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

Diagnosis: Psoriasis.
Treatment: Skyrizi (150mg dose) 75MG/ 0.83ML SC PSKT, Pre-service.

The insurer denied the Skyrizi (150mg dose) 75MG/ 0.83ML SC PSKT (subcutaneous Prefilled Syringe Kit), Pre-service.  The denial is overturned.

The patient is a woman with severe psoriasis affecting over 40% body surface area, which started more than 10 years ago.  She also has a history of non-Hodgkin's lymphoma in remission.  She has tried and failed multiple topical steroids, calcineurin inhibitors, vitamin D and phototherapy.

Yes, the treatment with Skyrizi is medically necessary.

The patient has severe psoriasis for which systemic therapy is indicated.  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.  Additionally, acitretin is contraindicated in women of childbearing potential.  Notwithstanding the above, the patient has a history of lymphoma and methotrexate is contraindicated because of that.

Therefore, given the above, the treatment with Skyrizi is medically necessary.

The patient has a history of lymphoma.  Methotrexate is contraindicated, because a well-known side effect of this medication is development of lymphoma.  Additionally, the patient is of childbearing potential.

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.

Based on the above data, Skyrizi is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted lower right second premolar. 
Treatment: D8080 Braces. 

The insurer denied the D8080 Braces. 
The denial is overturned. 

The patient is a female.  The request is for orthodontic benefits. The patient has an impacted lower right second premolar (tooth #29). The denial was due to a handicapping index score of eight. 

Yes, the proposed braces are medically necessary. 

The patient has an impacted (i.e. blocked out) lower right second premolar (tooth #29). The adjacent teeth have shifted on an angle into the space that tooth #29 should be in. This has caused multiple spaces between teeth on the lower right side. These will become food trap areas, with the resultant cavities being formed. The orthodontic treatment is needed to correct the tilted teeth, open up the proper space for tooth #29, and to allow it to erupt properly into position. This will close all the open spaces in this quadrant. This case has medical necessity. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

This is a male patient with a history of irritable bowel syndrome, familial Mediterranean fever and small bowel obstruction who presented with exacerbations of chronic intermittent diffuse abdominal pain associated with constipation.  He had not taken his prescribed medications in months. 

The patient's vital signs revealed the following: temperature = 37.1, pulse = 113, respiratory rate = 18, blood pressure = 147/92, and pulse oxygenation = 98% (percent).  The patient's exam was remarkable for right and left lower quadrant abdominal tenderness to palpation and mild guarding.  Labs showed white blood cells (WBC) = 16.9, hemoglobin/hematocrit (H/H) = 15.9/45, platelets (Plt) = 266, sodium (Na) = 140, potassium (K) = 4.1, blood urea nitrogen/creatinine (BUN/Cr) = 11.3/.9, and lactic acid = 2.3. An abdominal/pelvic computed tomography (CT) did not show obstruction. 

The patient was admitted.  Plan was to continue colchicine, daily kidney bladder ureter (KUB), and nothing by mouth (NPO).  On day two, the patient's abdominal pain had improved.  He was passing gas and had a small bowel movement.  There was no plan for acute surgical intervention.  He was to restart diet.  On day three, the patient had no abdominal pain, he was tolerating diet, and was cleared for discharge. 

No, the proposed inpatient admission was not medically necessary. 

This patient with a history of irritable bowel syndrome (IBS) and bowel obstruction was admitted with exacerbation of abdominal pain.  He did not have vomiting.  He was hemodynamically stable and afebrile.  Imaging was negative for obstruction.  He did not have dehydration or severe electrolyte abnormalities.  Intervention during admission included bowel rest and specialty consultation.  He did not require intravenous antibiotics.  Symptoms improved on day #2 and the patient was able to tolerate oral intake.  The patient was clinically stable and had not failed an observation level of care.  The proposed inpatient admission was not medically necessary. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anaphylaxis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a male with a history of food allergy and anaphylaxis. He presented with complaint of anaphylaxis. He developed facial swelling, urticaria, and trouble breathing. EMS (emergency medical services) administered epinephrine IM (intramuscular) x2 prior to his arrive to the ED (emergency department).

On presentation to the ED (emergency department), he had elevated blood pressure and was minimally responsive with a delayed capillary refill and tonsillar hypertrophy. He was admitted to the PICU (pediatric intensive care unit). An epinephrine drip was planned. Physical exam had noted diffuse wheezing, tachypnea with mild retraction. He was treated with epinephrine, albuterol, steroids, benadryl, pepcid, combivent, supportive care including oxygen. 

Yes, the Inpatient admission was medically necessary.
The patient presented with signs and symptoms suggestive of anaphylaxis. His presentation was severe and life-threatening, as he required multiple doses of epinephrine. Rebound anaphylaxis may occur after initial presentation, therefore, it is reasonable for him to have been admitted for management and observation of his anaphylaxis.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

As above, the patient presented with anaphylaxis that required multiple epinephrine. He was appropriately admitted to the PICU (pediatric intensive care unit).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Orthodontic Procedure/ braces. 
The insurer denied braces. 
The denial is upheld.

The patient is a female with a Class I occlusion with 2 millimeter (mm) overbite and 5mm overjet. She has severe maxillary and mandibular crowding. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. The subject under review is the medical necessity for braces.

The health plan's determination is upheld.

The requested treatment with braces is not medically necessary for this patient. She is very crowded, but no teeth are impacted. Her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior or posterior crossbites present. Using the Handicapping Labio-Lingual Deviations (HLD) index, the patient scored at a 20 (5 overjet, 2 overbite, 10 maxillary and mandibular anterior crowding, and 3 labio-lingual spread). Discounting the HLD score, there is still no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) The patient's overjet is more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6mm. (3) 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. 
Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, hypertension, gastroesophageal reflux disease, mixed incontinence and falls

Treatment increase in personal care assistance from 48 to 84 hours per week

The insurer denied coverage for increase in personal care assistance from 48 to 84 hours per week

The denial is overturned

This is an elderly patient with multiple medical problems including hypertension, osteoporosis and recent cerebrovascular accident (CVA) with right hemiparesis.  She lives with her daughter, who returned to work.  The request is for an increase in personal care assistance from 48 to 84 hours per week.

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance to total dependence for meal preparation, housework and shopping.  She requires extensive to maximal assistance for activities such as bathing, personal hygiene, dressing and toilet use/transfers.  She is occasionally bladder incontinent.  The patient has had a functional decline in the past 90 days due to the stroke.  She is unable to ambulate independently and is at significant risk for falls.  The patient has significant functional deficits with a recent decline due to the stroke, support her request for increase in personal care assistance from 48 to 84 hours per week to allow her to continue living safely at home.    

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

The increase in personal care assistance from 48 to 84 hours per week is medically necessary.  

The insurer's denial of coverage for increase in personal care assistance from 48 to 84 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Stelara 90 milligrams every 6 six weeks. 
The health plan's denial is overturned. 

The patient is a male with severe ileal Crohn's disease. He was started on Stelara at standard dosing every 8 weeks but later lost response. He had symptoms of a flare of his Crohn's disease 2 weeks prior to his scheduled injection. Therefore, the attending provider escalated the dose of Stelara to 90 milligrams (mg) every 6 weeks. His Crohn's disease is in remission on the escalated dose of Stelara. The attending provider is requesting the escalated dose of Stelara 90 mg subcutaneous (SC) every 6 weeks to treat this patient's Crohn's disease.

The health plan's determination is overturned.

Since this patient was not responding to standard dosing of Stelara, it is reasonable to increase the dose of Stelara to 90mg every 42 days (6 weeks). This patient has medically refractory Crohn's disease and has failed every other class of Food and Drug Administration (FDA) approved biological agent used to treat Crohn's disease. There are only a finite number of biological agents used to treat inflammatory bowel disease and the standard of care is to optimize dose of the biological agent before switching to another agent. Therefore, it is medically necessary to use Stelara 90mg SC every 6 weeks to treat this patient's severe Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain in Foot and Toes

Treatment magnetic resonance imaging (MRI)

The insurer denied coverage for magnetic resonance imaging (MRI)

The denial is overturned 

The patient is an adult female with complaints of right foot pain. Based on the records made available, the patient has ongoing right foot pain and was seeing her for this problem. The physician indicates in the appeal that the x-rays were taken and as such was the precursor to the request for the MRI (magnetic resonance imaging).  Given the clear guidelines of the insurance plan, this MRI should be authorized.

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

The insurer's denial of coverage for magnetic resonance imaging (MRI) of the foot is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar disorder, schizophrenia, osteoporosis, osteoarthritis, and diabetes

Treatment: home care/personal care HHC (home health care) - level 2 personal care services, per 15 minutes increase to for 35 hour(s) per week

The insurer denied coverage for home care/personal care HHC - level 2 personal care services, per 15 minutes increase to for 35 hour(s) per week

The denial is upheld.

The patient has chronic medical problems including bipolar disorder, osteoarthritis and diabetes mellitus. She lives alone in 2 bedroom apartment. She is requesting an increase in home care/personal care HHC - level 2 personal care services, consumer directed personal assistance services (CDPAS) for 35 hours/week (she currently has 30 hours/week).

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance for meal preparation, housework and shopping. She requires extensive assistance for bathing and lower body dressing. Activities such as personal hygiene, upper body dressing and toilet use require only limited assistance. She is occasionally and infrequently incontinent of bladder and bowel, respectively. The patient is cognitively intact and fully oriented. She ambulates using a cane or walker. Her functional ability and intact cognitive status do not support the requested increased home care/personal care HHC - level 2 personal care services, consumer directed personal assistance services (CDPAS) for 35 hours/week. Based on the documents reviewed, the current 30 hours/week are appropriate; allowing her to continue living safely at home.

From a physical medicine and rehabilitation perspective, the requested home care/personal care HHC - level 2 personal care services, consumer directed personal assistance services (CDPAS) for 35 hours/week is not medically necessary.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.

The insurer's partial denial of coverage for the home care/personal care HHC - level 2 personal care services, per 15 minutes increase to for 35 hour(s) per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse-Inpatient. 
The insurer denied inpatient admission-substance abuse inpatient detox. 
The health plan's determination is upheld. 

The patient is a male who was requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with use of one and one-half pints of liquor and beer together with daily use of up to $100 worth of crack cocaine and $50 worth of cannabis (marijuana). He had a history of alcohol and marijuana use beginning in late adolescence with use of cocaine beginning in early adulthood. He reported 12 or more prior substance use disorder/detoxification treatments, the most recent with a two-day stay and against medical advice (AMA) discharge with relapse; his treatment history included no rehabilitation treatments or involvement in self-help recovery groups. 

The patient was admitted for inpatient detoxification and other medical services following the assessment for safety issues and medical clearance. He received vitamin replacement therapy, and other supportive measures including as needed (prn) Benadryl for insomnia. The patient's hospital course progressed without incident. He was placed on an Ativan taper over a five-day time frame. The patient slept and received meals without complications. The patient received counseling with recommendation for clinically appropriate aftercare including ongoing involvement with counseling and educational groups. He declined medication assisted treatment. He was discharged with completion of the detoxification treatment with referral for clinically appropriate aftercare and rehabilitation substance-related treatment. The subject under review is the medical necessity inpatient for the substance abuse detox.

The patient's admission and continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could have been safely provided at a lower level of care in this case scenario. This answer is consistent with established practice guidelines, the scientific literature, and American Society of Addiction Medicine (ASAM) Criteria, as referenced below, and is entirely consistent with application of the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Migraine
Treatment: Pharmacy/Prescription Drugs

The health plan denied the requested prescription drug, Nurtec ODT. 
The health plan's determination is upheld.

The patient is a woman. Nurtec ODT (orally dissolving tablet) is prescribed for the prevention of migraines. Nurtec ODT was denied because the patient has not tried and failed Aimovig and Ajovy. The patient has previously tried and failed Emgality, Topiramate, and Venlafaxine ER. The provider has appealed the determination to deny Nurtec ODT.
At issue is the medical necessity of the requested prescription drug, Nurtec ODT.

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

No. Nurtec ODT is not medically necessary. The medication was denied because the patient has not tried and failed Ajovy and Aimovig. The patient has previously tried and failed Emgality. This medication binds to calcitonin gene related peptide (CGRP) lignad. While Ajovy works by a similar mechanism of action, Aimovig binds to CGRP receptors. Thus, the mechanism of action is different. Aimovig is Food and Drug Administration (FDA) approved for prevention of migraines. There are no data to show that Nurtec ODT is more effective than Aimovig. The patient does not have a known contraindication to the use of Aimovig. As such, the drug is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Autism
Autism related treatment

Diagnosis: Autism
Treatment: Applied Behavior Analysis (ABA)
The insurer denied Applied Behavior Analysis (ABA). The health plan's determination is overturned. 

The patient is a female diagnosed with autism spectrum disorder and attention deficit hyperactivity disorder. She has struggled in numerous domains and her clinical psychologist recommended applied behavioral analysis (ABA) therapy to address the patient's deficits in adaptive functioning and behavioral dysregulation. She has had assessments by occupational therapists, and completion of the Vineland measures of Adaptive functioning. She is currently receiving ABA therapy; however, coverage is being denied by the health plan stating that there was no "standardized autism measures, no assessment of cognitive or intellectual functioning , or assessment of adaptive of communication function and thus ABA treatment hours are not medically necessary.

Applied Behavior Analysis (ABA) - Adaptive Behavior Treatment by Protocol by Technician (110 Units), Family Adaptive Behavior Treatment Guidance by Clinician (20 Units), and Assessment and Treatment Planning (5 Units) is medically necessary for this patient.
ABA therapy is the gold standard treatment for autism. It is well accepted that ABA therapy comprises multiple segments including treatment by the technician, family guidance, and assessment/treatment planning and supervision. These services are not unique to this patient and are used to provide comprehensive services to individuals with autism spectrum disorder. There are many studies that support this type of ABA therapy for the treatment of autism spectrum disorder. Given the above, the requested ABA treatment is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis.

Treatment Dupixent 300 milligrams (mg) per 2 milliliters (ml) subcutaneous SOSY (solution prefilled syringe)

The insurer denied coverage for Dupixent 300 milligrams per 2 milliliters subcutaneous SOSY

The denial is overturned

The patient has a diagnosis of atopic dermatitis affecting the face, hands, and body.  The patient has failed therapy with topical steroids, tacrolimus, eucrisa, prednisone, and narrowband ultraviolet (NB-UVB) per the documentation.  According to the notes and prescription summary it appears that the patient was also given Dupixent.  The office notes indicate that the patient was on Dupixent in the past.   

The patient has a diagnosis of atopic dermatitis which would be amenable to systemic therapy.  The patient has failed topical therapy with steroids, eucrisa, and tacrolimus.  The patient appears to have failed therapy with UVB and prednisone.  It appears that Dupixent was provided in recent years.  The patient has failed appropriate topical and systemic therapies.  There is no documentation that the patient has had any complications to Dupixent use in the past.  Given the documentation provided, the use of Dupixent would be within the standard of care for this patient.  As such, the use of dupixent for the treatment of atopic dermatitis is medically necessary based on the clinical scenario and the documentation provided.  The decision is overturned.  

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

The insurer's denial of coverage for the medication Dupixent 300 milligrams per 2 milliliters subcutaneous SOSY is overturned. Medical Necessity is substantiated.