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

Diagnosis: Multiple Sclerosis.
Treatment: Vumerity.

The insurer denied Vumerity.  The health plan's determination is upheld. 

The patient is a woman with relapsing remitting multiple sclerosis. Treatment with Vumerity is the subject of this review. She has previously tried and failed Betaseron and dimethyl fumarate. She poorly tolerates dimethyl fumarate and has adverse reaction of flushing and gastrointestinal upset. Vumerity is denied because the patient has not tried and failed one other formulary agent after Betaseron.

A formulary exception is not indicated.

The formulary alternatives include Aubagio, Betaseron, Copaxone, Gilenya, glatiramer, Glatopa, Rebif and dimethyl fumarate. Of these, the patient has tried and failed Betaseron. She has flush and gastrointestinal upset with dimethyl fumarate. Of the remaining formulary alternatives, Aubagio and Gilenya would be considered to be likely as or more effective than dimethyl fumarate. However, there is no indication that the patient has tried and failed or has a contraindication to use of these products. These drugs are safe and effective for treatment of relapsing remitting multiple sclerosis and are Food and Drug Administration (FDA) approved for this indication.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Atrial fibrillation.
Treatment:  Eliquis.
The insurer denied coverage for Eliquis.  
The denial is upheld.

This is the case of a male with a history of coronary artery disease and prostate cancer. He presented to the emergency department with a heart rate of 160 beats per minute. A 12 lead electrocardiogram revealed atrial fibrillation with a rapid ventricular rate. The patient was treated with rate control agents and Eliquis oral anticoagulant therapy was prescribed. The insurer has denied coverage for Eliquis but will cover an alternative medication, Xarelto, which is on formulary. A letter is provided by the patient's provider stating that Eliquis should be approved due to a lower risk of gastrointestinal (GI) bleeding. The patient has no history of GI bleeding.

The formulary drug, Xarelto, is not likely to cause the patient an adverse reaction. The formulary drug has not been ineffective, and no documentation is provided to support that the patient has ever been treated with the formulary drugs. Both Eliquis and Xarelto therapies have been found to be non-inferior to warfarin. The 2019 American Heart Association, American College of Cardiology and Heart Rhythm Society Guidelines provide a Class I (level of evidence A) recommendation for treatment with novel oral anticoagulant regimen instead of warfarin. This recommendation was based on several randomized clinical trials that enrolled thousands of patients. The direct thrombin inhibitor medications and the Factor Xa inhibitor medications (including Xarelto/Rivaroxaban) were at least non inferior and in some cases superior to warfarin therapy. When Xarelto was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated non-inferiority to warfarin in preventing stroke or systemic embolism. (2) In conclusion, the patient should be treated with Xarelto. There is no evidence provided to demonstrate intolerance to the formulary medications, and there is also no clear evidence in the medical literature demonstrating a decreased rate of gastrointestinal bleeding with Eliquis. In conclusion, the formulary drug should be prescribed.

The insurer's denial of coverage for Formulary Exception for Eliquis is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Osteoarthritis. 
Treatment: Pharmacy/Prescription Drugs/ Orthovisc.
The health plan denied the requested formulary drug, Orthovisc as not medically necessary. The health plan's determination is upheld. 

This is a female with right knee osteoarthritis who has been recommended for Orthovisc. A progress report reveals a presentation with a one-month history of right knee pain in the absence of trauma. The pain localizes to the lateral aspect of the knee. The provider negates that the patient was previously treated elsewhere where they had Orthovisc injections with significant improvement in symptoms up until one month ago. The patient wants to consider doing another series of Orthovisc. The physical examination of the right knee reveals range of motion from 0-105 with pain and lateral joint line tenderness. The provider reports previously obtained x-rays of the knee demonstrate advanced lateral compartment osteoarthritis. The provider states the patient presents for evaluation of right knee pain which has been intermittent over the years but worsened in the past month, prior x-rays show advanced lateral compartment osteoarthritis, and the patient has responded well to viscosupplementation the past. There is a recommendation to repeat viscosupplementation. 
At issue is whether the formulary drug (Durolane, Euflexxa, Gelsyn-3, Supartz FX) will be or has been ineffective, would not be as effective as the non-formulary drug (Orthovisc), or would have adverse effects. 

Based on the available information, the health plan's determination is upheld, in whole. 

There is no indication that the patient has tried and failed treatment or experienced an intolerance with Durolane, Euflexxa, Gelsyn-3, Supartz FX. There is no documented contraindication to any of these alternatives. There is no available medical literature indicating Orthovisc leads to superior outcomes compared to Durolane, Euflexxa, Gelsyn-3, and Supartz FX. Additionally, there is no medical literature indicating Durolane, Euflexxa, Gelsyn-3, and Supartz FX can lead to adverse effects that do not occur with Orthovisc.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis. 
Treatment: Cosentyx Sensoready (300mg) 150MG/ML SC SOAJ. 

The insurer denied the Cosentyx Sensoready (300mg) 150MG/ML SC SOAJ. 
The denial is overturned. 

The patient is a male with psoriasis, treated with Stelara and Otezla. His provider is requesting Cosentyx. The health plan requires use of systemic immunosuppressive therapy. 

Yes, the requested Cosentyx is medically necessary. 

Cosentyx is an approved, appropriate and effective medication for psoriasis.  A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. Cosentyx is an IL-17 (interleukin 17) inhibitor, which has been shown to be among the most effective therapies, according to current peer-reviewed literature. 

Therefore, given the above, the requested Cosentyx is medically necessary. 

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: Overturned

Diagnosis: Right lower extremity weakness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a woman. She was admitted for right lower extremity weakness. CT (computed tomography) scan and lower extremity ultrasound were obtained. She was admitted for neurological consult, MRI (magnetic resonance imaging) brain and spinal cord, as well as frequent neurological checks.

The hospital admission was denied coverage by the health plan, as it was felt that her condition did not meet the criteria for hospital admission. The denial is being appealed.

Yes, the Inpatient admission was medically necessary.
The inpatient hospitalization was warranted. The patient had new onset neurological complaints which were intermittent. She also had a neurological examination that was not normal, with abnormal reflexes as well as difficulty walking. For a patient that previously did not have neurological deficits, the new onset symptom (intermittent) as well as abnormal neurological examination could be considered severe enough that she would not be able to do workup on the outpatient setting, because it is standard of care to do frequent neurological checks. This cannot be done as an outpatient, due to the risk of progressive neurological deterioration. Furthermore, she was also tachycardic which warrants telemetric monitoring.

Therefore given the above, the patient's hospitalization fell within MCG (Milliman care guidelines) guidelines for inpatient hospitalization.

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: Cough; shortness of breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She was hospitalized for CHF (congestive heart failure)/pneumonia. Her past medical history includes hypertension, diabetes and chronic congestive heart failure (HFrEF [heart failure with reduced ejection fraction]). She presented to the ED (emergency department) for evaluation of cough, shortness of breath times several days and dyspnea with minimal exertion.

The patient had no fever. Her blood pressure was elevated to 177/98 and subsequently stabilized. Heart rate was 75, and O2 (oxygen) saturation was 92%. On exam, she had bilateral pitting leg edema. EKG (electrocardiogram) was normal. Chest film was remarkable for left lower lobe infiltrate/ atelectasis and small bilateral effusions. ProBNP (prohormone brain natriuretic peptide) was elevated to 955. Treatment included O2 (oxygen) at 2 liters/minute by nasal cannula, IV (intravenous) furosemide, GDMT (guideline-directed medical therapy) and 2 antibiotics.
The patient was transitioned to oral furosemide and discharged to home with home health and outpatient follow-up.

No, the Inpatient admission  was not medically necessary.

Based on the peer reviewed medical literature, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) Guidelines titled: Heart Failure (ORG: M-190), inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. The care she received for uncomplicated, mildly decompensated chronic LV (left ventricle) systolic HF (heart failure) is routinely provided safely and effectively at a lower level of care. Therefore, the requested inpatient hospitalization was not medically necessary, based on the submitted information and the current published, evidence-based medical guidelines for heart failure.

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

Diagnosis: Maxillary crowding

Treatment: Braces

The insurer denied coverage for 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 maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss (mandibular anterior) in addition to other clinical findings. The orthodontist has completed the HLD (Handicapping Labio-Lingual Deviation) Index Report index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the Early and Periodic Screening Diagnosis and Treatment guidelines. 

Upon review of the submitted documentation, (study models were not provided for review), 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, New York State requires, the use of an orthodontic Index5 the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case the clinical circumstance does meet insurer and plan criteria to justify orthodontic care,

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 insertion of braces is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient has a Class II malocclusion with moderate crowding and protrusive maxillary incisors. He has a 7-millimeter (mm) overjet and 4 mm overbite. He is treatment planned for 24-30 months of orthodontics to correct the crowding and protrusion. At issue is the medical necessity of braces.

The requested treatment is medically necessary.

Teeth number (#) 8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma.
There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. (1) Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjets, which this patient has. (2)
For these reasons orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Nerve treatment on molar tooth, tooth 2.
The insurer denied nerve treatment on molar tooth, tooth 2. 
The determination is upheld.


The patient presented for the treatment of root canal therapy for molar number [#] 2 (3330) and pre fabricated post and core (2954) for tooth #2. Provided for review are previous letters of denial, correspondence from office staff, radiographic images, a single page of American Dental Association (ADA) claim forms, and authorization determinations. At issue is the medical necessity of the treatment of root canal therapy for molar #2 (3330).

No, from the documentation provided the requested therapy of root canal therapy for tooth #2 is not indicated/medically necessary.
The radiographic documentation does not show any signs of infection, there is no diagnosis of any condition by the treating provider, there are no clinical findings regarding the pulpal response to any exposure to cold or heat, no indication of any decay, nor any other rationale offered for the treatment being requested. Therefore, the treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is overturned.

This case involves a male who was seen in the emergency department after experiencing a syncopal episode earlier that day. Documentation indicated EMS (emergency medical services) reported hypotension with systolic pressures in the 70s. He was given a liter of fluids. Upon presentation, he no longer had symptoms. He has had 1 prior syncopal episode when he had COVID-19 (Coronavirus 2019). He had recently received his COVID-19 vaccine within the last month. The physical examination revealed he was tachycardic. It was recommended that he undergo laboratory and diagnostic studies. The documentation indicated he did have an elevated CK (creatinine kinase) at 239, with a troponin of 0.09, and a white blood cell count of 15.3. Additionally, his D-dimer (fibrin degradation fragment) was 0.64 and prothrombin time was 15.5. A CT (computed tomography) scan of the chest revealed atelectatic changes present without focal lobar lung consolidation. There was no evidence of pleural effusion or pneumothorax. A chest x-ray revealed no evidence of acute pulmonary disease. The documentation indicated he was admitted for further treatment. He continued with serial cardiac enzymes and was recommended to undergo a cardiac evaluation. It was recommended he also continue with medication monitoring. He underwent an echocardiogram, which was normal. Additionally, the recommendation was made for imaging of the head which revealed no acute findings.  

This inpatient hospital admission is justified.

The Troponin was 0.90, with normal being < (less than) 0.31 in this lab and D-Dimer was 0.64, with normal being < 0.50. The Troponin level being 3 times higher than normal is concerning for an acute cardiac event, which would necessitate an inpatient evaluation.

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

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

Diagnosis: Polycystic Ovarian Syndrome (PCOS). 
Treatment: Clomiphene Tab (tablets) 50 milligrams (mg). 

The insurer denied coverage for Clomiphene Tab (tablets) 50 milligrams (mg). 
The denial is overturned. 

According to the documentation submitted, this is a female with a history of secondary anovulatory infertility and polycystic ovarian syndrome (PCOS). She had a telemedicine visit with the Obstetrician/Gynecologist (OBGYN). The physician discussed treatment options including continuing Clomid or referral to a Reproductive Endocrinologist for possible intrauterine insemination (IUI). 

Clomid has been the most widely used treatment for fertility enhancement for the past years. The best candidates for Clomid are women with polycystic ovary syndrome (PCOS). Clomid is initially begun on cycle day 3, 4, or 5 at a dose of 50 mg (milligram) daily for five days. If ovulation does not occur in the first cycle of treatment, the dose is increased to 100 mg. Thereafter, the dose is increased by increments of 50 mg to a maximum daily dose of 150 mg until ovulation is achieved. The couple is advised to have intercourse every other day for one week beginning five days after the last day of medication. 

Clomid does not appear to be associated with adverse perinatal outcomes or an increased risk of congenital malformations. This patient has PCOS, she does not ovulate by herself. To conceive she needs to have her ovaries stimulated. Clomid is used routinely and is very effective for that purpose. Clomid was successful in helping this patient conceive once. Continuation of that therapy is medically necessary. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Clomiphene Tab 50 milligrams (mg) is considered medically necessary for this patient. The insurer's denial of coverage for Clomiphene Tab 50 milligrams (mg) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Inflamed Erythematous Boggy Scalp with Scarring Alopecia.
Treatment: Cosentyx 300MG DOSE-2.
The insurer denied the Cosentyx 300MG DOSE-2.
The denial is overturned.

The patient is a male with folliculitis decalvans. He has been treated with Humira, Accutane, oral and topical antibiotics, and intralesional steroids. His provider is requesting Cosentyx.  The health plan denied the request, as Cosentyx is not approved for this condition.

Yes, the Cosentyx is medically necessary.
No randomized trials have evaluated therapies for FD (folliculitis decalvans), and most information on treatment efficacy is derived from retrospective studies, case series, case reports, and other documentation of clinical experience.  Antibiotics and intralesional corticosteroid injections are considered first line.  Systemic steroids and Isotretinoin are second line options.  Case reports have shown benefit with dapsone, fusidic acid, IVIG (intravenous immunoglobulin) and anti-TNF (tumor necrosis factor) biologics.  The recent case report shows improvement with Cosentyx.  Therefore given that the patient has already tried and failed first and second line therapies as well as Humira, the request is medically necessary.

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