Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Surgical Services 
The insurer denied: nerve decompression 

The denial is upheld. 

The patient is a female with history of ruptured arteriovenous malformations (AVM) and tobacco use who presents with headaches and neck pain. On physical examination, patient is neurologically intact. The patient has undergone a trial of oral medications and occipital nerve blocks for occipital neuralgia. She underwent decompression of the right occipital nerve and implantation with muscle in 2018. The patient continues to have pain occipital pain which according to a letter from her surgeon is interfering with her quality of life and activities of daily living (ADLs). 

The subject under review is the further decompression of the occipital nerve, and whether this is likely to be more beneficial for the patient than any other standard treatment. 

The proposed further exploration and nerve decompression is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Occipital nerve decompression for the treatment of occipital neuralgia has not been shown to be more beneficial than any other standard treatment or treatments. Although the literature including case studies and reports show some improvement with occipital nerve decompression surgery, there is no class I or II evidence supporting the procedure. 

The standard of care for treatment of occipital neuralgia includes trial of oral medications and occipital nerve blocks. Also, cervical dorsal root rhizotomy and occipital nerve stimulator placement have been attempted but their success has been limited since there has not been randomized prospective large sample studies. Occipital nerve decompression also would be considered not standard of care for treatment of occipital neuralgia as there has not been randomized prospective large studies confirming its benefit and efficacy.
Appeal type: Medical necessity
Decision: Overturned

Other
Speech therapy

This patient is a male. He was born prematurely at 31 weeks gestation and has developmental delays and feeding difficulties. He is only able to consume a liquid diet. He is overweight for his age due to the high calorie drinks he is dependent on. Under review is the outpatient feeding therapy to allow age appropriate diet for this patient.

The health plan's determination is overturned. The requested special feeding program is medically necessary for this patient and is consistent with the generally accepted standards of care. There is sufficient peer reviewed evidence supporting the use of such multidisciplinary feeding programs. The patient has a major feeding problem and cannot consume regular foods orally. Feeding therapy for this child is meant to improve his food aversion, not for growth failure management. Gosa, Memorie M., et al. published a review that support the efficacy and benefit of joint nutrition and behavior intervention programs and systematic desensitization and conditioning behavioral therapy approaches to improve functional feeding and swallowing outcomes in children.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe axial spondyloarthritis 
Treatment: Cosentyx
The Cosentyx at a dose of 300 mg every 14 days is medically necessary.

The patient is a female with severe axial spondyloarthritis/psoriatic arthritis.  She has failed treatment with numerous biologics and DMARDs (disease-modifying antirheumatic drugs), although her specific treatment failures are not provided.  Per attached attending physician (AP) appeal note, she did well with a Cosentyx loading dose of 300 mg weekly for five weeks, but is flaring with Cosentyx maintenance dosing of 300 mg monthly.  Per attached progress note, she was treated with Cosentyx 300 mg every 14 days, along with methotrexate 10 mg twice weekly and Plaquenil 200 mg twice daily, and still experienced disease flares requiring intermittent prednisone dosing.  At a prior office visit, she was offered Xeljanz in combination with Cosentyx.  The appeal is for continuation of Cosentyx at a quantity increase dose of 300 mg every 14 days.

Cosentyx is FDA-approved for the treatment of psoriatic arthritis at a maximum maintenance dose of 300 mg every 4 weeks.  This patient with severe axial spondyloarthritis/psoriatic arthritis has been treated with off-label increased Cosentyx dosing of 300 mg every 14 days along with methotrexate and Plaquenil, and is still having breakthrough disease flares requiring courses of prednisone.  Although this increased Cosentyx dosing regimen is off-label, there are published cases series (referenced below) providing evidence that dose escalation with Cosentyx for the treatment of psoriasis results in clinical benefit, and is well-tolerated among patients who failed to respond adequately to the approved regimen.  This patient has been tolerating an increased Cosentyx dosing regimen in combination with methotrexate and Plaquenil, and did not respond to the approved Cosentyx maintenance regimen.  

As discussed above, there is support for off-label increased Cosentyx dosing, as requested for this specific patient, in the biomedical literature.  Therefore, continuation of Cosentyx 300 mg q14 days is clinically appropriate and required for the direct care and treatment of this specific patient.  This patient's severe axial spondyloarthritis/psoriatic arthritis would be adversely affected if the services were not provided, and based upon published case series, this is in accordance with generally-accepted standards of medical practice for a patient who has failed multiple biologics and DMARDs, and is not responding adequately to the FDA-approved regimen.  Therefore, continuation of Cosentyx at a quantity increase dose of 300 mg every 14 days is medically necessary for this patient.

Continuation of Cosentyx at a quantity increase dose of 300 mg every 14 days is medically necessary for this specific patient.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with  past medical history of Alzheimer's dementia, gait instability, urge incontinence, diabetes mellitus  2, permanent pacemaker, hyperlipidemia and degenerative joint disease.  She had been approved for 3 days of medical day care with 70 hours of personal care aide services.  The patient had an assessment tool done, and there was worsening status with managing medication, transportation, personal hygiene, dressing upper extremity/lower extremity (UE/LE), walking, locomotion, toilet transferring and stairs.  The health plan noted medical daycare allowance of 3 days per week was approved mistakenly, and they would be approving 1 day of medical daycare per week.  The patient has 24 hour care as documented by the weekly schedule included for review, which includes 3 days of medical daycare and coverage by the patient's son and personal care aides.  The adult day care provides medical services for the patient due to her diabetes mellitus type 2 and vital sign monitoring with history of permanent pacemaker.  In addition, she has therapy services at an adult day program due to gait instability and falls.  The patient's provider wrote a letter noting a medical day program 3 days per week is medically necessary for the patient.  At issue is the medical necessity of medical day care 3 days per week.
The health plan's determination is overturned.
The patient has been attending medical day care services.  The patient's medical provider noted adult day care 3 days per week is medically necessary.  The health plan had approved 3 days of adult day care.  The health plan had planned to approve one day of adult day care, as they noted they had mistakenly approved 3 days per week.  The patient requires 24 hour care and had worsening status in most activities of daily living (ADLs) in her last assessment tool.  The patient has diabetes mellitus type 2 and does have her blood sugar checked while at medical day care and receives needed therapy while at the medical day care.  Therefore, three visits per week of medical day care are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with moderate persistent asthma who presented to the emergency department with chest tightness.
He was well until a few days prior to presentation when he developed a runny nose, cough, wheezing, and nasal congestion. He was using nebulized albuterol every 3 hours at home but did not experience any significant improvement. His peak flow reading was 77% of expected. He had 2 prior emergency department visits for similar episodes in the past 12 months. He was also previously hospitalized for asthma in 2013. He developed worsening chest tightness on the day of presentation, and therefore was brought to the emergency department for further evaluation.
In the emergency department, he was described as appearing distressed. His physical examination was significant for respiratory distress with decreased breath sounds and wheezing. He was given 3 albuterol/Atrovent nebulized treatments as well as prednisolone, however, his wheezing persisted. He was therefore admitted for status asthmaticus.
Upon admission he was initially treated with albuterol every 2 hours, prednisolone, and Singulair. Over time, he improved, and was able to space to every 3 hour and then every 4 hour albuterol treatments. 
He was prescribed 5 days of treatment with prednisolone and albuterol every 4 hours the next 48 hours. He also received a flu vaccine.
The health plan's determination is overturned. This is a young patient who presented with status asthmaticus. He was experiencing worsening chest tightness at home despite using appropriate outpatient therapy. He presented in respiratory distress to the emergency department with decreased breath sounds and wheezing. His peak flow reading was 77% of expected. In the emergency department, he received intensive treatment with bronchodilators and corticosteroids, however, he continued to have wheezing. He required inpatient admission for continued frequent bronchodilator treatments (initially every 2 hours) along with close monitoring with additional therapy, if needed.
The decision-making at the time of admission for this patient was consistent with his young age, the presence of status asthmaticus that persisted despite appropriate and intensive treatments, and the need for ongoing frequent nebulized treatments with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital

The patient is a female who presented to the emergency department with chest pain, substernal tightness that was relieved by rest. Her chest pain started while she was walking. The patient also was complaining of dyspnea, but she denied orthopnea and paroxysmal nocturnal dyspnea (PND). The patient has history of diastolic heart failure, diabetes, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), osteopenia and morbid obesity. She was admitted to the hospital.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with chest pain. Her chest pain was atypical. The patient was hemodynamically stable, she was not in acute distress. Her troponin was negative, and her ECG was unremarkable. The patient had evidence of a congestive heart failure (CHF) exacerbation, but it was mild. She responded well to diuresis and her symptoms improved. Based on the above, the inpatient admission was not medically necessary. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Flat feet. 
Treatment: Custom Orthotics. 

The insurer denied the Custom Orthotics. The determination is overturned. 

The patient was seen for bilateral flatfeet. On examination, weakness and tenderness of the posterior tibial tendon was noted. X-rays demonstrated "normal alignment. There is a slight decrease in arch height noted on both sides". The patient has been wearing custom orthotics for 2 years; however, she has outgrown them. Since she has outgrown them, her pain has returned. She has attempted to use over-the-counter (OTC) orthotics and modify her activity with no relief. A request has been made for new custom orthotics. At issue is the medical necessity for custom orthotics. 

The requested custom foot orthotics (L3020 x 2) are medically necessary for this patient. The patient has experienced adequate relief of symptoms from custom orthotics over a period of two years. She only experienced a return of her symptoms when she outgrew her current orthotics. Thus, the effectiveness of this treatment modality has already proven to be successful in this patient. Therefore, there is no rationale for attempting other treatment modalities when this one has already given the patient relief.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory system /asthma 
Treatment: Inpatient hospital stay 

The insurer denied the entire inpatient hospital stay. The denial is upheld in whole. 

The patient with mild, intermittent asthma, (infrequent albuterol use, no prior intubation or recent hospitalization), Hashimoto's thyroiditis who presented with 3 days of dyspnea, chest tightness, and dry cough. She'd recently had a flu-like illness that last for 3 weeks with a negative outpatient evaluation (normal white blood cell count (WBC) without bands);The patient begun to feel better in the week prior to presentation, then developed the above symptoms 3 days before presenting. Then 1-2 days before presenting, also developed (N) nausea /(V) vomiting (D) and diarrhea. 

No, the inpatient admission was not medically necessary For the asthma flare, the patient did not have severe symptoms and had no evidence of organ dysfunction, with no encephalopathy, hemodynamic instability, respiratory distress or significant gas exchange abnormality, acute kidney injury, major electrolyte abnormality, or other acute issue. The patient was saturating well on only 2 Liters of oxygen and was weaned to RA on the day of admission and had no hypercarbia on the blood gas. The patient  improved quickly and only required Prednisone and nebulizer treatments. The lack of recent admissions, failed outpatient treatment, and prior intubations all suggest the risk of a bad outcome was low. The patient  improved within a lower level of care time frame. 

The elevated Tn was not accompanied by chest pain or ECG changes. A cardiology consult on day 1 was not concerned about acute coronary syndrome (ACS). The  History, EKG, Age, Risk factors, and troponin. (HEART) score suggest a low risk of major events. Serial cardiac enzymes trended down on day 1, and a coronary CTA found no concerning evidence of ischemia. No other concerning diagnoses were found or entertained (pulmonary embolism (PE), dissection, pericarditis, etc). Given low risk of and concern for ischemia and quick down-trending of enzymes, an inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal. 
Inpatient Hospital. 

Diagnosis: Abdominal Pain. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a child who presented to the emergency department (ED) with a 2 day history of abdominal pain. The location of pain was right lower quadrant (RLQ), and additional symptoms included anorexia. There was no fever, cough, sore throat, or vomiting. The patient was seen by the primary care physician (or provider) (PCP) who gave Zofran and sent her to the ED for further evaluation. 

The inpatient hospitalization was not medically necessary. This patient was brought to the ED for evaluation of abdominal pain. There was initial concern for appendicitis, but the ED work-up was non diagnostic. The patient's condition improved while in the ED and vital signs remained stable. He was admitted to the inpatient unit for overnight observation and re-evaluation. He was discharged home the following day. His care was appropriate for a lower level. The inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Endocrine/Metabolic/Nutritional 
Pharmacy/Prescription drugs 

Diagnosis: Idiopathic short stature 
Treatment: Nutropin 

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

The patient is a male who is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). He was born after term gestation and his birth weight was 7 lbs 6 oz while birth length is not available. His mother's height is 60 inches and father's height is 67 inches (mid parental height of 66+/-2''). 

Nutropin is not medically necessary for this patient. His growth velocity was 6.0 cm per year (83%tile for age) in 3 months. Although growth velocity in such a short time frame may not reflect actual annual growth, previous growth points are not provided to allow for calculation of growth velocity over a longer time period. In those 3 months, his weight dropped to -3.3 SD while height slightly improved to -2.9 SD which is also consistent with nutritional growth retardation (NGR). His short stature cannot be considered idiopathic. This patient is quite short for his age, but he is not from tall parents and his mid parental height is only 66+/-2 inches. Although he is even short for his genetics, apparently he is growing normally and his bone age is delayed. Focus of attention at this point should be to improve his weight gain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cognitive impairment.
Treatment:  Increase in personal care assistance to 24 hours per day, seven days per week, split between CDPAS/PCA.

The insurer denied the Increase in personal care assistance to 24 hours per day, seven days per week, split between CDPAS/PCA.  The denial is overturned. 

Yes, the Increase in personal care assistance to 24 hours per day, seven days per week, split between CDPAS/PCA is deemed medically necessary. 

The patient is a female with a history of cognitive impairment secondary Alzheimer's disease, dysarthria, Type 2 Diabetes Mellitus and dizziness.  Due to impairments related to her multiple conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  An appeal review requested for potential approval of an increase in personal care assistance to 24 hours per day, seven days per week, split between CDPAS/PCA.

Recent documentation from the patient's physician indicates that the patient has been demonstrating progressive functional and cognitive decline and is unable to perform any of her ADLs, including toileting, transfers, mobility, bathing and dressing. For these reasons, 24 hours/day split shift care is necessary, as the patient does require overnight toileting and bed mobility assistance, which cannot be offered with the currently approved plan.  For these reasons, the proposed treatment of an increase in personal care assistance to 24 hours per day, seven days per week, split between CDPAS/PCA is deemed medically necessary to aid in increased ability to complete ADLs and for safety/fall prevention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental.
Treatment: Orthodontics/Dental.
Denial reason: Medical necessity of the orthodontics.
The health plan's determination of medical necessity is overturned in whole. 

The braces are medically necessary for this patient. 
The patient in question has an anterior of teeth 10 and 11 andpresents with a skeletal Class I malocclusion with minor spacing in the maxilla and minor crowding in the mandible. Patient is treatment planned for orthodontics to address the crowding and crossbite.
This patient presents with an anterior crossbite on teeth 10 and 11, as well as severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. If this patient is left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Dental Disorder.
Treatment Braces.
The health plan denied Braces.
The determination is upheld.


The patient has a Class I occlusion with slightly deep overbite and appropriate overjet. He has minor maxillary and mandibular crowding. He is treatment planned for 18-24 months of orthodontics to correct his malocclusion. At issue is the medical necessity of braces. The braces are not medically necessary. There is no medical reason to correct his malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) However, this patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion.(2) If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, the requested treatment is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Taltz. 
The denial was upheld in whole. 

The patient is a male with psoriatic arthritis. The issue in this case is that Taltz is being denied by the health plan as the patient has not tried/failed all formulary drugs both brand and generic (Humira, Stelara, Xeljanz, Cosentyx, Otezla, Orencia) prior to a trial of Taltz. The patient has tried Enbrel only, but it was ineffective; (per chart review, he had active psoriasis and some joint pain and inflammation while on Enbrel).

The formulary drugs (Humira, Stelara, Xeljanz, Cosentyx, Otezla, Orencia) will not be ineffective and would be as effective as the non-formulary drug Taltz and would not have additional adverse effects. All of these drugs are appropriate and indicated for psoriatic arthritis (PsA). For example, in 2015 in New England Journal of Medicine, an article entitled "Secukinumab Inhibition of Interleukin-17A in Patients with Psoriatic Arthritis," concluded that "secukinumab was more effective than placebo in patients with psoriatic arthritis, which validates interleukin-17A as a therapeutic target." Moreover, another study published in Annals of Rheumatic Disease concluded that "adalimumab was effective in patients with PsA."