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

Diagnosis: Chronic Low Back Pain
Treatment: Pain Management Services/Spinal Cord Stimulator, 18 Units (spinal cord stimulator trial)
The insurer denied coverage for Pain Management Services/Spinal Cord Stimulator, 18 Units (spinal cord stimulator trial)
The denial is upheld

This patient has chronic low back pain and no prior spine surgery. The patient takes Diclofenac and Lyrica for pain and has had 4 Epidural Steroid injections. Magnetic resonance imaging (MRI) shows disc herniation at Right L (lumbar) 5 impinging on the nerve root and neuroforminal stenosis at L4-L5.  The patient has not had a surgical consultation.  The request is for a Spinal Cord Stimulator (SCS) trial.	

Mekhail et al (1) conducted a systematic review for various indications.  Patients with back pain without prior surgery have weak support data in comparison to Failed Back Surgery syndrome.

Eckerman et al (2) conducted: "A systematic literature search which was performed to identify studies reporting outcomes for SCS in chronic back pain patients (with or without secondary radicular leg pain) without prior surgery using date limits from database inception ." Study results were analyzed and described qualitatively.

A total of ten primary studies (16 publications) were included. The included studies consistently demonstrated favorable outcomes in terms of pain reduction and functional improvement following SCS therapy. Improvements also occurred in quality-of-life scores; however, not all studies reported statistically significant findings. Additionally, the studies reported that SCS resulted in high patient satisfaction, reductions in opioid use, and an acceptable safety profile, although these data were more limited.

Findings from this systematic review suggest SCS has an acceptable safety profile in patients with chronic back pain without prior surgery and is associated with improvements in pain, function, and opioid consumption. This review supports the notion of SCS as a first-line surgical therapy in patients whose chronic back pain has been difficult to manage by conservative treatment, particularly in the subgroup of patients whose source of pain cannot be clearly identified or is multifactorial. Overall, the current evidence suggests that SCS is a promising, suitable, and minimally invasive therapy for managing chronic back pain patients who have not previously undergone spinal surgery. However, long term effectiveness and complication rates are not well established, and it is not certain that the requested procedure has the same or lower risks than standard therapies.

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 Pain Management Services/Spinal Cord Stimulator, 18 Units (spinal cord stimulator trial) services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted tooth
Treatment: Braces (Comprehensive Orthodontic Treatment)
The insurer denied: Braces (Comprehensive Orthodontic Treatment)
The denial is: Overturned

The patient is a female with impacted tooth #20. She presents with a skeletal Class II malocclusion and significant crowding. She is treatment planned for 36 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to address the crowding and to create space to bring the impacted tooth into the arch, but treatment was denied due to lack of medical necessity.

The health plan's determination is overturned. 

The requested treatment with braces (comprehensive orthodontic treatment) is medically necessary. It is in the best interest of patient to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered.1Approximately 10% of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology.2 The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth.2 If left untreated the damage that can occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Systemic Lupus Erythematosus (SLE). 
Treatment: Benlysta 200MG/ML (milligrams per milliliter) injection. 
The insurer denied: Benlysta 200MG/ML (milligrams per milliliter) injection. 
The denial is overturned. 

This patient is an adult female with history of systemic lupus erythematosus (SLE). She has had a malar rash, photosensitivity, inflammatory arthritis, pleurisy, oral and
nasal ulcers. She has a positive antinuclear antibody (ANA), double stranded deoxyribonucleic acid (DNA) and elevated erythrocyte sedimentation rate (ESR). She has previously tried and failed conventional disease modifying anti-rheumatic
drugs (DMARDs) hydroxychloroquine, methotrexate and leflunomide. The request for Benlysta was initially denied due to documentation not showing that the patient had active lupus from a SELENA-SLEDAI score greater than six and blood tests
showing certain results such as an antinuclear antibody (ANA) greater than or equal to 1:80 or anti-double stranded deoxyribonucleic acid (dsDNA) antibody greater than or equal to 30 international units per milliliter. The reason the provider is 
appealing the determination is because the patient has active lupus and needs advancement in therapy. 

The proposed treatment is medically necessary. 

The patient has a diagnosis of systemic lupus. The patient has a SELENA-SLEDAI score of ten based on clinical history and last physical exam showing active lupus. The patient has a reported positive antinuclear antibody (ANA) test but there was no submitted documentation showing that antinuclear antibody (ANA) was greater than 1:80. Clinical research studies do not indicate that the antinuclear antibody (ANA) has to be positive to a certain number to be considered when evaluating whether someone has potential lupus. The patient has a positive double stranded deoxyribonucleic acid (DsDNA) but it is not greater than the recommended 30 international units per milliliter per plan policy. Benlysta is Food and Drug Administration (FDA) approved for the treatment of systemic lupus in those patients who are autoantibody positive. It does not indicate the level of positivity that the labs need to be prior to starting Benlysta. The patient has other lupus features including malar rash, inflammatory arthritis and oral ulcers. The patient has already tried and failed many standard conventional disease modifying anti-rheumatic drugs (DMARDs) and does need further advancement of therapy and therefore the proposed lupus is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pitt-Hopkin Syndrome. 
Treatment: Ultralight Wheelchair. 
The insurer denied: Ultralight Wheelchair. 
The denial is overturned in whole. 

The patient is a female with Pitt-Hopkin Syndrome, seizure disorder and global developmental disability. She is non-ambulatory with history of stroller for mobility for her toddler years, and then wheelchair for primary mobility from after toddler years to the present. Physical therapy wheelchair evaluation notes, indicate that the patient has completely outgrown her current wheelchair. The subject under review is the medical necessity for an ultralight wheelchair. 

The health plan's determination is overturned. 

The requested Ultralight wheelchair is medically necessary for this patient. She is dependent on a wheelchair for all mobility with no reasonable expectation of achieving independent mobility, as documentation notes minimal weight bearing in gait trainer during physical therapy sessions only. The patient has been in an ill-fitting wheelchair for her current home. Physical therapy documentation notes that the ordered wheelchair will fit in the patient's home and be able to be used there by the patient for all mobility and activities of daily living (ADLs). 

A seating and mobility evaluation completed documents the child has completely outgrown her current wheelchair, which was six years old at the time of the evaluation. The evaluation thoroughly documented the necessary wheelchair and modifications and the medical necessity of each for safety, skin integrity, ability to use in transport and ability to grow with her anticipated growth. Home layout and function are noted, as well as the fact that she has been wheelchair dependent and able to use the wheelchair in the home. The reason for denial was listed as lack of home evaluation. Documentation for review detailed a home assessment, and the presence of a ramp into the home. It is further documented by the physical therapist that the requested wheelchair will fit through all areas of the home, and the patient will be able to be in it for over 8 hours a day and perform all ADLs in the chair. This patient has clear medical necessity for the requested Ultralight Wheelchair as this is her only means of mobility and she has completely outgrown her current wheelchair.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary crowding
Treatment: Braces
The insurer denied: Braces
The denial is overturned.

The patient is a teenage male. The request is for orthodontic benefits. The patient has Class II canines, severe maxillary crowding, impacted maxillary second premolars and lower left permanent canine. The health plan denied coverage of the request due to handicapping index score of 23.

The requested braces are medically necessary.

The patient has an impacted lower left permanent canine (anterior tooth). This is an automatic qualifier according to the handicapping index scale. Having the canines (all 4) in their proper position is very important. Without the canines being in their proper position, there can be no "canine guidance" during the chewing cycle. This will allow for the other teeth to grind against each other in a traumatic way and over time, could cause fractures and/or loosening of teeth. The lower left canine in this patient needs to be orthodontically put in its proper position. There is medical necessity in this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Glaucoma
Treatment: Cosopt PF (preservative-free) 2%/0.5% (percent) Eye Drops
The insurer denied: Cosopt PF (preservative-free) 2%/0.5% Eye Drops
The denial is overturned.

The patient is an adult female with primary open angle glaucoma for whom coverage of Cosopt PF (preservative-free) (dorzolamide-timolol) 2%/0.5% Eye Drops is the subject of review. Coverage was previously denied by the health plan, as it was not identified that the patient had tried and had inadequate treatment response, intolerance, or contraindication to the required number (3) of formulary alternatives. Formulary alternatives include dorzolamide-timolol, latanoprost, travoprost. Upon appeal, the provider states that the patient has been under care for the past 3 years and her intraocular pressure has been best controlled while on her current regimen of Cosopt PF (preservative-free) without adverse reactions from the eye drops. The patient has an allergy to the preservative benzalkonium. Reportedly, the patient has previously tried dorzolamide/timolol, Combigan, timolol, lumigan, latanoprost, and dorzolamide/timolol PF (preservative-free).

Yes, the requested Cosopt PF (preservative-free) is medically necessary.

In this case, Cosopt PF (preservative-free) (dorzolamide-timolol) is requested for the treatment of primary open angle glaucoma. This request represents continuation of care where the patient has allergy to the preservative BAK (benzalkonium chloride) and has failed two of the three formulary alternatives (dorzolamide-timolol and latanoprost). While the patient has not reportedly tried and failed the remaining formulary alternative, travoprost, the patient has already tried and failed Lumigan (bimatoprost) and latanoprost, which are considered more effective at lowering intraocular pressures than travoprost. Therefore, as the patient is also well controlled on the current regiment and additional step therapy requirements place the patient at unnecessary risk of decompensation, the medical necessity of Cosopt PF (preservative-free) is established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Migraine
Treatment: Nurtec 
The insurer denied Nurtec. 
The denial is upheld.

The patient is a female with migraine headaches. The patient is diagnosed with chronic migraine. Nurtec is requested for prevention of migraine. The patient has previously tried and failed gabapentin, topiramate, propranolol, and sertraline. The drug was denied due to missing information about medications tried and failed. The provider appealed the determination. The subject under review is the medical necessity for Nurtec.

The health plan's determination is upheld.

No, the treatment with Nurtec is not medically necessary. The documentation clearly indicates that the patient has a diagnosis of chronic migraine. Chronic migraine is defined as greater than 15 headache days and greater than eight migraine days per month for the last three months. However, Nurtec is not Food and Drug Administration (FDA) approved or literature supported for prevention of chronic migraine. This drug is only FDA approved and literature supported for prevention of episodic migraine. As such, the patient does not have an FDA approved indication. The diagnosis of chronic migraine appears in the letter of appeal and the chart notes. The patient has tried and failed a number of drugs for prevention of migraine including propranolol, sertraline, topiramate, and gabapentin. However, the patient does not have a recognized indication for the use of this drug and there are other available injectable Calcitonin gene-related peptide (CGRP) inhibitors that are FDA approved for prevention of chronic migraine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Morbid obesity.
Treatment:  Weight loss surgery (procedure code 43659).

The insurer denied coverage for weight loss surgery (procedure code 43659).  The denial is upheld.

As per the medical records, this is a patient with a history of severe morbid obesity, and a Body mass index (BMI) of 41.79. Her doctor noted in a progress note that the patient had joined their bariatric surgery program with a BMI of 42. She has attempted a significant number of diet and exercise programs. The results were inadequate. He noted the patient presented for a 2nd visit after a workup for revisional Roux-en-Y Gastric Bypass (RYGBP) with distalization. He noted the esophagogastroduodenoscopy (EGD) demonstrated a normal sized pouch. She had a previous gastric bypass revision surgery as per the providers note. He noted the patient has done well from their bariatric surgery program. She has completed her multidisciplinary evaluation including medical clearance, lab work, psychiatric evaluation and nutritional evaluation. She was seen again and it was noted that she will be scheduled for surgery pending the outcome of that visit.

Clinical Utilization Management (UM) guidelines from Anthem for Bariatric surgery and other treatments for clinically severe obesity policy number CG-SURG-83 were included. The policy noted that surgical repair/correction or reversal following gastric bypass is considered medically necessary when there is documentation of a surgical complication related to the original surgery such as fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, stricture, documented Gastroesophageal reflux disease (GERD) or pouch enlargement due to vomiting.

Based upon the evidence provided, the reviewer has to agree with the insurer, as this patient has had, as per the records, gastric bypass and then a revision of the gastric bypass. According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 26th Edition Gastric Restrictive Procedure with gastric bypass by laparoscopy ORG: S-513 (ISC), this patient does not meet criteria for this procedure.
	
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 weight loss surgery (procedure code 43659) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immunologic Disorders/Alopecia Areata (Alopecia Universalis)
Treatment: Pharmacy/Prescription Drugs/Olumiant
The health plan denied the requested medication, Olumiant, as not medically necessary. The health plan's determination is overturned.

The patient is a female with alopecia universalis, treated with topicals, systemic steroids, and intralesional injections. The provider is requesting Olumiant. 
At issue is whether the requested health service/treatment of Olumiant is medically necessary.

The health plan's determination of medical necessity is overturned, in whole.

Yes. Olumiant is now Food and Drug Administration (FDA) approved for alopecia areata. This class of medication has transformed the treatment of this extremely treatment resistant condition.
According to the meta-analysis by Phan et al regarding janus kinase inhibitors (JAK) in general, in 30 studies and 289 cases, there were 72.4% (percent) responders, good responders 45.7% and partial responders 21.4%. Mean time to initial hair growth was 2.2  6.7 months, and time to complete hair regrowth was 6.7  2.2 months.
In the randomized controlled trial (King et al), a total of 110 patients were randomized (placebo, 28; Baricitinib 1-milligram (mg), 28; 2-mg, 27; 4-mg, 27). The Baricitinib 1-mg dose was dropped after the first interim analysis based on a lower severity of alopecia tool (SALT) response rate. At week 36, the proportion of patients achieving a SALT score of 20 was significantly greater in Baricitinib 2-mg (33.3%, P (clinical significance) = .016) and 4-mg (51.9%, P = .001) groups versus placebo (3.6%). Baricitinib was well tolerated with no new safety findings.
Therefore, Olumiant is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis

Treatment: Taltz

The insurer denied coverage for Taltz

The denial is upheld

The patient is an adult male with a past medical history significant for prostate cancer who was diagnosed with psoriasis. The patient has failed methotrexate therapy, ultraviolet (UV) light therapy, and topical therapy. The patient was given two samples of Taltz, and a request was placed for ongoing Taltz therapy. The appeal letter notes that Taltz is denied due to lack of tuberculosis (TB) test negativity being documented. The request is for Taltz for treatment of psoriasis.  

The denial letter indicates that the denial of Taltz therapy was based on the lack of documentation of a negative TB test within the last 6 months. The provided medical records indicate that TB test requirement was discussed with the patient. A quantiferon TB test appears to have been ordered along with multiple other tests; however, the results are not documented or provided within the documentation provided.  As per the Food and Drug Administration (FDA) prescribing information, "TB: Evaluate for TB prior to initiating treatment."

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the Taltz is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Taltz
The insurer denied: Taltz
The denial is: Upheld

The patient is a male with psoriasis. Body surface area affected is 30%. He has tried and failed clobetasol, diprolene ointment, Temovate, and Dovonex. The medication under review is Taltz (ixekizumab).

The health plan's determination is upheld in whole.

The requested health service/treatment of Taltz (ixekizumab) is not medically necessary for this patient. The patient has no true contraindications to the preferred alternatives: Phototherapy, and Methotrexate or Cyclosporine. According to the "national physician specialty society recommendations" for psoriasis - the American Academy of Dermatology Psoriasis Guidelines- and dermatology literature, phototherapy and methotrexate are effective treatments for the management of psoriasis. (1, 2)
Within the peer-reviewed literature, Racz et al. writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks". (3) Mehta et al. writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with greater than (>)10 % affected body surface area who have not responded to topical treatments...narrow band (NB)-UVB effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile." (4)
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Taltz is not necessary. It is noted that the patient has failed topical steroids. However, there is no documentation provided that the patient has tried and/or failed phototherapy or methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Taltz medically more appropriate than the other options.

Therefore, the administration of Taltz is not strongly supported for this patient, and Taltz is not medically necessary for this patient based on the current evidence-based medical literature.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who initially presented to the emergency department with concerns of a scrotal abscess. Pertinent history included obesity, diabetes mellitus, and congestive heart failure. Initial vital signs revealed a temperature of 98.5oF, heart rate (HR) 89, blood pressure (BP) 126/76, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 95% on room air. Initial examination documented the patient as alert and oriented with a scrotal 2 centimeter (cm) indurated abscess with surrounding cellulitis. 

Based on the clinical documentation provided, evidence based literature and standards of care, an inpatient hospital admission was not medically necessary. The patient presented with scrotal pain and was diagnosed with a scrotal abscess. Initial evaluation found the patient to be afebrile, hemodynamically stable, and with a mild leukocytosis. Laboratory testing revealed an HGB A1C 4.8%. Urology consulted and performed a bedside incision and drainage. Empiric antibiotics were initiated thereafter. Following observation care, clinical improvement was achieved, oral intake was tolerated, and pain was adequately controlled. No other issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have a failure of outpatient therapy, HgbA1C > 10%, limb-threatening infection, bacteremia, persistent altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, inability to maintain oral hydration, or severe pain requiring inpatient management. In addition, the patient did not require an associated surgical procedure (ie. abscess drainage, debridement) not amenable to outpatient, emergency department, or observation care or any other condition, treatment, or monitoring requiring inpatient admission.