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

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

The patient is female who was followed by her gynecologist for multiple symptomatic uterine fibroids. She underwent a robot-assisted laparoscopic myomectomy with hysteroscopy. Multiple fibroids were removed in a procedure of duration over 5 hours. The inpatient hospital admission is under review.

The inpatient hospital stay was not medically necessary. There was no documentation of any unexpected pain issues (all patients after surgery have some pain and require medications). Her pain medications were oral, just as she would use at home after discharge. The patient's vitals were normal the day after surgery.

The American Congress of Obstetricians and Gynecologists (ACOG) outlines criteria for discharge after outpatient procedures, and states vitals need to only be within 20% (percent) of baseline. The physician notes on postoperative day 1 suggested a routine postoperative course with plans for discharge. Again, there was no reference to an unanticipated event. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurative
Treatment: Humira Pen - CD/UC/HS Starter 80MG/0.8ML SC, pre-service
The insurer denied the Humira Pen - CD/UC/HS Starter 80MG/0.8ML SC, pre-service.
The denial is overturned.

The patient is a female with hidradenitis, treated with topicals, spironolactone, birth control, doxycycline, and minocycline.

The patient's provider is requesting Humira. The health plan denied coverage for the request due to requirement for 3 months of oral antibiotics and no paid claims for Doxycycline. This denial is being appealed.

Yes, the requested Humira is medically necessary.

The patient has tried oral antibiotics.

Hidradenitis suppurativa/acne inversa (HS/AI) is a chronic, painful, inflammatory skin disorder of the folliculopilosebaceous units characterized by the development of inflammatory nodules, pustules, sinus tracts, and scars, primarily in intertriginous areas. Current treatment recommendations are listed below.

Patients with Hurley stage I HS/AI (hidradenitis suppurativa/acne inversa) present with single or multiple nodules and abscesses without associated sinus tracts or scarring. Daily treatment of the involved areas with topical clindamycin is recommended with a topical antiseptic wash can also be used for showering, and intralesional corticosteroids or punch excisions.

Patients with Hurley stage II HS/AI (hidradenitis suppurativa/acne inversa) exhibit recurrent inflamed nodules and abscesses, some of which lead to sinus tracts and scarring. Treatment includes continuation of preventive, plus medical and surgical, therapy. For the medical treatment of the inflammatory component of Hurley stage II disease, oral tetracyclines are recommended for first-line therapy. Acitretin and antiandrogenic agents may also provide benefit. The sinus tracts of Hurley stage II HS/AI (hidradenitis suppurativa/acne inversa) will not resolve with antibiotic therapy and may require surgical deroofing (unroofing) if they are recurrently inflamed.

Hurley stage III HS/AI (hidradenitis suppurativa/acne inversa) is characterized by diffuse or nearly diffuse involvement of the affected area (intertriginous or not) with fluctuant nodules, interconnecting sinus tracts, and extensive scarring. For the nonsurgical treatment of Hurley stage III HS/AI (hidradenitis suppurativa/acne inversa) that cannot be managed with oral antibiotics, oral retinoids, or hormonal therapy, Humira/adalimumab is recommended as the next-line therapy.

Therefore, given that the patient has tried and failed a combination of tetracycline antibiotics and hormonal therapies, Humira is medically necessary.

The two phase 3 studies (PIONEER I and PIONEER II) demonstrated that HS (hidradenitis suppurativa) patients achieved a statistically significant greater clinical response than patients who received placebo (58.9% [percent] vs 27.6%).

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

Diagnosis: Localized infection to the left elbow

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

The patient with past medical history significant for hypertension and cervical radiculopathy who presented to the emergency department with complaints of left elbow pain and erythema. 

Vitals on presentation included: T. (temperature) 98.6 F (Fahrenheit), BP (blood pressure)-124/88, P (pulse)-78, RR (respiration rate)-18, O2 (oxygen) saturation-98% on RA (room air). Laboratory results included the following: WBC (white blood cell count) -7.4, HGB (hemoglobin) -14.4, HCT (hematocrit) -43.1, creatinine-0.71, glucose-99, lactate-0.78, CRP (c-reactive protein) -88.8.

The patient was admitted with a possible right elbow cellulitis. He was empirically started on intravenous antibiotics (vancomycin and Zosyn). Left elbow x-ray showed mild soft tissue swelling suggestive of bursitis. Orthopedics consulted and deemed no surgical intervention was necessary. The patient remained afebrile, and hemodynamically stable. He was discharged to continue oral antibiotics as an outpatient. 

According to documentation, patient presented with a possible left elbow cellulitis. Otherwise, he was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal WBC. X-ray of the elbow was suggestive of bursitis. Orthopedics deemed that no surgical intervention was necessary. He had a localized infection or inflammation, with no evidence for a disseminated infection. Based on above findings, patient met observation level of management.  

The prior determination of the denial of the inpatient hospital admission has been upheld.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypereosinophilic syndrome
Treatment: Nucala
The insurer denied Nucala.
The determination is upheld.


The patient has a request for Nucala. She has hypereosinophilic syndrome (HES). The absolute eosinophil count (AEC) was decreased to 2700 on prednisone 20 milligrams (mg). She has dry eyes. A bone marrow biopsy was negative. She is now off prednisone. She is stable on Nucala. She has T cell clonality suspicious for lymphocyte-variant hypereosinophilic syndrome (L-HES). She was otherwise asymptomatic. The eosinophil count was as high as 7530. She is asymptomatic and this was found incidentally. At issue is the medical necessity of Nucala.

No. It is not medically necessary. The patient possibly has L-HES and is using this as a monotherapy and has not had at least 2 HES flares. She is asymptomatic and this was found  incidentally.
Roufosse et  al 2020 conducted a randomized, multicenter, double-blind, placebo-controlled, phase III trial was conducted across 39 centers in 13 countries. Eligible patients had FIP1-like-1-platelet-derived growth factor receptor-alpha (FIP1L1-PDGFRA)-negative HES, experienced 2 or more flares (worsening of HES-related symptoms or blood eosinophil count requiring therapeutic escalation) in the previous 12 months, and had a screening blood eosinophil count greater than or equal to 1000 cells/microliter (L). Patients were randomized (1:1) to subcutaneous mepolizumab (300 mg) or placebo every 4 weeks for 32 weeks, plus existing HES therapy. The primary outcome was the proportion of patients with 1 or more flares (worsening of HES-related symptoms necessitating therapy escalation or greater than or equal to (>=) 2 courses of blinded rescue oral corticosteroids) during the study; in addition, patients who withdrew early from the study were counted as having a flare. Safety end points were also assessed. The proportion of patients experiencing 1 or more flares/withdrawing from the study was 50% lower with mepolizumab versus placebo (15 of 54 [28%] versus (vs) 30 of 54 [56%]; probability [P] = .002). Logistic regression analysis was consistent with the primary analysis (odds ratio, 0.28; 95% confidence interval (CI), 0.12-0.64; P = .003). Similar proportions of patients in the mepolizumab and placebo groups experienced on-treatment adverse events (48 of 54 [89%] vs 47 of 54 [87%]).
In this case, the patient has not tried and failed first line therapies and is using this as monotherapy which is not standard of care (SOC).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior cross bite.

Treatment: Braces.

The insurer denied coverage for braces.

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radio graph, panoramic radio graph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss (teeth #10 (lateral incisor upper left) and #23 (lateral incisor)) 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 cross bite 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 required handicapping malocclusion medical necessity requirements attaining a score of 6 points on the HLD index where 26 points is required. 

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 Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program1) 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. 

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

Diagnosis: Heartburn
Treatment: Esophagogastroduodenoscopy (EGD)
The insurer denied the EGD.
The determination is upheld.

The patient had an esophagogastroduodenoscopy (EGD) for evaluation of heartburn. The medical records provided indicate the patient was on omeprazole daily, but do not elaborate on the duration of omeprazole use prior to the EGD being done. At issue is the medical necessity for an EGD to evaluate gastroesophageal reflux disease (GERD).

No, the requested health service/treatment of EGD is not medically necessary for this patient.

According to the current American College of Gastroenterology Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease, patients presenting with typical symptoms of heartburn and regurgitation should be given empiric medical therapy with a proton pump inhibitor. The diagnosis of gastroesophageal reflux disease is made using some combination of symptom presentation, objective testing with endoscopy, ambulatory reflux monitoring, and response to antisecretory therapy. Empiric proton pump inhibitor therapy (trial) is a reasonable approach to confirm gastroesophageal reflux disease when it is suspected in patients with typical symptoms. There is no indication that the patient has had an appropriate trial and failure of proton pump inhibitor therapy for 8 weeks to manage his symptoms.

Therefore, esophagogastroduodenoscopy for this patient would not be in accordance with generally accepted standards of medical practice or clinically appropriate, in terms of type, frequency, extent, site and duration for the patient's illness.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Axillary hyperhidrosis

Treatment: Botox injection

The insurer denied coverage for Botox injection

The denial is upheld 

The patient is a female with axillary hyperhidrosis. There is no documentation of the patient having failed topical or oral medications commonly used for hyperhidrosis. The requested medication is Botox injection.  

Based on the submitted documentation Botox is not medically necessary. There is no documentation provided that the patient has failed traditional therapies for hyperhidrosis which are known to improve the condition. Treatment with topical therapies such as Aluminum chloride (Drysol) as well as oral therapies such as glycopyrrolate are known to improve the symptoms of hyperhidrosis and are within the standard of care for therapy and are associated with a limited side effect profile. One such example is the conventional treatment oxybutynin, which has been shown to be effective for hyperhidrosis. Wolosker et al writes in "A randomized placebo-controlled trial of oxybutynin for the initial treatment of palmar and axillary hyperhidrosis" that "Treatment of palmar and axillary hyperhidrosis with oxybutynin is a good initial alternative for treatment given that it presents good results and improves quality of life." (5).

The conventional agents are appropriate agents for the treatment of the patient's hyperhidrosis. The conventional medications should be tried and failed prior to initiating Botox. After review of the documentation provided, there is no documentation provided that would justify the patient requiring treatment with Botox prior to the conventional alternatives such as oxybutynin. Based on the submitted documentation and the standard of care, the decision is upheld.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Formulary Exception for Botox to treat primary axillary, palmar, or gustatory hyperhidrosis is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Axillary hyperhidrosis.
Treatment: Botox injection.
The insurer denied coverage for Botox injection.
The denial is upheld 

The patient is a female with axillary hyperhidrosis. There is no documentation of the patient having failed topical or oral medications commonly used for hyperhidrosis. The requested medication is Botox injection.  

Based on the submitted documentation Botox is not necessary. There is no documentation provided that the patient has failed traditional therapies for hyperhidrosis which are known to improve the condition. Treatment with topical therapies such as Aluminum chloride (Drysol) as well as oral therapies such as glycopyrrolate are known to improve the symptoms of hyperhidrosis and are within the standard of care for therapy and are associated with a limited side effect profile. One such example is the conventional treatment oxybutynin, which has been shown to be effective for hyperhidrosis. Wolosker et al writes in "A randomized placebo-controlled trial of oxybutynin for the initial treatment of palmar and axillary hyperhidrosis" that "Treatment of palmar and axillary hyperhidrosis with oxybutynin is a good initial alternative for treatment given that it presents good results and improves quality of life." (5).

The conventional agents are appropriate agents for the treatment of the patient's hyperhidrosis. The conventional medications should be tried and failed prior to initiating Botox. After review of the documentation provided, there is no documentation provided that would justify the patient requiring treatment with Botox prior to the conventional alternatives such as oxybutynin. Based on the submitted documentation and the standard of care, the decision is upheld.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Formulary Exception for Botox to treat primary axillary, palmar, or gustatory hyperhidrosis is upheld.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female with morbid obesity, BMI (body mass index) 47. She underwent laparoscopic sleeve gastrectomy. The patient has a history of hypothyroidism. The patient completed necessary preoperative work up.

The patient's inpatient admission was denied coverage by the health plan. This denial is being appealed.

Yes, the Inpatient admission was medically necessary.
The patient underwent laparoscopic sleeve gastrectomy. As per the MCG (Milliman Care Guidelines) outlined in the appeal letter, this procedure is still warranting an inpatient level of care admission after the procedure. The patient was discharged home the next day, and was doing well. There are studies demonstrating the beneficial effect of possible outpatient stay for laparoscopic sleeve gastrectomy, however one of the studies had a sample size discrepancy, and this is not verified by randomized controlled trials.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient met criteria for inpatient level of care after laparoscopic sleeve gastrectomy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dilated cardiomyopathy

Treatment: Air ambulance services

The insurer denied coverage for air ambulance services

The denial is overturned

The patient is a male with a history of systolic congestive heart failure and dilated cardiomyopathy due to a mutation of the Nebulin Related Anchoring Protein (NRAP) gene. The patient was stabilized following Berlin Heart EXCOR left ventricular assist device (LVAD). The patient was noted to have low level hemolysis requiring monthly blood transfusions. Multidisciplinary team treatment resulted in a decision to explant the LVAD following recovery of left ventricular function. The only team with sufficient experience in explanting the Berlin Heart EXCOR device was at a particular facility. The patient was sent via air ambulance to that facility.

The health care plan did not act reasonably with sound medical judgment and in the best interest of the patient. This patient was suffered from dilated cardiomyopathy due to an NRAP gene mutation. This gene mutation has been identified as a cause of severe childhood dilated cardiomyopathy. (1) Several studies have demonstrated that the Berlin Heart EXCOR device can provide supportive therapies and allow for a bridge to orthotopic heart transplant in young children with congenital cardiomyopathy. (2,3) Following multidisciplinary evaluation, this patient was found to have sufficient myocardial recovery allowing for LVAD removal. Moreover, complications associated with LVAD devices include hemolysis and thromboembolism. He was noted to have hemolysis requiring blood transfusion. The provider from the receiving facility submitted two letters stating that the patient should be transferred for LVAD removal without delay. He noted that LVAD therapy in the setting of improving cardiac function carried a substantial risk of thromboembolic complications. Such complications are clearly reported in the medical literature. (2,3) It should be noted that the receiving facility was a major center involved in the initial trial leading to Food and Drug Administration (FDA) approval of this device in children. This was an international study involving 17 centers. There were 48 children implanted and the receiving facility was the provider in 17 of these patients. In conclusion, transport by air ambulance was medically necessary. 

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 air ambulance services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a male who presented to the emergency department with complaints of seizures. The documentation indicated he is a very limited historian due to slow speech. He does have a history of alcohol abuse, seizures, and asthma. He took trazodone and drank a lot of beer and passed out. He woke up on the floor and noted that he had urinated on himself and assumed he had a seizure. He stated his kidneys hurt and that his calves were cramping. It is also noted that he was seen 2 days prior for left facial and left upper extremity numbness and dysarthria. He underwent a CT (computed tomography) scan of the prior visit which showed no acute findings. The physical examination revealed a blood pressure 130/98. Oxygen saturation was 97%. Neurologically he appeared tired. He was moving all extremities very slowly. Strength and sensation were equal throughout. Speech was slowed. It was recommended he undergo laboratory and diagnostic studies. The documentation indicated he underwent an EKG (electrocardiogram) showing a sinus rhythm with a rate of 85 bpm (beats per minute). The recommendation was made for admission for an EEG (electroencephalogram) as well as neuro (neurological) monitoring. The laboratory studies revealed a CK (creatinine kinase) of 215. The urinalysis revealed a small amount of blood in the urine. There was a normal chest x-ray.  A CT scan of the brain revealed no acute intracranial abnormality and no significant changes compared to prior examination. The recommendation was made to continue monitoring during the admission due to alcohol withdrawal. He was admitted for further treatment. He continued with treatment that included monitoring as well as drug and alcohol counseling. 

The patient had a non-focal neuro exam, normal head CT, with a history of seizures.  Hence, he could have been monitored under an observational status, with further treatment and management being done as an outpatient.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.