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

Diagnosis: orthopedic/musculoskeletal. 
Treatment: pharmacy/prescription drugs. 
The insurer denied: diclofenac epolamine 1.3% patch. 
The denial is upheld.

The patient is a female with a history of low back pain who is requesting coverage for diclofenac patches. A prior authorization request was available for review. It was indicated that the patient tried lidocaine ointment, voltaren gel, ibuprofen, meloxicam, which did not help. There are no medical records available for review. The subject under review is whether the formulary drugs would be ineffective; or that that the non-formulary drug would be more effective.

The health plan's determination is upheld.

No, there is no credible evidence to substantiate that all of the formulary drugs would be ineffective, have been ineffective, would not be as effective as diclofenac patch, or would have worse adverse effects.
Based on a thorough review of the information provided there is no documented evidence that the patient has tried and failed all of the formulary drugs or that these drugs would necessarily cause adverse effects. There is some information provided in a prior authorization request, but this information does not substantiate that the patient tried and failed all formulary agents. Also, based on the standard of care and the peer reviewed literature cited in the references superiority of the requested non-formulary medication compared to the preferred agents has not been established by controlled clinical trials.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease and Alzheimer's dementia
Treatment: Increase Personal Care Aide (PCA) Level II Services for a Total Amount of 168 Hours per Week
The insurer denied the Increase Personal Care Aide (PCA) Level II Services for a Total Amount of 168 Hours per Week.
The denial is overturned. 

This patient is a male with Parkinson's disease and Alzheimer's dementia.  The patient is requesting level II personal care assistant (PCA) services.

The proposed treatment, Increase Personal Care Aide (PCA) Level II Services for a Total Amount of 168 Hours per Week, is medically necessary.
Medically necessary services are those which are:
- safe 
- effective
- generally accepted national standard of medical practice 
- not provided primarily for convenience of the patient or the practitioner 
- the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice for this patient's scenario.

A statement from the patient's provider notes the patient has progressive Parkinson's disease and dementia.  It states the patient has moderate dementia, poor sleep pattern, poor gait, and multiple falls.  It states the patient requires 24 hour care.  An assessment performed shows minimally impaired cognition and memory problems. Functional status was as follows:  total dependence with meal prep, housework, and shopping; extensive assistance with managing finances, phone use, personal hygiene, upper body dressing, and bed mobility's maximal assistance with managing medication, bathing, lower body dressing, walking, locomotion, and toileting; and independent with eating.  This shows deterioration in functional status compared to assessment performed.

Level II personal care service is indicated for individuals that need assistance with housekeeping, cleaning, meal preparation, grocery shopping, and laundry as well as assistance with personal needs, including bathing, dressing, grooming, toileting, walking, feeding, assisting with administering medications, preparing meals with special diets, and routine skin care. This patient has Parkinson's disease and dementia with progressive decline per assessments performed. The patient's functional status is compromised needing assistance with activities of daily living (ADLs) as well as personal care.  He requires max to total care with all areas of functioning with the exception of eating.  The assessment does support the medical necessity for level II live-in Personal Assistance Service to provide daily 24 hour assistance.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorder
Pharmacy/Prescription Drugs

Diagnosis: atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent. 
The health plan's determination is upheld. 

The patient is a male with atopic dermatitis, treated with topical steroids, Protopic and Dupixent. The patient was established on Dupixent but stopped it temporarily after contracting COVID. Under review is the medical necessity of Dupixent.

Dupixent is not medically necessary for this patient.
While the patient seems to have had this medication approved in the past, there is no documentation that the patient has demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis in children. This would include aggressive topical measures with emollients and wet-to-dry wraps, bleach baths, and phototherapy, which are considered first and second line therapies for eczema. Systemics such as cyclosporine can also be used in atopic dermatitis. Clinical trials are ongoing for children under age 6, but Dupixent is not yet Food and Drug Administration (FDA) approved for this age group. Dupixent is not appropriate or medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Problems. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied treatment with Dupixent. 
The health plan's denial is upheld.

The patient is a male with moderate to severe atopic dermatitis (more than 20% body surface area involvement) that involves the abdomen, back, upper and lower extremities, and the groin. The patient is in severe discomfort, pain, and itching. The patient has tried and failed numerous treatments, including topical triamcinolone, tacrolimus, and Eucrisa, as well as oral Atarax and phototherapy. The subject under review is the medical necessity for Dupixent.

No, treatment with Dupixent is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line oral medications such as Methotrexate, or Azathioprine. There is no sufficient documentation of alcohol use that would preclude use of these aforementioned agents. Dupixent is not proven to be superior to all other plan preferred alternatives as per comparative, controlled studies. Therefore, as consistent with current literature reviews [1-4], the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chest Pain.
Treatment:  Inpatient admission.
 
The insurer denied the inpatient admission.  The denial was overturned.

This is a male patient with a history of hypertension and tobacco use.  He presented to the Emergency Department (ED) with complaints of difficulty breathing and chest pain.  In the ED his blood pressure was 161/105, pulse oxygen saturation was 99% on room air. Subsequent ED pressure noted as 160/88.  A physical examination was preformed that revealed his lungs were clear with tachycardia, no edema.  The initial lab findings showed troponin of 0.12 and repeat of .04 hours later, brain natriuretic peptide of 646.  Urine toxicology was positive for cannabinoids.  Electrocardiogram (ECG) showed sinus tachycardia with ST convex in anterior precordial leads which resolved over time.  Chest X-ray revealed bilateral perihilar and upper lobe airspace disease, likely representing edema.  The patient was admitted for chest pain and shortness of breath.  The patient was consulted by pulmonologist and cardiologist.  Echocardiogram revealed left ventricular dilation with severe systolic dysfunction with grade 2 diastolic dysfunction, dilated and hypokinetic right ventricle mitral and tricuspid regurgitation and severely reduced systolic left ventricular function with reduced ejection fraction to 20%.  The patient signed out against medical advice (AMA) despite explaining the risks and consequences of leaving the hospital.

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

The patient presented with chest pain that, while atypical, was associated with Tn elevation that returned to normal in hours and with ECG changes suggestive of ischemia.  Chest imaging was also suggestive of edema.  With these findings admission for ACS was supported.  The carrier's denial of coverage for the inpatient admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bell's Palsy
Treatment: Inpatient Hospital
The health plan denied the requested hospital stay. 
The health plan's determination is upheld.

This patient is a female who presented to the emergency department with headache and facial asymmetry. She was found to have left-sided facial weakness and was diagnosed with Bell's Palsy. An associated zoster infection was considered. Her workup was significant for an elevated erythrocyte sedimentation rate of 68. A brain magnetic resonance imaging (MRI) revealed scattered microvascular changes. She underwent a spinal tap.

She was placed on oral steroids. A lumbar puncture was attempted. There was no further treatment until 3 days later when she underwent a lumbar puncture under fluoroscopy. She was diagnosed with idiopathic Bell's Palsy and was provided with Valacyclovir and with other corneal protection. She was discharged.

At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No. The patient presented with acute facial weakness consistent with a peripheral cranial nerve VII neuropathy. Acute stroke required exclusion and was ruled out with a brain MRI. That left a differential diagnosis of idiopathic Bell's Palsy versus a viral or post viral infectious cranial neuropathy. Such infections are usually caused by a herpes virus (zoster or simplex), both of which may be treated with an antiviral such as Acyclovir or Valacyclovir. There is no evidence otherwise that the patient had any acute neurological dysfunction. She did not have any evidence of a hemiparesis or any other focal neurological deficit other than the facial weakness. She did not exhibit any signs of meningitis. She did not have a fever. She did not exhibit any evidence of seizures or any evidence of a of an infection.

Additionally, there is a delay in care, as the initial lumbar puncture was attempted and the lumbar puncture under fluoroscopy was not performed until three days later (with an intervening weekend).

The patient could have been treated in the emergency department with a brain MRI, lumbar puncture (fluoroscopy if needed) with discharge once an acute structural abnormality of the brain and acute meningitis had been ruled out. There would be no expectation of further neurological decline and there was no need for neuro checks, cardiac monitoring, neurological monitoring, hemodynamic, or other critical care monitoring. She could have been safely discharged from the emergency department or observation once meningitis or a structural abnormality were ruled out. There is therefore no medical necessity for acute inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (skeletal Class I, maxillary and mandibular crowding, deep bite and impacted maxillary canines). 

Treatment: D8080 - comprehensive orthodontic treatment of the adolescent dentition and D9670 - monthly visit x 12.

The insurer denied coverage for braces D8080 and D8670. 

The denial is overturned. 

This is a female patient who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary and mandibular crowding, deep bite and impacted maxillary canines. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 13 points on review by their internal reviewers. 

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care the HLD index is utilized. This index provides 6 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 impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care for this patient. In this case, the clinical circumstance does meet the insurer and the plan criteria to justify orthodontic care.

The coverage of D8080 - comprehensive orthodontic treatment of the adolescent dentition and D9670 - monthly visit x 12 is considered medically necessary for this patient.

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

The medical necessity for braces D8080 and D8670 is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease. 
Treatment: Lab Work/Blood Tests. 
The insurer denied antibody testing procedure (SARS-CoV-2). The denial is upheld.

The patient is a male who presented to his physician, for unknown reasons. According to the patient's statement, he was at the physician office for an unrelated reason and was offered an antibody test, and the patient was told by the physician that the test would be covered, as he would not have had the test if it were not covered.
This review is for the medical necessity of SARS-Cov-2 IgG antibody in an asymptomatic previous uninfected individual. This test was denied based upon lack of medical necessity.

The health plan's determination is upheld in whole.

Medical necessity for testing for SARS-Cov-2 IgG antibody was not established. Insufficient evidence is available for review to support the medical necessity for the testing. There were no physician progress notes available for review. As previously stated, the patient is a 31-year-old male who went to the physician, reason unknown. The claim was billed out with International Classification of Disease (ICD) 10 code Z00.00, Z 11.59, Z 11.4. The patient had the antibody test as listed above along with other tests. From the claims data, ICD 10 code, it appears that the patient was asymptomatic. There is no evidence of recent polymerase chain reaction (PCR) testing for Covid 19. The patient statement along with the provided information does not support medical necessity for this testing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperkalemia; Chronic Kidney Disease
Treatment: Inpatient Hospital Stay
The insurer denied coverage for inpatient hospital stay.
The denial is upheld. 

This male patient has a past medical history of diabetes mellitus with neuropathy, hypertension, chronic kidney disease (CKD) and coronary artery disease status post bypass surgery. The patient presented to the Emergency Department (ED) with subjective complaints of right flank pain for 3 weeks. It was worsening over the last 3 days. There was no radiation of pain. The pain was worse with coughing or bending at the waist. Prior to this, the patient only had pain with activity, but the pain was now there all the time. The patient denied shortness of breath, fever, recent travel, and sick contact. The patient's blood pressure was 155/95, and his heart rate was 79. On physical examination, the patient had a distended abdomen with positive costovertebral angle tenderness. The patient's electrocardiogram (EKG) was consistent with first degree atrioventricular (AV) block; otherwise, it was normal. The patient's computed tomography (CT) scan of the abdomen and pelvis revealed no acute process and he had cholelithiasis without evidence of cholecystitis. The patient was treated with intravenous (IV) medications and oral Lokelma. The patient was given oral hydralazine for blood pressure management. The patient's potassium was 6.1, and his creatinine was 2.29.  The patient was admitted for further evaluation and management of hyperkalemia in the setting of chronic kidney disease. The patient underwent a nephrology consultation. The patient's blood pressure normalized. The patient was discharged to follow-up with his primary care physician.

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. The patient presented with hyperkalemia and an elevated serum creatinine. The patient required treatment of his hyperkalemia with Lokelma as well as intravenous fluids and oral medication for blood pressure control. With this treatment, the patient clinically improved and was stable for discharge. Upon review of the medical records, the patient could have been appropriately treated in the observation setting. The acute inpatient level of care was not medically necessary. 

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

The medical necessity for the inpatient hospital stay is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite.
Treatment: Braces/monthly visits.

The insurer denied braces/monthly visits. The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on teeth 7 and 10. She presents with a Class II malocclusion with severe crowding in the maxilla and moderate crowding in the mandible. Her cephalometric x-ray shows she has an anterior open bite. She is treatment planned for 30-36 months of orthodontics with extraction of teeth 5, 12, 21 and 28 to address the crowding, crossbite, and open bite, but the treatment was denied due to lack of medical necessity.

Braces and Monthly Treatment Visits are medically necessary for this patient. Treating with orthodontics and extractions is less invasive than treating with surgery later.
This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant crowding. 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. Additionally, the patient has an anterior open bite. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite.
Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. This patient is treatment planned for extractions, which is less expensive and less invasive than orthognathic surgery. If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, Braces and Monthly Treatment Visits for this patient are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental or Orthodontic Procedure. 
The insurer denied: comprehensive orthodontic treatment of adolescent dentition and periodic treatment visits. 
The determination is overturned.

The patient is a male. He has a Class II malocclusion with significant spacing and protrusive maxillary incisors. He has an 8 millimeter (mm) overjet. He is treatment planned for 24-30 months of orthodontics to correct the spacing and protrusion, but his insurance company rejected the claim on the basis that treatment is not medically necessary.
The subject under review is the medical necessity for the requested treatment.

The health plan's determination is overturned.

The requested treatment of comprehensive orthodontic treatment of the adolescent dentition and periodic orthodontic treatment visits are medically necessary for this patient. Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma.

There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. Closing the space present will make the teeth significantly less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjets, which this patient has. For these reasons orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Durable Medical Equipment (DME).

The insurer denied DME for medical necessity.  The denial was upheld. 

This female patient presented with adolescent idiopathic scoliosis of the thoracic region, and juvenile idiopathic scoliosis of the thoracic region.  The office note showed that the patient was seen for a follow-up of her scoliosis. She was seen previously. She had done well with no major issues and was not having significant pain. She had been treated with a Rigo Cheneau brace and was wearing it for 12 hours a day. Her examination showed that viewing from behind, there was no trunk shift and a little blunting of her left flank. Adams forward bend showed a right thoracic prominence noted with no lumbar prominence. There was no abnormal pigmentations or evidence of dysraphism in the skin. Deep tendon reflexes were brisk and symmetric. Babinski's was normal. The right thoracic (T) curve was 16 degrees from T6-T12, 13 degrees last visit, and 21 degrees 12 months previously. The left lumbar (L) curve was 12 degrees from T12-L4 which was unchanged. She was a Risser 0, triradiate cartilage was closing. Sanders 2, almost 3.

Assessment was that the patient was doing well with no significant change in her curve and had improved from presentation. She currently needs a new brace, as her other brace is ill fitting as she has grown more than 3 inches since her last brace was made. She is to continue with 10 to 12 hours of bracing daily. Plan was for repeat evaluation after the new brace was in place with repeat clinical x-ray and evaluation. Scoliosis films in the brace will also need to be performed. The prescription is for a custom three-dimensional Rigo Cheneau brace.

At issue is the medical necessity of the back brace.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Back Brace is not medically necessary for this patient.

The requested specialized custom brace is not medically necessary. This is a 3D custom brace. There are standard braces available for juvenile and adolescent idiopathic scoliosis that are as effective as a custom brace. Studies show that while the Rigo Cheneau brace is effective at preventing progression of scoliotic curves, Charleston bending braces and other thoracic lumbar sacral orthosis (TLSO) are equally as effective. Literature shows that Rigo Cheneau braces are effective and work well; however, they do not work better than other standard braces.

Therefore, the requested health service/treatment of Back Brace is not medically necessary.