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

Diagnosis: Asthma Exacerbation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

The patient is a child with a history of moderate persistent asthma who was sick with a cough and increased work of breathing. The patient had been started on Amoxil for a strep throat on the day prior to the admission. The patient's mother brought the patient to the emergency room (ER) when the patient's increased work of breathing and coughing did not improve with 3 doses of albuterol at home.

In the ER the patient was noted to have a cough and tachypnea with bilateral wheezing and prolonged expiratory phase of respiration. The pulse oximeter reading was 93% (percent) on room air. The patient is followed by a pediatric pulmonologist who has prescribed Symbicort, montelukast and Spiriva. There were plans to start the patient on treatment with Mepolizumab in June for moderate persistent asthma. The patient is also diagnosed with Eosinophilic esophagitis and is followed by Pediatric Gastroenterology. The patient has had 2 Pediatric Intensive Care (PICU) admissions in the past and during the most recent admission required treatment with bi-level positive airway pressure (BIPAP). 

The patient received 3 treatments with DuoNeb, dexamethasone, magnesium sulfate and an intravenous (IV) bolus of normal saline. This was followed by 2 additional treatments with albuterol. A chest x-ray was unremarkable but a blood gas was significant for an elevated partial pressure of carbon dioxide (pCO2) reading of 50.4. Following treatment in the ER the patient was still noted to have wheezing and the decision was made to admit the patient with a diagnosis of status asthmaticus for continued treatment with albuterol every 3 hours.

The patient was treated appropriately in the ER for a cough, wheezing and increased work of breathing. The patient was noted to be in acute respiratory distress when they arrived in the ER despite having received 3 treatments with albuterol in the home. The patient did not improve in the ER and because of the diagnosis of moderate persistent asthma with an elevated pCO2 of 50.4 and previous requirement for admission to the PICU on 2 occasions the patient was at high risk for respiratory deterioration and it was appropriate and consistent with the standard of care to admit the patient to the hospital for albuterol every 3 hours.

Admission to the hospital was medically necessary for a child with moderate persistent asthma that had an elevated pCO2 level of 50.4. The patient's condition was not stable enough to permit safe discharge.

Based on the above, the insurer's denial must be reversed. 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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate Cancer
Treatment: Foundation Medicine comprehensive molecular 
profile test
The insurer denied: Foundation Medicine comprehensive molecular profile test
The denial is overturned.

The patient is an adult male with metastatic prostate cancer. The provider has performed FoundationOne testing.

The proposed treatment is medically necessary.

For men with prostate cancer, the National Comprehensive Cancer Network (NCCN) supports testing for homologous recombination repair (HRR) and microsatellite instability (MSI) for all men for therapy decisions. The only United States Food and Drug Administration (FDA) approved companion diagnostics for homologous recombination repair is FoundationOne. As such, this was necessary. There are no other approved companion diagnostics for Olaparib therapy in prostate cancer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 Braces, D8670 monthly visits x 12

The insurer denied coverage for D8080 Braces, D8670 monthly visits x 12

The denial is upheld

 
The patient is a child under the care of an orthodontist for the treatment of his dentition and the crowding. The orthodontist has evaluated the patient and diagnosed with skeletal class one and class two canines. There is moderate crowding and moderate overbite and overjet. There is a posterior molar in crossbite as well.

The prior denial noted in order to approve this service, the following criteria must be met DentaQuest Clinical Criteria for Comprehensive Orthodontics; These criteria are not met because additional documentation was received, but it does not support the need for this service. The patient failed review of published auto qualifiers and did not reach a Handicapping Labio-Lingual Deviation (HLD) score of 26 to qualify for orthodontic benefits.

Upon my review of Handicapping Labio-Lingual Deviation (HLD), it was clear the patient fell in the region which is not above the threshold for coverage. This includes the overjet and overbite, crowding and ectopic canine and molar in crossbite. 

The HLD for this patient includes overjet 3 millimeters (mm) and overbite 3 mm, anterior crowding of both arches 2x5=10, and labiolingual spread  2-3 for total of HLD score -19. 
Therefore, the medical records provided for review at this time do not support the request for D8080 Braces, D8670 monthly visits x 12.

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 D8080 Braces, D8670 monthly visits x 12 services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces
The insurer denied: D8080 Braces
The denial is overturned.

This patient is a teenage male. Denial of coverage of comprehensive orthodontic treatment is being appealed.

The requested braces are medically necessary.

The orthodontic treatment is medically necessary. The health plan's initial review denied coverage of the treatment due to a score of 24 on the Handicapping Labio-Lingual Deviation (HLD) index. However, upon review, the patient is found to have a Handicapping Labio-Lingual Deviation score of 26. The patient is found to have the following scores: overjet 6, overbite 5, crowding 2x (times) 5 = (equal) 10, and labio-lingual spread 5, for a total score of 26. Given this score, the denial of orthodontic treatment was not appropriate. The braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol/Drug Withdrawal
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult male with a history of alcohol dependence. He presented with alcohol intoxication. He complained of headache and neck and back pain. The patient's vital signs were stable and afebrile. His exam was remarkable for bilateral hand tremors and tongue fasciculations. Pertinent labs were white blood cell count 3.46, hemoglobin 10.4, and platelets 200. A computed tomography (CT) scan of the head and cervical spine showed no acute disease. Chest x-ray showed no acute disease. The patient was admitted for alcohol withdrawal. The plan of care included intravenous fluids and Clinical Institute Withdrawal Assessment (CIWA) protocol. Home medications for chronic conditions were resumed. On day # (number) 2, the patient's Clinical Institute Withdrawal Assessment score was six. He was tolerating diet without nausea and vomiting. On day #3, the patient had improved from day #2. He was noted to have ongoing hand tremors. The patient was discharged on day #4.

The proposed treatment was not medically necessary. 

This patient with a history of alcohol dependence was admitted after presenting with alcohol withdrawal. He was hemodynamically stable and afebrile. Findings included hand tremors and tongue fasciculations. He did not have persistent vomiting, delirium, or seizures. Labs were remarkable for mild anemia. He did not have arrhythmia. He did not have severe electrolyte abnormalities. He was able to tolerate by mouth intake. He was admitted with a plan for intravenous fluids, Clinical Institute Withdrawal Assessment protocol, and resuming home medications for chronic conditions. The patient was clinically stable and did not have findings of severe alcohol withdrawal. He did not have risk factors such as history of delirium tremens, seizures, or comorbid conditions that required inpatient admission. He had not failed a lesser level of care. The patient remained clinically stable during the hospital stay without signs of severe alcohol withdrawal. The requested inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

This is a case of a male admitted for diagnosis of shortness of breath from parainfluenza virus. The patient presented with parainfluenza virus. Symptoms started the Saturday prior to admission. Symptoms included body aches, headache, fever, chills, and cough. Vital signs demonstrated temperature 98.2F (degrees Fahrenheit), pulse 91, blood pressure 133/84, respiratory rate 20 and O2 saturation 94% (percent). Physical exam showed no distress with wheezes, and rhonchi. Infectious disease consult was requested and no antibiotics were recommended. Pulmonology consult was requested and they recommended a prednisone taper, Symbicort, albuterol, and Mucinex. After symptom improvement, he was then able to be discharged.

The inpatient hospital services were not medically necessary.

The patient in this case was admitted for shortness of breath due to parainfluenza virus. He did not require Intensive Care Unit (ICU) treatment, have an immuno-compromising condition, underlying lung disease, or underlying heart disease. There was no significant abnormal vital sign. He was evaluated by infectious disease and no antibiotics were recommended. He was evaluated by pulmonology who treated him with standard measures including prednisone, Symbicort, albuterol, and Mucinex. There was no hypoxia. There was no hemodynamic instability. There was no leukocytosis. Venus potential hydrogen (pH) was normal at 7.32. There was no altered mental status or evidence of significant carbon dioxide retention.

Although the patient required services in the hospital setting, the monitoring, diagnostics testing, and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness and lightheadedness
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This adult male was hospitalized for weakness and lightheadedness. His past medical history includes insulin-dependent diabetes, hypertension, nonobstructive coronary artery disease, stage 3 chronic kidney disease, and alcohol use disorder in remission with past delirium tremens. The patient presented to the emergency department (ED) for evaluation following a witnessed near syncope. While at work, he felt weak and lightheaded and fell to the floor without loss of consciousness. Blood glucose was 230. He admitted to taking his medications including insulin in the morning and did not eat. In the ED, blood pressure was elevated to 177/107. Electrocardiogram (EKG) showed inverted T-waves (intervals on EKG), and repeat tracing showed nonspecific T-wave abnormality. Head computed tomography (CT) scan showed chronic infarctions and chronic small vessel ischemic changes. Chest x-ray was remarkable for cardiomegaly. Troponin panel was non-diagnostic and flat. The clinical impression was that the patient had a vasodepressor episode from not eating. Treatment included intravenous normal saline, aspirin, carvedilol, chlorthalidone, losartan, thiamine, and folic acid. Echocardiogram revealed moderate left ventricular hypertrophy, left atrial enlargement, and a small pericardial effusion. Blood pressure came under control and, and the patient was deemed stable for discharge to home. The requested coverage for inpatient hospital admission was denied based on the patient's policy and the patient is appealing the decision.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, the requested service, inpatient stay, was not medically necessary. There was not a medical need for the acute inpatient hospital stay because criteria are not met, including suspicion of imminently dangerous cause, like pericardial tamponade, pulmonary embolism, syncope causing injury requiring hospitalization, inpatient admission rather than observation care because of a significant finding or clinical condition judged too severe or too persistent to be within scope of observation care, such as hemodynamic instability that is severe or persistent, cardiac arrhythmias of immediate concern, acute coronary syndrome or myocardial infarction, structural cardiac disorder like severe aortic stenosis or suspected as cause that requires immediate correction, respiratory distress, stroke, seizures, altered mental status, severe electrolyte abnormalities requiring inpatient care or other significant finding or clinical condition judged not to be within scope of observation care. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received for uncomplicated vasovagal syncope is routinely provided safely and effectively at a lower level of care. Therefore, the requested health service is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Obesity
Treatment: Ozempic
The insurer denied Ozempic.
The determination is upheld.

This is a female patient with a past medical history of obesity, hyperlipidemia, vitamin D deficiency, and prediabetes who was eventually started on Ozempic. The patient lost 42 pounds and her hemoglobin A1c decreased to 5.4. The patient stated that Ozempic resolved the metabolic and hormonal issues that had placed her at risk for diabetes as well as other serious illnesses. The patient's endocrinologist sent a letter stating the patient had been using Ozempic with a positive clinical response to therapy. The letter stated the patient had successfully lost 16.51 percent (%) of her body weight with therapy. In addition, the letter stated the patient tried and failed Victoza, Phentermine, Metformin, Topiramate, Naltrexone, and Belviq. The insurer sent a final adverse determination continuing to deny coverage for Ozempic stating the medication is FDA-approved for Type 2 Diabetes and is considered experimental/investigational for obesity and therefore was unable to be approved. The patient's endocrinologist sent another letter requesting reconsideration of a denial of coverage for Ozempic noting although Ozempic is not currently approved for weight loss there is evidence to show that a byproduct of therapy with Semaglutide yields significant weight loss. Ozempic is under review.
The proposed health service or treatment Ozempic is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening disabling condition or disease. Standard treatment for prediabetes and obesity includes an informal diet, supervised diet, exercise, and pharmacological treatment. The patient has tried multiple pharmacological treatments in the past, documented as unsuccessful but has not tried all medications approved for the treatment of obesity in the same family as Ozempic. Specifically, Saxenda and Wegovy are FDA-approved for weight loss. There is no documentation that the patient has diabetes mellitus type 2 which is the condition Ozempic is FDA approved to treat. The patient does not have a life-threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Obesity.
Treatment: Ozempic.
The insurer denied Ozempic.
The determination is upheld.

This is a female patient being prescribed Ozempic for the diagnosis of obesity. Coverage for this medication was denied by the health plan, and this denial is the subject under review.
The patient provided a letter of support. It states that she has been using Ozempic with good response. She was previously a pre-diabetic but reports that her most recent A1C was 5.4. She lost 42 pounds on the medication. When coverage was denied for her medication, she gained 8 pounds back. She feels that the medication is necessary.
The patient's physician provided a letter of support for this appeal. The letter states that her current body mass index (BMI) is 33.3. She has diagnoses of obesity, hyperlipidemia, and prediabetes. Prior medication trials have included metformin, Ozempic, Victoza, and Contrave. The physician notes that Ozempic is not currently approved for weight loss but that there is evidence that this is a byproduct of therapy with the active ingredient, semaglutide.
The health plan prescribing guidelines for glucagon-like peptide 1 (GLP)-1 agonists for the treatment of diabetes were provided for review. These medications, including the requested medication Ozempic, are only approved by the Food and Drug Administration (FDA) to treat type 2 diabetes. Therefore, they are only considered for approval and patients who have this diagnosis. Ozempic is under review.

The requested medication Ozempic is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
The patient and the physician are correct that semaglutide has been demonstrated to be safe and effective in promoting weight loss in patients with obesity. However, this medication is FDA-approved and marketed under the brand name Wegovy when used for the treatment of obesity. The requested medication (Ozempic) has the same active ingredient as Wegovy (semaglutide), but it is not the Food and Drug Administration (FDA) approved for that indication. The FDA-approved medication for weight loss, Wegovy, is based on the dosing schedule that demonstrated efficacy in randomized controlled trials. Usage of Ozempic at the dosages that have been studied for diabetes would be considered off-label usage at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Obesity.
Treatment: Ozempic.
The insurer denied Ozempic.
The determination is upheld.

This is a female patient with a history of obesity, Vitamin D deficiency, depression, and hyperlipidemia. She is requesting continued coverage for Ozempic. In an appeal letter, her provider indicated that the patient had previously tried and failed Metformin, Lomaira, Ozempic, Victoza, and Contrave. In the next paragraph, the provider indicates that the patient is currently on Ozempic 2 milligrams (mg)/dose. In the patient's appeal letter, she indicates that she has been on Ozempic. Ozempic is under review.
The proposed health service or treatment Ozempic is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.
Based on a thorough review of the information provided, the requested Ozempic is not likely to be more beneficial than any standard treatment or treatment for the insured's condition of obesity. Ozempic is Food and Drug Administration (FDA) approved for the treatment of diabetes, and there is no evidence that the patient has diabetes. Ozempic is not FDA-approved for the treatment of weight loss, and the off-label prescribing of Ozempic is not recommended especially considering that there are other similar agents (Saxenda, Wegovy) that are FDA-approved for the treatment of weight loss.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Rheumatoid arthritis.
Treatment:  Rinvoq 30 mg (milligrams) daily.

The insurer denied Rinvoq 30 mg (milligrams) daily.  The health plan's determination is upheld.

The patient in question is diagnosed with rheumatoid arthritis and hydradenitis suppurativa. Previously, they were undergoing treatment with infliximab at a dosage of 10mg/kg (milligrams/kilogram) administered intravenously every two months. However, this treatment was poorly tolerated, leading to adverse effects such as finger stiffness, pain, and swelling. Concerns were raised regarding the effectiveness of Remicade, as it did not appear to alleviate the symptoms. Consequently, it was decided to discontinue the infusions of Remicade and switch to Rinvoq. 

Rinvoq 30 mg daily is not medically necessary for this patient. The Food and Drug Administration (FDA) approved dosing for rheumatoid arthritis Rinvoq is 15 mg once daily, the requested dose (30 mg) is higher than the approved dosing.  The optimal dosing regimen for Rinvoq at 30 mg daily for the treatment of Rheumatoid Arthritis or hidradenitis suppurativa (HS) has not yet been determined, as it is currently undergoing clinical trials for HS. However, there is more available data on the dosing of Humira or adalimumab and Rinvoq for rheumatoid arthritis. In the case of rheumatoid arthritis treatment, the recommended dose for Rinvoq is 15 mg once daily, and it should be administered accordingly.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain. 
Treatment: Pain Injection (62323 x 1). 
The insurer denied Pain Injection (62323 x 1). 
The health plan's determination is overturned. 

This is a female who has chronic back pain with radiation down to buttocks and right leg. Her pain is exacerbated with prolonged walking and improved by sitting and lumbar flexion. She had tried physical therapy (PT) and Ibuprofen with minimal relief. Her pain level is 10/10 at its worst with difficulty performing activities of daily living (ADL). An X-ray of lumbar spine showed stable borderline L (Lumbar)4 on L5 grade 1 to 2 anterolisthesis. Magnetic resonance imaging (MRI) showed L4/5 anterolisthesis with bilateral recess/foraminal stenosis. This patient was evaluated by neurosurgery and was recommended to an epidural injection and facet injection for diagnostic and therapeutic purposes. 

The Pain Injection (62323 x 1) is medically necessary for this patient. 
This patient has severe back pain with radicular pain in the right leg. She failed physical therapy (PT) and non-steroidal anti-inflammatory drugs (NSAIDs). Further treatments are medically necessary to improve her pain function. Her symptoms and Imaging studies indicate her L4/5 level pathology is potentially the primary generator. The requested pain injection is the next step intervention. It is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Multiple Sclerosis
Treatment: Formulary exception for Kesimpta
The insurer denied: Formulary exception for Kesimpta
The denial is overturned.

The patient is an adult female with multiple sclerosis. She was previously on dimethyl fumarate, and most recently, Ocrevus. On Ocrevus, she was having intolerable side effects, including heart palpitations and weight gain. Her provider wishes to start Kesimpta. The request was previously denied coverage by the health plan, as the health plan requires having tried 3 formulary agents. The denial is being appealed.

The health plan should cover the Formulary exception for Kesimpta.

Ocrevus was effective for the patient, but not tolerable due to infusion reaction and side effects from steroids. Kesimpta has the same mechanism of action, but it is not an infusion. As such, there is no infusion reaction or steroids. Other medications have different mechanisms of action and may be less effective for the patient. Therefore, given the above, the health plan should cover the formulary exception for Kesimpta.