (procedure code 20939). 
The insurer denied: Bone Marrow Aspiration (procedure code 20939). 
The denial is upheld. 

The patient is an adult female. Two months ago, it was noted that the patient is status post C1-C2 fusion and suboccipital decompression with harvest of bone marrow the previous month for treatment of atlantoaxial instability and foraminal stenosis in the setting of Ehlers-Danlos syndrome. Prior to surgery, the patient reported chronic headache, neck and back pain, dizziness, blurred and double vision, imbalance, vertigo, fatigue, muscle cramps and sleep disturbances. On neurologic exam the patient had evidence of diplopia on lateral gaze. She additionally had evidence of decreased facial symmetry. She had hypoesthesia over the face in the upper cervical dermatomes down to C5. On reflex exam, her patellar exams were 2 to 3+ and her Achilles exams were 3+. Her abdominal reflex was absent on the left and present on the right. On computed tomography imaging studies, the patient had a 4 degree angular displacement at C1-C2 associated with 95 percent loss of facet overlap constituting a Fielding type 1 rotatory subluxation. On the right, there was a 40 percent angular displacement with 90 percent loss of facet overlap. Magnetic resonance image documented the clival axial angle at 134 in flexion. One week following surgery, the patient reported that her diplopia had resolved, and her pain improved. 

The health plan should not cover the proposed treatment, specifically bone marrow aspiration for infusion into the graft. 

There is insufficient support on the part of the literature for bone marrow aspiration as an adjunct to cervical fusion. In addition, the health plan considers the use of bone marrow aspirate experimental and investigational as an adjunct to spinal fusion given the lack of evidence in the current literature. The primary issue is the lack of prospective multicenter trials with long-term follow-up. Additionally, the impact of the environment of mesenchymal cells with regard to effectiveness, specifically when used for regenerative purposes, is multifactorial and cannot be addressed solely in a singular patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ehlers-Danlos, C (cervical) 1-C2 instability. 
Treatment: Bone Marrow Aspiration (procedure code 20939). 
The insurer denied: Bone Marrow Aspiration (procedure code 20939). 
The denial is upheld. 

The patient is an adult female with a history of Ehlers-Danlos and possible C1-C2 instability. The attending physician also believes that there is some crowding at the foramen magnum, and he is proposing suboccipital craniectomy to expand the foramen magnum in conjunction with the C1-C2 fusion. The attending physician is recommending use of bone marrow aspirate and allograft for the graft material. 

The health plan should not cover the proposed treatment. 

The use of bone marrow aspirate has not been shown to be effective. Its use is considered experimental/investigational. 
This is an experimental/investigational procedure without established clinical efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ehlers-Danlos, C (cervical) 1-C2 instability. 
Treatment: Bone Marrow Aspiration (procedure code 20939). 
The insurer denied: Bone Marrow Aspiration (procedure code 20939). 
The denial is overturned. 

The patient is an adult female who underwent C1-C2 fusion for atlantoaxial instability and Ehlers-Danlos (EDS). During surgery, bone marrow aspiration was conducted to assist with the graft. 

The health plan should cover the proposed treatment. 

This is within the standard of care and is medically appropriate. 
The requested health service is more beneficial than any standard treatment for the patient's condition. The requested health service is appropriate, warranted and should be approved. This would be considered medically appropriate. The surgery requires bone growth cells to assist and improve the likelihood of fusion. Obtaining bone marrow from aspiration is an appropriate and medically indicated approach to achieve additional bone growth cells that will improve the likelihood of fusion. This is in addition to allograft which is also appropriate and in conjunction with the autograft that this aspiration provides. Therefore, this is medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left thigh cellulitis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld .


This is an adult male with benign past medical history who presented to the emergency department with complaints of pain, swelling, and erythema (redness) to the left upper thigh.

Vitals on presentation included: Temperature 97.0 degrees Fahrenheit, Blood Pressure 148/91, Pulse 87 beats per minute, Respiratory Rate 18 breaths per minute, oxygen (O2) saturation 99% on room air. Laboratory values were notable for the following: white blood cell count (WBC) 10.4, Hemoglobin (Hgb) 14.9, Hematocrit (Hct) 42.8, Creatinine 1.02, Glucose 107, Lactate 0.73.

The patient was empirically started on intravenous antibiotics (vancomycin) for left thigh cellulitis and underwent an incision and drainage procedure with a small amount of purulent fluid drained. The patient remained afebrile, hemodynamically stable and clinically improved. He was discharged to continue oral antibiotics as an outpatient.  

According to documentation, the patient presented with a left thigh cellulitis. Otherwise, he was afebrile and hemodynamically stable. Laboratory results were unremarkable, including a normal white blood cell (WBC) count. The patient had no documented co-morbid conditions and no evidence of a disseminated infection. 

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

Diagnosis: Fever, Chills
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who was hospitalized secondary to the presence of a fever, chills, and myalgia for 1 day which began after a prostate biopsy. Additional medical history includes hypertension.  Initial laboratory data demonstrated an acute kidney injury, hypokalemia, and hyperlactatemia. Initial treatment included the provision of intravenous fluids, potassium supplementation, and empiric intravenous antibacterial therapy (aztreonam). Cultural data was unrevealing. Clinical improvement was noted, and he was discharged home with prescribed oral levofloxacin therapy. At issue is the medical necessity of an inpatient stay.

Based on the information provided, the requested health service/treatment of inpatient admission was not medically necessary for this patient. The patient's initial presentation was concerning for sepsis given the presence of tachycardia, hypotension, and elevated serum lactate. However, this patient's vital signs quickly normalized with the provision of intravenous fluids. Similarly, this patient's acute kidney injury (AKI) and hypokalemia improved within 24 hours after the provision of intravenous fluids and supplemental potassium. There was no evidence of electrocardiogram (ECG) changes based on metabolic abnormalities. All culture data was unrevealing. Based on this information, it is clear this patient required diagnostic assessment and medical treatment, but this assessment and treatment could have been safely and provided at a lower level of care. Acute inpatient care was not medically necessary due to the prompt improvement in this patient's hemodynamics, renal function, and metabolic abnormalities.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary Embolism
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a history of hypertension and prostate cancer with recent prostatectomy 6 weeks prior. His presenting complaints were right lower extremity swelling and pain, and intermittent dyspnea. The physical exam was notable for right lower extremity swelling and tenderness. Lab results were notable for negative cardiac markers. Radiology was notable for an ultrasound showing acute occlusive deep vein thrombosis (DVT) in the right lower extremity, and computed tomography angiography (CTA) of the chest with bilateral upper and lower lobe pulmonary emboli. The patient was given an intravenous (IV) heparin infusion and admitted to an inpatient level of care. At issue is the medical necessity of an inpatient stay.
The hospital admission was medically necessary.
The patient presented with a high risk pulmonary embolism, with the simplified Pulmonary Embolism Severity Index placing him in the "high risk" category. His major risk factors were male sex and history of prostate cancer. Inpatient level of care was medically necessary to permit close monitoring of the patient and provide rapid response to any clinical decompensation. The patient was at higher risk for bleeding due to the recent prostatectomy as well. A lower level of care would not have been appropriate.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: ADHD, Predom Inattentive Type
Treatment: Formulary exception for Lisdexamfetamine 
Dimesylate 70mg (milligrams) Oral Caps
The insurer denied a formulary exception for Lisdexamfetamine 
Dimesylate 70mg (milligrams) Oral Caps
The denial is upheld.

The patient is an adult male diagnosed with attention deficit hyperactivity disorder (ADD)-inattentive type. The patient is prescribed Vyvanse (brand lisdexamfetamine) at a dose of 
70 milligrams daily. The health plan has denied the request for brand lisdexamfetamine and requires that the patient has failed treatment with the generic formulation due to intolerance or adverse effects and/or that three formulary alternatives be tried and failed before prior authorization for a non-formulary ADHD (attention deficit hyperactivity disorder)/ADD (attention deficit disorder) medication will be covered (step therapy). Formulary alternatives include generic formulations as follows: 
amphetamine-dextroamphetamine (Adderall extended release), methylphenidate immediate or extended-release (Ritalin or Ritalin extended-release and Concerta), atomoxetine (Straterra), 
dextroamphetamine (Dexedrine), and dexmethylphenidate (Focalin extended release) as well as guanfacine. The patient's clinician is requesting coverage for treatment with the non-formulary drug, Vyvanse (brand lisdexamfetamine) for treatment of ADHD (attention deficit hyperactivity disorder).

The health plan should not cover the Formulary exception for Lisdexamfetamine Dimesylate. 

In this case, the health plan's formulary alternatives are available and reasonable. The formulary alternatives are as likely to provide the same therapeutic benefit as the non-formulary drug, Vyvanse (brand lisdexamfetamine). The formulary alternatives and generic Vyvanse and non-formulary drugs are all equally likely to pose a risk for adverse effects. The patient's prescribing clinician has not provided evidence of failed trials with other medications that are available from the plan formulary and covered under the plan for the treatment of ADHD (attention deficit hyperactivity disorder). Formulary alternatives include generic formulations of Adderall extended release and immediate release, Concerta/Metadate extended release, Ritalin and Ritalin extended release, Focalin extended release, and Strattera, none of which have been reported to have been tried and failed in this case. The requested Formulary exception for Vyvanse (brand lisdexamfetamine) should not be covered by the health plan.
This answer is in keeping with the New York State instruction for this review and consistent with the scientific literature, published guidelines, and prevailing standards of care for the treatment of the condition diagnosed in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The determination is upheld.

This is a patient being prescribed Wegovy auto-injectors for the diagnosis of obesity. The patient is not currently being treated with the requested medication. She has been taking Ozempic 1 milligram (mg) weekly. She is using this medication in conjunction with Trokendi extended release (XR) 50 milligrams (mg) to promote weight loss. The patient's current body mass index (BMI) is 29.9. The patient's other medical conditions include premenstrual dysphoric disorder (PMDD), fibromyalgia, obstructive sleep apnea (OSA), and polycystic ovary syndrome (PCOS).
The health plan denied coverage for the requested medication. Wegovy is currently under a supply shortage. The medication requires a titration through five different dosages to reach a maximum of 2.4 mg per week, which is the dose that has demonstrated efficacy for weight loss. Until all of the dosages are reliably available, the plan is not approving any new requests for Wegovy. At issue is the medical necessity of Wegovy.
The requested health service of Wegovy has not been demonstrated to be medically necessary for this patient.
There has been a national shortage of Wegovy, which has resulted in difficulty in patients obtaining the required doses once they start treatment. The clinical studies that resulted in the approval of Wegovy did not investigate the effects of starting and stopping treatment. Only the highest dose of 2.4 mg per week has demonstrated efficacy and weight loss. Additionally, the effect of this medication when used in combination with Trokendi has not been investigated. Therefore, at this time the recommendation to delay initiation of treatment until the medication is accessible and all criteria are met is a reasonable approach. Wegovy has not been demonstrated to be medically necessary based on the documentation provided.