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

Diagnosis: Malignant neoplasm of temporal lobe.
Treatment: Tibsovo (250mg tablet 2 tablets by mouth once daily for one year).
The insurer denied the Tibsovo (250mg tablet 2 tablets by mouth once daily for one year).
The denial is overturned.

The patient is a female with anaplastic astrocytoma and IDH1 (isocitrate dehydrogenase 1) mutation. The provider is requesting Tibsovo. This was denied coverage as it was considered not medically necessary by the Plan.

Yes, the requested treatment with Tibsovo is medically necessary.
The standard of care threshold for the off label use of chemotherapeutic regimens for persons with terminal cancer require at least one clinical trial or clinical guidelines supporting use published in the peer-reviewed medical literature. The use of Tibsovo has been evaluated in at least one clinical trial that enrolled persons with glioma and IDH1 (isocitrate dehydrogenase 1) mutation (Mellinghoff et al.). This study showed, "In patients with mIDH1 [mutant isocitrate dehydrogenase 1] advanced glioma, ivosidenib 500 mg [milligrams] once per day was associated with a favorable safety profile, prolonged disease control, and reduced growth of nonenhancing tumors."

Therefore, in this clinical context, in which the patient has an advanced stage tumor, this treatment would be considered appropriate. Therefore, the requested treatment with Tibsovo is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep Impinging Overbite. 
Treatment: D8080 Braces. 

The insurer is denied coverage for D8080 braces. 

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.  In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care as on examination of the intraoral clinical images, there is evidence of palatal gingival recession due to direct impingement of the teeth on the gingival soft tissues.  The clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. 

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

The clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care. 

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

The insurer's denial of coverage for D8080 braces is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angina. 
Treatment: Inpatient hospital admission. 

The insurer is denied coverage for inpatient hospital admission. 

The denial is upheld. 

This female patient has a history of hypertension, hyperlipidemia, diabetes mellitus type 2, varicose veins and current smoking status. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented for elective percutaneous revascularization. She underwent an uncomplicated procedure, and a drug eluting stent was placed in the right coronary artery. She was discharged the following day. 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 admission was not medically necessary.  The patient could have been managed at a lower level of care. 

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 inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: suicidal statements

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is overturned. 

This male patient has a history of hypertension, hyperlipidemia, obesity, degenerative disc disease, depression, daily alcohol use, right precentral/postcentral gyrus intraparenchymal hemorrhage due to vascular malformation status post endovascular intervention, falls with head strikes and possible focal epilepsy.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicidal plan or intent are in need of hospital treatment and also reports that patients with major depressive episodes and substance/alcohol use are at increased risk of suicide. He reportedly had altered mental status and suicidal statements and depression as it was reported that he had suicidal thoughts with a plan and he gave away his wedding ring and was not future oriented, had anger, poor impulse control and judgment, decreased energy, sleep, and concentration. He also reportedly had a family history of suicide. He was considered a danger to self, unable to care for basic needs, and in need of 24 hour hospital treatment in the medical hospital on the neurology service until he was transferred to the psychiatric unit in the hospital. He reportedly was put on 1:1 for suicide precautions and was seen by the psychiatric consultant who stated that he was considered a danger to self, unable to care for basic needs, and in need of 24 hour psychiatric hospitalization when medically cleared. This patient had altered mental status with worsened depression including suicidal thoughts and plan and escalating alcohol use and was considered unable to care for basic needs and a danger to self and in need of 24 hour hospital treatment then. This patient required 1:1 observation for suicide precautions during the denial period and was transferred to a psychiatric unit for inpatient mental health hospital treatment.  

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

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

Diagnosis: Polychondritis with polyarthritis. 
Treatment: Injection, rituximab, 10 milligrams (mg). 

The insurer is denied coverage for Injection, rituximab, 10 milligrams (mg). 

The denial is upheld. 

This male patient has a history of osteoarthritis, scleritis/uveitis, and rheumatoid arthritis. 

According to the current peer-reviewed medical literature, systemic treatment is generally reserved for resistant inflammation. Patients with ongoing inflammation may require systemic glucocorticoid therapy or additional anti-inflammatory or immunosuppressive agents. In patients with uveitis who are resistant to therapy, subsequent therapeutic options include a tumor necrosis factor (TNF) inhibitor, such as adalimumab; a switch to a different anti-metabolite; a glucocorticoid, either regionally or orally, usually on a temporary basis; or the combination of an anti-metabolite with a calcineurin antagonist. According to referenced literature this medication is indicated for multiple diseases that include rheumatoid arthritis in combination methotrexate as well as granulomatosis with polyangiitis in combination with glucocorticosteroids.  The submitted documentation indicated this patient has a rare condition of recurring episcleritis with associated systemic inflammatory disease and relapsing polychondritis with polyarthritis.  The documentation indicated he has had treatment with multiple medications previously, however, did not have an appropriate response.  Given the patient has a rare disease, there is a paucity of abundant literature specifically regarding treatment with this medication; however, there are small studies with the possibility of benefit with treatment of the requested medication for this condition.  While the use of the requested medication is an appropriate treatment option, there is no indication for use over the recommended preferred options. The health plan acted reasonably with sound medical judgment. 

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 Injection, rituximab, 10 milligrams (mg) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Developmentally delayed. 
Treatment: Private duty nursing (PDN) 30 hours per week. 

The insurer is denied coverage for private duty nursing (PDN) 30 hours per week. 

The denial is upheld. 

This female patient has a history of developmental delay, partial epilepsy, infantile spasms and Lennox-Gastaut seizures. 

The American Academy of Pediatrics has published guidelines for home care of infants, children, and adolescents with chronic disease: "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." Further, the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. 

As discussed in Up to Date: 

"Parents of children with frequent, prolonged seizures are often provided with transmucosal benzodiazepines for home rescue therapy in an attempt to overcome delays in treatment related to emergency transportation and provision of intravenous access. Such problems have led to increased use of transmucosal routes of antiseizure medication delivery, such as rectal, buccal, intranasal, and sublingual administration, that allow for earlier initiation of rescue therapy in the home or prehospital setting [6]. 

The largest experience is with rectal diazepam, although accumulating evidence suggests that buccal midazolam is also safe and may be more effective than rectal diazepam [6-8]. Intramuscular and intranasal administration of midazolam appears to have similar efficacy as rectal diazepam. Transmucosal administration of midazolam will likely become first-line therapy for out-of-hospital emergency therapy once a convenient formulation for nonmedical personnel is approved and available." 

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 private duty nursing (PDN) 30 hours per week is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep caries

Treatment: Root canal, post and core, and crown for teeth numbers 14 and 19

The insurer denied coverage for root canal, post and core, and crown for teeth numbers 14 and 19.

The denial is overturned.

Based on the submitted documentation which includes copies of full mouth series radiographs, narrative letters from the patient and insurer correspondence, it
appears that this patient presented to the dentist for dental care. Deep caries were noted on teeth #14 and #19 on examination and endodontic therapy was recommended in addition to post root canal post and core and crowns for these teeth.  The insurer has denied these services stating that the services are not medically necessary as the documentation indicates that there are sufficient posterior occlusal points of contact.  

The submitted radiographs support the recommended treatment. Both teeth exhibit large carious lesions involving or approximating the pulp chamber radiographically.  These teeth would require endodontic therapy in order to maintain them and prevent future infection in this patient.  Both these teeth will have adequate residual coronal structure for support of post and core and crowns and adequate residual periodontal alveolar bone height.  The standard of care in general dental practice would be endodontic therapy for these teeth and subsequent post and core and crowns, as recommended, which would have an excellent long-term prognosis with the recommended treatment.

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient.
 
Based on the above, the medical necessity for the root canal, post and core, and crown for teeth numbers 14 and 19 is substantiated. The insurer's denial is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Posterior and Upper Neck Pain
Treatment: (64575, 64590) Occipital Nerve Stimulation
The insurer denied the (64575, 64590) Occipital Nerve Stimulation.
The denial is overturned.

The patient is a male.  The provider indicated that the patient had undergone a previous successful trial with reported significant pain relief greater than 60%.

Treatment notes reflect that the patient has previously undergone Botox and medication management without significant improvement.  He reportedly underwent trial of peripheral field occipital stimulator that gave him greater than 60% improvement.  The patient reportedly has ongoing history of occipital neuralgia.  Previous treatments included cervical surgeries, injections, radiofrequency ablation, and medication with persistent pain being noted.

Yes, the health plan should cover the requested health service.
The available medical records indicate the patient has occipital neuralgia that has been refractory to other standard first-line treatments.  The available medical records indicate the patient has undergone treatment including a temporary placement with a reported significant benefit of more than 60% reduction in pain.  Current available peer review literature supports that this treatment may be useful and has demonstrated effectiveness for the treatment of occipital neuralgia, persistent pain that has failed other conservative management.  There are no other reasonable alternatives to therapy that may result in significant improvement and as such would be considered standard of care in this unique case of this patient.

The request is regarding an occipital nerve stimulator.  The previous denial indicated that the requested treatment was considered experimental and investigational.

Yes, the requested health service or treatment is more beneficial than any standard treatment for the patient's condition or disease.

Current available peer review literature supports that this treatment may be useful and has demonstrated effectiveness for the treatment of occipital neuralgia, persistent pain that has failed other conservative management.  There are no other reasonable alternatives to therapy that may result in significant improvement and as such would be considered standard of care in this unique case of this patient.
Treatment notes reflect that the patient has previously undergone Botox and medication management without significant improvement.  He reportedly underwent trial of peripheral field occipital stimulator that gave him greater than 60% improvement.  The patient reportedly has ongoing history of occipital neuralgia.  Previous treatments included cervical surgeries, injections, radiofrequency ablation, medication with persistent pain being noted.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Posterior and Upper Neck Pain
Treatment: (64575, 64590) Occipital Nerve Stimulation
The insurer denied the (64575, 64590) Occipital Nerve Stimulation.
The denial is upheld.

The patient is a male who had a successful occipital nerve stimulator trial with 60%
relief. The patient has a history of chronic migraines and occipital neuralgia. The
patient has failed occipital nerve blocks, Botox and medications; he has pain that
affects daily living

Per the policy; Occipital nerve stimulation was denied as it is considered
investigational. Per the treating provider, based on published literature, there is
evidence to support this modality.

The patient is described as having a history of neck and occipital headaches, mid
thoracic and low back pain. He had 60% improvement from occipital nerve
stimulator trial. He has a history of cervical post-laminectomy pain syndrome status
post C3-C4 posterior cervical surgery and would not be a candidate for C2 lead
placement. The patient had implantation of peripheral field occipital stimulator
leads. The patient was cleared by Psychology. The patient desires permanent
implantation after a successful occipital nerve stimulator trial. Earlier this year, the
patient had severe neck pain and headaches. Computed tomography (CT) showed
nonunion at C3-C4, and C2-C3 on left. Three months later, the patient was status
post left C2-C4 radiofrequency ablation (RFA). A year ago, the patient has a
computed tomography of the cervical spine.

No, the health plan should not cover the requested health service.

No, the requested health service or treatment is not more beneficial than any
standard treatment for the patient's condition or disease.

The patient has tried pain medications, injections and surgeries. However, as per
the medical literature, more research needs to be conducted in order to fully
understand the nuances of electrical nerve stimulators, to serve as viable
therapeutic intervention for migraines.

"Considering the ease of implant and minimal side effects, implant of peripheral
nerve stimulators to stimulate the occipital nerve is a promising treatment modality
for patients with chronic headache who present with features of occipital neuralgia.
However, wider use of this treatment modality is subject to further studies." (1)
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Posterior and Upper Neck Pain
Treatment: (64575, 64590) Occipital Nerve Stimulation
The insurer denied the (64575, 64590) Occipital Nerve Stimulation.
The denial is overturned.

The patient is a male with chronic migraine and cephalgia with diagnosis of occipital
neuralgia. The patient has failed occipital nerve blocks, Botox and medication
management. The patient had a trial of occipital nerve stimulator which provided
pain relief greater than 60%. The patient was recommended for occipital nerve
stimulator.

Yes, the health plan should cover the requested health service.
The patient has been diagnosed with occipital neuralgia, he has failed an adequate
trial of nonsurgical management and had short term improvement with injections,
and a trial stimulator. Based upon these characteristics, he would be a good
candidate for the surgery and therefore the health plan should cover placement of a
permanent lead and generator.

Yes, the requested health service/treatment is more beneficial than any standard
treatment for the patient's condition/disease.
The permanent implantation is medically necessary and appropriate for this patient.
The surgery is appropriate; this is a relatively low risk procedure that most
neurosurgeons are able to perform.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Psoriasis
Treatment: Siliq 210mg/1.5 Syringe, 210mg By Subcutaneous Injection Week, 0,1 and 2 Followed By 210 mg Every 2 Weeks
The insurer denied the Siliq 210mg/1.5 Syringe, 210mg By Subcutaneous Injection Week, 0,1 and 2 Followed By 210 mg Every 2 Weeks
The denial is upheld

The patient is a woman with severe psoriasis for whom Siliq is requested. She has tried and failed Stelara, Taltz, Cosentyx and multiple topical steroids.

No, the requested treatment with Siliq is not medically necessary.
The patient has severe psoriasis, for which systemic therapy is indicated. She is not a candidate for phototherapy because of the location of psoriasis in the scalp, which cannot be reached by phototherapy. In the era of biologic therapies for psoriasis, use of methotrexate, cyclosporine or acitretin is not the most appropriate first line treatment, because their long term safety and efficacy are inferior to biologic therapies.

Biologics show superior results to conventional systemic therapies (70% improvement versus 40% improvement) for the treatment of patients with moderate to severe psoriasis, as measured by decrease in simple-measure for assessing psoriasis activity (S-MAPA) (physician global assessment [PGA] multiplied by body surface area) at week 24. These results were observed despite the fact that patients on biologics had a greater baseline severity and had a greater number of previous treatments.

The plan offers multiple formulary options for biologic therapies that are on par with the efficacy and safety of Siliq, such as Skyrizi and Tremfya, neither of which have a black box warning, and both of which have reported excellent efficacy data from clinical trials.

Based on the above data, the requested Siliq is not medically necessary for this patient.

The plan offers multiple formulary options for biologic therapies that are on par with the efficacy and safety of Siliq, such as Skyrizi and Tremfya, neither of which has a black box warning, and both of which have reported excellent efficacy data from clinical trials.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis
Treatment: Dupixent Inj 300mg /2ml once weekly
The insurer denied the Dupixent Inj 300mg /2ml once weekly
The denial is upheld 

The patient is a male with severe atopic dermatitis, over 80% BSA (body surface area) prior to use of Dupixent.  The patient also has lupus, asthma, and neuropathy.  He was dramatically improved on Dupixent.  His provider is requesting continuation at every week dosing. Prior to Dupixent, the patient tried and failed prednisone, topicals and phototherapy.

No, the Dupixent once weekly is not medically necessary.
The medication is not prescribed within the published dosing guidelines.

The clinical documentation does not support improvement on Dupixent weekly, and a psoriasiform dermatitis was likely.  The patient was transitioned to medications for psoriasis. Dupixent is not appropriate for psoriasis.  Furthermore, there is limited medical literature supporting the use of Dupixent weekly.