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

Diagnosis: Moderate dyshidrotic dermatitis. 
Treatment: Dupixent 300mg/2mL SC SOPN, Pre-service. 
The insurer denied the Dupixent 300mg/2mL SC SOPN. 
The denial is overturned. 

The patient is an adult female with moderate dyshidrotic dermatitis that has failed treatment with topical steroids (betamethasone valerate 0.1% ointment, betamethasone augmented 0.05%), and crisaborole, but she has done well with narrowband ultraviolet B (UVB) phototherapy.  The last medical chart note documents prescription of tacrolimus ointment.  The patient has also received topical and oral antibiotics for super infection and oral antihistamines.  A letter from her treating physician also documents failure of tacrolimus and mupirocin ointments, as well as excimer laser.  The request is for Dupixent injection. 

Yes, the requested Dupixent is medically necessary. 

The patient has moderate to severe dyshidrotic dermatitis which has failed topical steroids (betamethasone valerate 0.1% ointment, betamethasone augmented 0.05%), tacrolimus 0.1% ointment, mupirocin 2% ointment, and crisaborole.  The patient has also received topical and oral antibiotics for superinfection and oral antihistamines.  Her treating physician also documents failure of excimer laser. 

Dupilumab (Dupixent, Regeneron Pharmaceuticals and Sanofi Genzyme) is a novel biologic medication recently approved by the United States Food and Drug Administration (FDA) for the treatment of moderate-to-severe atopic dermatitis in adults who have not achieved adequate control with topical medications.  Dyshidrotic eczema is a distinct entity, often considered on the spectrum of atopic dermatitis, that primarily affects the palms and soles.  it is often associated with considerable morbidity and is frequently challenging to treat.  Even though dyshidrotic eczema affects a limited body surface area, it is frequently refractory to super potent topical corticosteroids and may require treatment with phototherapy or systemic immunosuppressants.  Several case reports and case series (three to 15 patients) have reported using dupilumab in the treatment of refractory dyshidrotic dermatitis. 

Based on the medical records, the patient has used multiple topical therapies (steroids, phosphodiesterase-4 [PDE4] inhibitor, calcineurin inhibitor), topical and oral antibiotics and excimer laser without adequate response.  Dupixent is an appropriate next step in her management.  Therefore, Dupixent is medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Herpes Labialis

Treatment: Sitavig

The insurer denied coverage for Sitavig.

The denial is upheld.

This is the case of an adult female patient. The treating provider has diagnosed the patient with chronic herpes labialis. According to an encounter note, "The patient has been on Sitavig therapy. The patient is unable to swallow tablets, therefore, buccal tablet is requested. The plan asks for failure of three formulary alternatives. She has used oral acyclovir in the past, and topical with benefit."

According to a treatment note, "the patient is on oral and topical Acyclovir with stable results."

Per Chi C. C., "Herpes simplex virus type 1 infection usually causes a mild, self-limiting painful blistering around the mouth, with 20% [percent] to 40% of adults affected at some time. Primary infection usually occurs in childhood, after which the virus is thought to remain latent in the trigeminal ganglion. Recurrence may be triggered by factors such as exposure to bright light, stress, and fatigue. We found evidence that oral acyclovir and oral valaciclovir may be more effective than placebo." 

Per Leung, A., & Barankin, B., "For episodic treatment, oral antiviral agents, such as acyclovir (Zovirax), valacyclovir (Valtrex) and famciclovir (Famvir), are superior to topical antiviral therapy. Valacyclovir and famciclovir have greater oral bioavailability and are better absorbed than acyclovir, require less frequent dosing, but are more expensive and are not approved for children. Topical antiviral agents such as 5% acyclovir cream/ointment (Zovirax)  hydrocortisone (Xerese), 1% penciclovir (Denavir) cream, and 50 mg [milligrams] Buccal Adhesive Tablet (ABT-50 mg) can also be used for episodic treatment of herpes labialis. These topical agents are not effective in the prevention of recurrent herpes labialis. For chronic daily suppressive therapy, oral antivirals are the treatment of choice." 

The formulary drug has low risk of adverse reaction; this is true when compared to the requested medication. The formulary has not been ineffective, based on the patient's clinical history. The notes indicate the oral and topical treatment is successful.     

There is no indication that the requested drug would be more effective than the formulary medications, which does come in liquid form.

The insurer's denial of coverage for Formulary Exception for Sitavig is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post falls
Treatment: Personal Care Aide (PCA) Service, Level II: 12 Hours per Day - 7 Days per Week; 12 Hours per Day - 7 Days per Week (Split Shift) - Total of 168 Hours per Week, Pre-service
(PLAN APPROVED 12 Hours per Day 7 Days per week - 84 hours total)
The insurer denied the Personal Care Aide (PCA) Service, Level II: 12 Hours per Day - 7 Days per Week; 12 Hours per Day - 7 Days per Week (Split Shift) - Total of 168 Hours per Week, Pre-service
(PLAN APPROVED 12 Hours per Day 7 Days per week - 84 hours total)
The denial is upheld.

This male's granddaughter is appealing denial of PCA (Personal Care Assistance) 24 hours per day split shift.  He has been approved for PCA 84 hours per week.  UAS (Uniform Assessment System) evaluation completed shows the patient requires setup for eating, limited assistance with bed mobility, extensive assistance with personal hygiene and toilet use, maximal assistance with dressing, walking, locomotion, bathing, toilet transfer, meal preparation and medication management, and total dependent with housework.  He receives support from daughters and
neighbors. DME (durable medical equipment) includes a shower chair, shower grab bar, walker and incontinent supplies.

Appeal statement from granddaughter notes the patient has fallen 7 times when he is home without an attendant and needs help throughout the night with toileting. Falls have occurred due to rollator turning over and transferring from commode to bed.

No. The requested health service is not medically necessary because it is not consistent with standard of care.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient was approved for 84 PCA hours per week based on UAS (Uniform Assessment System) evaluation completed. His granddaughter is appealing denial of PCA (Personal Care Assistance)168 hours per week, split shift due to repeated falls. Daughter also notes the patient is incontinent.  UAS evaluation shows the patient needs assistance with bed mobility, personal hygiene toileting, dressing, walking, locomotion, bathing, meal preparation, medication management, and housework. The appeal statement identifies a fall after transferring from commode to bed, a fall due to rollator turning over, and cause of other falls not noted.  The documentation provided does not support tasks will be performed at night. PCS (personal care service) is not indicated when there are no tasks being performed or for supervision.  The approved PCA (personal care aide) 84 hours per week is sufficient to provide assistance with ADLs (activities of daily living) and personal care as noted above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite with severe soft tissue damage.

Treatment: D8080 braces and D8670 monthly visit x12

The insurer is denied coverage for D8080 braces and D8670 monthly visit x12

The denial is upheld. 

This female patient has no past medical history.

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, a Handicapping Labiolingual (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 deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontics. 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 attaining 13 points (4 points overjet, 6 points overbite, and 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 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 health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the D8080 braces and D8670 monthly visit x12 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic Arthritis and Psoriasis

Treatment: Cosentyx

The insurer denied coverage for Cosentyx

The denial is overturned.

The patient has a past medical history of rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, drug-induced Lupus erythematosus, and fibromyalgia.  The provider requested Cosentyx to treat active psoriatic arthritis and psoriasis.  The provider indicated the medication would not be utilized in combination with any other disease modifying anti-rheumatic drug (DMARD).  The patient had a negative tuberculosis test within 6 months of initiating therapy.  The patient was currently receiving Cosentyx and had achieved or maintained a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms of the condition since starting treatment with the requested drug.

Cosentyx is considered medically necessary for this patient.

Per the information provided, this patient has achieved low disease activity with psoriatic 
arthritis on Cosentyx. The guidelines for the treatment of psoriatic arthritis (PsA) say that either remission or low disease activity should be the goal of treatment. It is very reasonable to continue treating her with this biologic DMARD and attempting to change the DMARD at this time will likely cause her disease to flare and possibly set her back weeks or possibly months, negatively impacting her quality of life. If she were to be started on Cosentyx again after failing other therapies, there is no guarantee that the same outcome would be achieved.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Cosentyx is considered medically necessary for this patient.

The insurer's denial of coverage for Cosentyx is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Onset of a Pneumomediastinum. 
Treatment: Hospital Admission. 

The insurer denied coverage for hospital admission. 

The denial is overturned. 

This is the case of a teenage male with a one-day history of chest pain and difficulty taking a breath. He was breathing fast and was taken by his parent to the Emergency Room (ER) for an evaluation. He indicated that he had played a vigorous contact game of soccer the day prior to the admission. He also indicated that he had started to feel the chest pain shortly after eating. 

In the ER, he complained of chest pain, and he appeared anxious. He was breathing at an elevated respiratory rate of 30 breaths per minute. He described his pain as an 8 out of a scale of 10. On physical exam he was noted to have wheezing in the left base and right upper lobe. He was treated with methylprednisolone and 2 treatments with Duoneb. He was also treated with Toradol. He complained of chest pain while lying on his side and dyspnea while lying flat on his back. Blood testing was unremarkable, and a chest x-ray was clear. A computed tomography (CT) scan of the chest was then performed which demonstrated the presence of free air with anterior and middle pneumomediastinum and mild interstitial emphysema of the right apex of the lung. He was treated in the ER with pain medication and the decision was made to admit him to the hospital for monitoring. The next day when his chest pain had improved, and he was discharged home. 

The patient was treated appropriately in the ER for an acute onset of a pneumomediastinum. He was in significant pain and appeared anxious to the medical staff. He was also being treated for wheezing. The decision to admit the patient for treatment of pain and observation for progression of the air accumulation in the chest or other potential side effects from a pneumomediastinum was consistent with the standard of care. 

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

The acute inpatient admission is medically necessary. 

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis and Dehydration. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient had a history of liver cancer and presented with vomiting and diarrhea. The diarrhea was not bloody. In the emergency room the blood pressure was 74/49. By the time of admission, the blood pressure was 124/81. The abdominal exam was benign. A computed tomography (CT) scan revealed liver cancer and diverticulosis. The creatinine was initially 1.61 on repeat came down to normal the following day. He received intravenous hydration and his symptoms improved. He was able to tolerate a diet. 

Clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, acute renal failure as defined by a 3-fold rise in the serum creatinine severe electrolyte disorders and an inability to maintain oral hydration after observation care. The patient did not have these conditions. Hemodynamic instability is also an indication for admission if the hypotension persists despite appropriate treatment. In this care, the hypotension resolved with intravenous hydration. 

This patient had a gastroenteritis and dehydration. Intravenous hydration was required. The blood pressure and renal function then improved. The intravenous hydration could have been given with observation status. He did not meet Milliman Care Guidelines (MCG) criteria for admission for gastroenteritis. The healthcare plan acted reasonably and with sound medical judgement. An inpatient hospitalization was not medically necessary. 

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

Diagnosis: Chest pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male at the time of admission to the hospital, with a past medical history significant for asthma, gastroesophageal reflux disease (GERD), smoking and cocaine abuse who presented to the Emergency Room with complaints of chest pain that was constant and non-exertional for weeks long duration. The patient was hypertensive. Electrocardiogram (ECG) revealed no acute ischemic changes. Troponin was negative. Chest x-ray revealed possible consolidation or effusion. The patient was admitted to rule out acute coronary syndrome (ACS). A nuclear stress test was ordered, however the patient left against medical advice.

No, the proposed inpatient hospital admission was not medically necessary.

This patient presented for evaluation of atypical chest pain. The cardiac enzymes were negative and the patient was referred for a nuclear stress test, however did not complete the work-up.  There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right flank pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a pregnant female, 34 weeks plus two days gestation, with history of pyelonephritis and kidney stone requiring stent placement with prior pregnancy.  The patient presented with complaint of right flank pain, right costoveterbral angle tenderness, nausea and vomiting.  Her urinalysis demonstrated moderate leukocyte esterase, zero to two white blood cells (0-2 WBC), no bacteria, and negative nitrite.  Her renal ultrasound demonstrated severe right hydronephrosis, no right ureteral jet.  The patient was afebrile on presentation.  Her white blood cell count was normal at 89.  Her creatinine was 0.8.  The patient was admitted to obstetrics and gynecology (OB/GYN) and taken to the operating room the next day for stent placement.  

No, the proposed inpatient admission was not medically necessary.
The Milliman Care Guideline criteria for admission include pregnancy of 24 weeks gestation or beyond if pyelonephritis and ureteral obstruction. This patient presented afebrile, with normal white blood cell count, no mention of lower urinary tract symptoms, urinalysis that demonstrated zero to two white blood cells, negative nitrite, no bacteria, and absence of debris in collecting system or concerns of pyelonephritis on ultrasound.  Rather, the patient had severe hydroureteronephrosis on the right with normal renal function. Given the absence of symptoms of infection, urine analysis (UA) without bacteria, ultrasound without suggestion of pyelonephritis, and absence of fever, the patient's diagnosis was severe right hydroureteronephrosis for which the patient could be treated at a lower level of care.

This patient was denied acute inpatient care due to the lack of meeting the Milliman Care Guideline criteria as there is lack of sufficient documentation of the presence of pyelonephritis.  The patient could be managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, progressive vascular dementia, coronary heart disease, hypertension, atrial fibrillation

Treatment: coverage for the personal care services, Level 111 of 24 hour split shift (12-hour shifts, twice per day) 7 days per week

The insurer denied coverage for coverage for the personal care services, Level 111 of 24 hour split shift (12-hour shifts, twice per day) 7 days per week

The denial is overturned.

This case involves a female diagnosed with Alzheimer's disease, progressive vascular dementia, coronary heart disease, hypertension, atrial fibrillation, aortic stenosis, osteoarthritis, contractures in stage of all joints, vitamin D (calciferol) deficiency, anemia of chronic inflammation, and pressure ulcers. The information provided for the review noted that the patient lives alone in a 2-bedroom apartment, located on the second-floor townhouse. 

Assessments noted that the patient was alert, awake, but was nonverbal and non-ambulatory. She required assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient was totally dependent for all activities. She was unable to sit upright and was being fed pureed solids with a consumption of thickened liquids. Additionally, the patient was incontinent of bowel and bladder and required the use of adult diapers. It was determined that the patient needed maximum assistance managing not only her medications but also personal care services. The physician was requesting level 111 of 24-hour split shift (12-hour shifts, twice per day) 7 days/week. Previously, a modified approval was given regarding the services with the belief that the patient's needs can be adequately met with personal care services of 24 hours live-in, 7 days/week. There was no indication that the patient needed split shift care, even though she had been receiving the services for most years. The previously approved personal care services 24 hours split shift will continue to be approved.

This individual clearly requires full-time care. It's prudent to continue the current program. Cutting off the services does not carry any rational explanation. Clearly the individual is not improved. 

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

The insurer's denial of coverage for the personal care services, Level 111 of 24 hour split shift (12-hour shifts, twice per day) 7 days per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right knee pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

This is a female with right knee pain. She was diagnosed with osteoarthritis and had received conservative treatments which were not helpful. She was admitted to hospital for an elective total knee replacement. Her past medical history was significant for morbid obesity and sleep apnea. Her post-surgical course was non complicated. She originally was to be referred for inpatient rehabilitation but was able to be discharged to home.

Yes, the proposed treatment was medically necessary.
The medical records substantiate necessity of treatment as provided. The facts were the patient had several underlying medical conditions which would place her at increased risk for complications. She was morbidly obese with a body mass index (BMI) of 52. She had sleep apnea and required continuous positive airway pressure (CPAP). She was also hypertensive. She was reported to be grade III by the American Society of Anesthesiologists (ASA). 

The patient's post-surgical course showed elevated blood pressure at her initial visit to physical therapy. Her pulse oximeter also was noted to be at 93%.  The patient was unable to make any progress with physical therapy on post-operative day (POD) #1. The record denotes "required 2 person assist and could not do a few steps." Her knee buckled. She was not able to be mobilized without two people. The records support inability to be managed outside of a hospital environment, ie - she would be unable to reach a chair without two people helping her. 

The patient's overall clinical status does not fulfill Milliman Care Guideline (MCG) Ambulatory list for total knee replacement (TKR).