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

Diagnosis: Rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA). 
Treatment: Actemra. 
The insurer denied Actemra. 
The health plan's determination is upheld. 

The patient is a woman with a history of rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA). The issue in this case is intravenous (IV) Actemra is being denied by the health plan. 

Actemra is not medically necessary for this patient. As stated, there is no medical reason she cannot try the preferred medications listed. As per UpToDate, in patients who fail conventional disease modifying anti-rheumatic drug (DMARD), tumor necrosis factor (TNF) inhibitors (e.g., Enbrel), JAK (Janus kinase) inhibitors, IL-6 (Interleukin 6) antagonists, Orencia and Rituxan are all indicated to treat moderate to advanced RA. As published in J Rheumatol in 2001, 'etanercept continued to be safe and well tolerated, and its clinical benefit was sustained for a median of 25 months and for as long as 43 months in patients with RA'.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient is a an adult who was brought to the emergency room with complaints of a near syncopal episode.  She did report that her menstrual cycle started that day, and it was heavier than usual. The patient has a long history of anxiety with panic attacks.  Electrocardiogram (EKG) was normal.  Her hemoglobin was 5.7. The patient was transfused with 2 units packed red blood cells and started on Aygestin.  Ultrasound showed an enlarged uterus suggestive of  adenomyosis.  The endometrium was also noticed to be thickened.  Because the patient kept complaining of lightheadedness the decision was made to admit her. The patient was given an additional unit of blood and Aygestin was continued. She was also given tranexamic acid.  The plan was to discharge her. 

However, the patient kept complaining of dizziness and was kept in hospital for a dizziness workup. In addition, the patient was noted to have odd behavior. She was evaluated by neurology and an electroencephalogram (EEG) was done.  Her problems during this admission were as follow:  Near syncope: computed tomography (CT) of head and magnetic resonance imaging (MRI) of the brain were normal, EEG was negative, toxicology screen was negative, she was evaluated by neurology with no further workup needed.  Adjustment disorder: Psychiatry recommended Risperdal. Hip pain. Symptomatic anemia. Abnormal perimenopausal bleeding. Chest pain. The patient was discharged. 

This patient had symptomatic anemia. She fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 grams per deciliter (g/dl). Thus, transfusion was necessary. 

Transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). The need for transfusion is not a reason for admission. The patient could have been transfused as an outpatient. 

Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include: active massive hemorrhage, active hemolysis, cognitive impairment, heart failure, chest pain, syncope.  This patient was stable and did not have any of the above. 

Based on all of the above, the admission was not medically necessary.  The patient could have been transfused and discharged home after ensuring that the patient was stable. 

With regard to her other  complaints,  the most worrisome was her odd behavior. However,  neurology and psychiatry consults and extensive studies (EEG, CT and MRI) revealed no acute process. Furthermore, the psychiatrist on his note stated that there was no need for a psychiatry admission.  

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

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

Diagnosis: Myocardial infarction

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned.
 

This is a case of an adult that presented to the hospital complaining of left foot and ankle pain for four days. Past medical history was significant for dilated cardiomyopathy with a left ventricular ejection fraction (LVEF) of 15-20% (percent), persistent atrial fibrillation, implantable cardioverter defibrillator (ICD), cerebrovascular accident (CVA) and schizoaffective disorder. On presentation to the hospital vital signs were stable: Blood pressure 117/93 and pulse 86. The physical exam revealed pedal edema left 3+ (plus), right 1+ to the ankle. A 12-lead electrocardiogram (ECG) revealed atrial fibrillation with a controlled ventricular rate, intraventricular conduction delay and a QT (interval on an ECG) of 469 milliseconds. Serum blood testing revealed an elevated high sensitivity troponin of 479 nanograms per liter (ng/L). Serial testing demonstrated persistent elevation. The patient was admitted to the hospital for observation and testing. An Echocardiography revealed a severely depressed LVEF. Imaging studies of the left ankle demonstrated no fracture. The patient was diagnosed with type II (2) myocardial infarction and treated with decongestive therapies and discharged home after several days.

This patient presented with a type II myocardial infarction. His HEART (a risk calculation) score put him in a high-risk category, consistent with a high risk of future cardiac events. He was admitted and ultimately treated with anticongestive therapies. Based on his high-risk score using both the HEART and thrombolysis in myocardial infarction (TIMI) risk stratification, the admission for work up was medically necessary. Risk assessment of patients presenting with chest pain and ST (interval on an ECG) changes on the ECG as well as negative cardiac enzymes was performed by Sanchis. Using their risk stratification schema, this patient would have a high risk of future myocardial infarction or death within one year. In conclusion, acute care hospital admission was medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted mandibular canine
Treatment: Braces and monthly visits
The insurer denied coverage for braces and monthly visits
The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, this patient presented for evaluation for orthodontic care. The orthodontist identified impacted mandibular canine among other findings. The orthodontist completed the Handicapping Labio-Lingual Deviations (HLD) index choosing the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated on the HLD index. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index by internal reviewers attaining a score of 11 points. The orthodontist is appealing the decision on behalf of the patient.

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 completed the HLD index, choosing the impacted permanent anteriors criterion to justify orthodontic care. The clinical circumstance as documented (mandibular canine) meets this criterion for approval of care.

Regarding the validity of the Handicapping Labio-lingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these 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 recommendation is to overturn the denial as the clinical circumstance, as presented, meets and substantiates the medical/dental necessity of orthodontic care and meets the accepted criteria for approval.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for braces and monthly visits is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pre-diabetes. 
Treatment: Mounjaro. 
The insurer denied Mounjaro. 
The health plan's determination is upheld. 

The patient is a woman with a history of prediabetes, hypertension, hyperlipidemia, fatty liver and morbid obesity. Her hemoglobin A1c level was 5.8. Her body mass index (BMI) was 41.6. Coverage for Mounjaro is at issue. The drug was prescribed for weight loss.

Mounjaro is not medically necessary for this patient. 

Mounjaro (tirzepatide) an injectable medication that is Food and Drug Administration (FDA) approved for use to improve blood sugar control in adults with type 2 diabetes, as an addition to diet and exercise. While it has been shown to result in significant weight loss in patients with and without diabetes and clinical trials have shown that blood glucose levels in the majority of obese patients with prediabetes returned to normal after Mounjaro-induced weight loss, it has not, at this point, been approved for a weight loss indication. 

Since Mounjaro is not FDA approved for use in this situation it cannot be determined to be in accordance with generally accepted standards of practice. Also, while it may be effective in aiding in weight loss for this patient, it cannot be determined that her current condition would be adversely affected if it were not provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces.
The insurer denied Braces.
The determination is upheld.

This is a patient with moderate maxillary and minor mandibular crowding. Tooth number (#) 11 has erupted labial within the arch due to lack of space. The patient has a class II occlusion with 4-millimeter (mm) overjet and 3 mm overbite. The patient is treatment planned for orthodontics to align the teeth and correct the bite but the plan. At issue is the medical necessity of braces.

While the patient has crowded teeth, 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. (2) This patient has a 4 mm overjet but research shows overjet would not affect oral health related quality of life unless it was greater than 6 mm. (3) If the patient's teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostatectomy
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male with a diagnosis of prostate cancer. Past medical history is significant for obesity, hyperlipidemia, and hypertension. He presented for an elective robotic radical prostatectomy. His vital signs, labs and physical examination on admission were normal. He underwent an uncomplicated procedure after which he was admitted on the inpatient service for observation. There were no post-operative complications, and he was discharged home the next day. 

The inpatient hospital admission was not medically necessary.
The majority of patients who undergo robotic radical prostatectomy can be discharged within 24 hours of the procedure. In this case, the procedure was an elective scheduled procedure. The patient did not have any significant risk factors which increased risk of post-operative complications. His post-operative course was essentially normal without any significant complications or issues with pain control. Observation at a lower level of care for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis

Treatment: Taltz

The insurer denied coverage for Taltz

The denial is upheld.

The patient has a diagnosis of psoriasis. The providing office has not provided sufficient clinical information to determine prior failed and tried medications. The health plan has multiple available biologic options, including Humira, Stelara, Tremfya, Cimzia, Skyrizi, and Cosnetyx.   

Based on the medical documentation, Taltz is not medically necessary. There is no documentation of a contraindication nor a specific Taltz indication which would favor the use of Taltz over multiple formulary alternatives. Taltz and Cosentyx are both within the Il-17 inhibitor class and would be expected to have similar efficacy and safety. Without blinded, controlled studies evaluating the safety and efficacy of Cosentyx with Taltz it is reasonable to assume that both medications have a similar safety and efficacy profile given their similar mechanism.  There is no documentation provided which would warrant the use of Taltz over alternatives, including Cosentyx. The use of Taltz would not be medically necessary over approved alternatives in a patient who has not tried any alternatives and with no contraindication to the available alternatives. The denial is upheld based on the documentation provided.  

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

The medical necessity for Taltz is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chest Asymmetry
Treatment: Masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral.
The insurer denied: Masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral to be performed. 
The denial is: Overturned in part.

The patient is a female to male transgender patient who underwent gender confirming mastectomies and now complains of asymmetry with too much tissue removed on one side and not enough removed on the other side. Despite the surgery he continues to bind his chest. 
On physical examination there were healed peri areolar incisions with bilateral chest contour deficits more so on the right and areolar skin creases also greater on the right and bilateral lower pole skin redundancies. An undated photo shows a deflated left breast with redundant lower pole skin/skin fold and right partially deflated breast. This is clearly outside the wide range of "normal" appearance determined by referencing the gender with which the patient identifies. Another set of undated photos show a slight indent on the left at 4 o'clock, minor excess lower pole breast tissue on the right, a significant right central mound depression, a basically normal male chest appearance without excess skin with the arms raised overhead, acceptable male appearing left chest with the arms down and normal male torso contour. The subject under review is the medical necessity for masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral. 

Based on the photos in the reviewed materials surgery on the left chest is not medically necessary because the left chest is inside the normal range of appearance for a male chest however, the right chest is outside the normal range of appearance for a male chest. Therefore, surgery on the right is medically necessary to create a chest contour within the normal range of appearance for a masculine chest.
13101 and 13102 are not medically necessary because they are global to/covered by 14001. Normal appearance on the right will require redistribution of the remaining subcutaneous tissue from the lower pole to the central mound. This will require 14001 and 15771 and 15772. Therefore, 14001, 15771 and 15772 on the right are medically necessary but surgery on the left and 14000 are not medically necessary. It is further not medically necessary that the patient have this performed by an out of network physician.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chest Asymmetry
Treatment: Masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral to Dr. Anandev Gurjala to be done at Marin General Hospital in Greenbrae, CA 
The insurer denied: Masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral to Dr. Anandev Gurjala to be done at Marin General Hospital in Greenbrae, CA 
The denial is: Overturned in part

The patient is a female to male transgender patient who underwent gender confirming mastectomies and now complains of asymmetry with too much tissue removed on one side and not enough removed on the other side. Despite the surgery he continues to bind his chest. 
On physical examination there were healed periareolar incisions with bilateral chest contour deficits more so on the right and areolar skin creases also greater on the right and bilateral lower pole skin redundancies. An undated photo shows a deflated left breast with redundant lower pole skin/skin fold and right partially deflated breast. This is clearly outside the wide range of "normal" appearance determined by referencing the gender with which the patient identifies. Another set of undated photos show a slight indent on the left at 4 o'clock, minor excess lower pole breast tissue on the right, a significant right central mound depression, a basically normal male chest appearance without excess skin with the arms raised overhead, acceptable male appearing left chest with the arms down and normal male torso contour. The subject under review is the medical necessity for masculine top surgery revision codes (13101. 13102, 14000, 14001, 15771 and 15772) consult for in-network coverage for an out of plan referral to Dr. Anandev Gurjala to be done at Marin General Hospital in Greenbrae, CA medically necessary for this patient.

Based on the photos in the reviewed materials surgery on the left chest is not medically necessary because the left chest is inside the normal range of appearance for a male chest however, the right chest is outside the normal range of appearance for a male chest. Therefore, surgery on the right is medically necessary to create a chest contour within the normal range of appearance for a masculine chest.
13101 and 13102 are not medically necessary because they are global to/covered by 14001. Normal appearance on the right will require redistribution of the remaining subcutaneous tissue from the lower pole to the central mound. This will require 14001 and 15771 and 15772. Therefore, 14001, 15771 and 15772 on the right are medically necessary but surgery on the left and 14000 are not medically necessary. It is further not medically necessary that the patient have this performed by out of network physician Dr. Gurjala at Marin General Hospital.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pompe Disease. 
Treatment: Lumizyme (dosed at 40mg (milligrams)/kg (kilograms) weekly. 

The insurer denied: Lumizyme (dosed at 40mg (milligrams)/kg (kilograms) weekly. 
The denial is overturned. 

The patient is an adult male with atypical infantile Pompe disease. Treatment with Lumizyme 40 mg/kg (milligrams/kilogram) is the subject of this review. The drug was denied coverage by the health plan based on the requested dose. The provider appealed the determination. The provider indicates that the patient is currently receiving 47 mg/kg (milligrams/kilogram) every other week although the plan indicates that the patient has only been approved for 20 mg/kg (milligrams/kilogram) every other week. 

The health plan should cover the requested Lumizyme. 

Although the requested dose is not supported by the FDA (United States Food and Drug Administration) prescribing information, the peer reviewed literature suggests that there are improved outcomes for patients treated with higher doses of this medication and more frequently. 

The requested Lumizyme is more beneficial. 

The request is for Lumizyme 40 mg/kg (milligrams per kilogram) weekly. The FDA (United States Food and Drug Administration) and manufacturer approved dosing is 20 mg/kg (milligrams per kilogram) every other week. The physician has submitted literature for the increased dose of 40 mg/kg (milligrams per kilogram) per week from an open label single-center study that concluded the higher dose of 40 mg/kg (milligrams per kilogram) per week improves outcome measures. This finding was repeating in a larger cohort study that showed improved outcomes with higher dosing. Patients with infantile Pompe disease treated with the high enzyme replacement therapy dosage of 40 mg/kg (milligrams per kilogram) per week had significantly improved survival when compared with patients treated with the standard recommended enzyme replacement therapy dosage of 20 mg/kg (milligrams per kilogram) every other week. This is an orphan condition. There are unlikely to be randomized controlled trials comparing the doses. However, the current body of literature suggests that 40 mg/kg (milligrams per kilogram)/week leads to improved outcomes for patients with infantile onset Pompe disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Pompe Disease. 
Treatment: Lumizyme (dosed at 40mg (milligrams)/kg (kilograms) weekly. 

The insurer denied: Lumizyme (dosed at 40mg (milligrams)/kg (kilograms) weekly. 
The denial is overturned. 

The patient is an adult male with Pompe Disease. The provider has requested Lumizyme 40 mg/kg (milligrams per kilogram) weekly. 

The health plan should cover the requested Lumizyme. 

Lumizyme is FDA (United States Food and Drug Administration) approved for his condition. There are at least two clinical trials supporting that the requested increased dose of 40 mg/kg (milligrams/kilogram) per week results in improved survival, ventilator-free survival, and motor outcome irrespective of immunomodulation outcomes for persons with Pompe's disease (Poleman et al., 2020; Chien et al., 2020). Therefore, the requested medication and dose is consistent with standard of care.