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

Diagnosis: heterozygous familial hypercholesterolemia
Treatment: Praluent (alirocumab)
The insurer is denied coverage for Praluent (alirocumab)
The denial is overturned. 

This female patient has a history of familial hypercholesterolemia, back pain, hypertension, myalgia and hypothyroidism.  Labs drawn showed cholesterol 243, triglycerides 239, very-low-density lipoprotein (VLDL) cholesterol 43 and low-density lipoprotein (LDL) cholesterol (calculated) 148.  The patient was noted to be intolerant to multiple statins. She was to try Repatha. Authorization for Praluent (alirocumab) is requested.

Current American Heart Association (AHA) and American College of Cardiology (ACC) guidelines clearly note that in patients with atherosclerotic cardiovascular disease (ASCVD) or high risk conditions of future ASCVD risk and statin associated muscle symptoms or recurrent muscle symptoms (despite appropriate rechallenge), randomized trial proven non statin therapy should be considered. (Reference 1) Evolocumab was demonstrated to reduce major adverse cardiovascular events by 15% in the FOURIER randomized clinical trial (2).  Alirocumab demonstrated a significant reduction is ASCVD events when administered to patients with a history of acute coronary syndrome (ACS) on maximally tolerated statin therapy. (3)  AHA/ACC guidelines recommend the use of PCSK9 inhibitors in patients with atherosclerotic coronary disease and LDL levels greater than 70mg/dl in patients intolerant to statin therapy. (Reference 1) In the ODDYSSEY ALTERNATIVE double blind randomized trial patients that were intolerant to statin therapy were randomized to treatment with alirocumab, zetia or rechallenge with atorvastatin.  Alirocumab reduced LDL-C by 45% versus Zetia's 15% reduction. Moreover, there was a statistically significant reduction in skeletal muscle adverse events when compared to atorvastatin. (4) In this case, medical records clearly indicate that this patient suffered from statin induced myalgia on multiple agents.  In addition, this patient carries a diagnosis of HeFH which places her at high risk of future ASCVD events.

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

The carrier's denial of coverage for the Praluent (alirocumab) is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Dental
Dental/Orthodontic Procedure

Diagnosis: anterior crossbite. 
treatment: Comprehensive Orthodontic Treatment of the Adolescent Dentition (Braces) and Periodic Orthodontic Treatment Visit.
The insurer denied the Comprehensive Orthodontic Treatment of the Adolescent Dentition (Braces) and Periodic Orthodontic Treatment Visit. 
The health plan's determination is overturned.

The patient in question is a female with a crossbite of anterior teeth 7 and 10. She presents with a skeletal Class III malocclusion with minor spacing in the maxilla and moderate spacing in the mandible. She is treatment planned for of 24-30 months of orthodontics to address the crowding and crossbite.

Comprehensive Orthodontic Treatment of the Adolescent Dentition (Braces) and Periodic Orthodontic Treatment Visit is medically necessary for this patient.
This patient presents with an anterior crossbite on teeth 7 and 10, as well as severe spacing. 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. It appears the lower anterior teeth are migrating labially in the arch.
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neurodegenerative dementia and physical deconditioning.
Treatment: Personal Care Services (PCS) Level 2, 24 hours per day, 7 days per week (live-in). 
The insurer denied coverage for Personal Care Services (PCS) Level 2, 24 hours per day, 7 days per week (live-in). 
The denial is upheld. 

This is a female patient with a past medical history of mixed vascular disease, neurodegenerative dementia with behavioral disturbance, cerebral microvascular disease, mood disorder, physical deconditioning, hypertension, malignant neoplasm of the breast, hearing loss, malignant neoplasm of the adrenal gland, aortic valve regurgitation, abnormal gait, carotid bruit, hyperlipidemia and atrial fibrillation. An increase to personal care services (PCS) Level 2, 24 hours per day, 7 days per week (live-in) is being requested. 

Based on the patient's medical history and functional status prior to a recent hospitalization and rehab facility admission, the patient needs assistance with all daily activities; and with very limited informal help, she is dependent on personal care services for assistance with all daily activities. She needs assistance with all instrumental activities of daily living (IADLs). This includes preparation and service of all 3 meals per day to ensure the patient is not skipping meals due to inability to prepare/serve a meal, or forgetting to eat. She needs activities of daily living (ADLs) assistance for bathing daily; and personal hygiene and dressing morning and evening. She needs assistance for toileting and incontinence care which occurs at various unscheduled times of the day and night. The patient's mobility is impaired, and she needs help with transfers and walking around her home to help decrease occurrence of falls. She needs verbal cueing/prompting in addition to physical assistance to ensure safe performance of mobility and other ADLs. 

As per New York State (NYS) regulations for personal care services, 24 hour care can be provided as live-in services or continuous (split shift) services. In order to qualify for 24 hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8 hour sleep period each day. If the patient's care needs are of such frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services are indicated, i.e. split shift.

Based on available information, there are serious concerns as to whether 24 hour live-in services can meet all of the patient's care needs. There is insufficient information of the patient's current medical and functional status and discharge plan from the rehab facility to determine whether personal care services can meet the patient's care needs at home, and the amount of services needed. 

The medical necessity for personal care services cannot be determined at this time. 
The insurer's denial of coverage for the requested Personal Care Services (PCS) Level 2, 24 hours per day, 7 days per week (live-in) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Otezla
The insurer denied the Otezla.
The determination is upheld.

The patient has a recently-diagnosed psoriasis of the dorsal hands, as well as palmoplantar psoriasis that includes the fingers. The condition is associated with fissures. The patient has previously tried and failed topical Eucrisa, Elidel, Tacrolimus, Desoximetasone, as well as intramuscular Kenalog. As per the clinic notes, the patient does not consume alcohol. The patient was previously diagnosed as having dyshidrotic eczema. The clinical records include photos, and both the clinic notes and photos suggest dyshidrosis more than psoriasis of the hands or palms.

At issue is the medical necessity of Otezla.

The Otezla is not medically necessary. The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as methotrexate. The patient has no documented treatment failure with, or true medical contraindication to, either Methotrexate, Cosentyx, Enbrel, Cimzia, Stelara, Tremfya. Therefore, the requested Otezla is not medically necessary.

Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly or more efficacious compared to the requested Otezla, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Otezla is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraines

Treatment: Ubrelvy (ubrogepant)  

The insurer has denied coverage for Ubrelvy (ubrogepant).

The denial is overturned. 

This female patient has a history of epilepsy, migraines and a closed head injury. The patient was diagnosed with epilepsy as a child. She initially presented with staring spells. The patient had generalized seizures. The patient has experienced bilateral severe throbbing headaches following a closed head injury. There are no preceding visual symptoms or photopsias. The patient has associated nausea, photophobia and sometimes dizziness. The patient's symptoms are also triggered by weather changes. It was noted that she has migraines 1 to 2 times per month. A magnetic resonance imaging of the brain showed small focus of increased signal at the left frontal subcortical white matter. The treatment plan for migraines without aura are Ubrelvy 50 milligram tablets with 1 tablet as needed for the onset of headaches and Ajovy 225 milligrams per 1.5 milliliter subcutaneous auto-injector every month. The physician indicated that the patient should continue her current migraine medication to include Ajovy as well as Ubrelvy (ubrogepant).

Based on the review of the medical record, this patient has a history of significant migraine headaches as well as epilepsy with prior history of a closed head injury. Of significance, the patient is currently taking Ubrelvy and Ajovy from the standpoint of migraine ablation and prophylaxis with clinical benefit and without side effects. Both agents have demonstrated in clinical trials benefit in terms of migraine ablation and prophylaxis. While the formulary drugs are not likely to cause an adverse reaction or to be ineffective, Ubrelvy and Ajovy have been shown to be more effective in cases with medically refractory migraine headaches. Thus, the decision should be reversed and the request for formulary exception should be approved in this case.

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

The carrier's denial of coverage for the Ubrelvy (ubrogepant) is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient is a male with a past medical history of hypertension, chronic knee pain, chronic low backache, intermittent smoking, depression, and anxiety.  The patient arrived at the emergency department with subjective complaints of pain in the chest.  He underwent an unwitnessed ground-level fall while he was ambulating with unknown loss of consciousness/syncope.  The patient had mild amnesia regarding the events.  He reported he was ambulating and felt exacerbation of his chronic low back pain as well as left knee pain which caused him to miss a step and fall.  He was unsure whether he had a syncopal event, but he believes so as he woke up and found himself on the ground for an unknown amount of time that the patient believed was several minutes.  He had subjective complaints of mild right shoulder pain, bilateral knee pain, paraspinal low back pain, and chest wall pain with intermittent mild shortness of breath.  He denied cardiac work-up or known cardiac disease.  He denied a history of diabetes but reported he had been told he was prediabetic.  He had a family history of cardiac disease in his mother.  The urine drug screen in the emergency department was positive for cocaine, benzodiazepines, and cannabinoids.  He was admitted to telemetry to rule out acute coronary syndrome.  A nuclear stress test revealed a left ventricular ejection fraction of 53% with normal wall motion.  The patient underwent serial troponin testing, which was negative.  The patient was subsequently discharged.

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

The inpatient admission was considered medically necessary for this patient.

An unexplained syncope is worthy of admission.  Per the records, he complained of "pain in the chest," which raises the possibility of a cardiac dysrhythmia.  The syncope could have also been due to a new onset seizure.  Although his urine drug screen was positive for cocaine, benzodiazepines, and cannabinoids (CBD), it cannot be used as the sole reason for his syncope.  Cocaine can induce a cardiac dysrhythmia as well as a seizure.  The reason for the syncope needed to be evaluated as there were many possible reasons.  The admission was medically necessary.

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

Diagnosis: Chronic renal failure. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This female patient had a history of chronic kidney disease stage IV requiring temporary hemodialysis twice, previous elevated troponin level, lung cancer treated with right upper lobe resection, asthma/chronic obstructive pulmonary disease (COPD), hypertension, iron deficiency anemia, and heart failure with preserved ejection fraction (50% in 9/20).  She presented to the emergency department (ED) with a several month history of progressive and episodic generalized cramping body, upper abdominal, and joint pain, relieved with morphine sulfate or oxycodone.  Initial vital signs included blood pressure (BP) 135/70, heart rate 119, temperature 98.7 F, and oxygen saturation 100%.  Examination was remarkable for epigastric pain, pitting lower extremity edema, and guaiac positive stool.  Laboratory test results included white blood cell (WBC) count 8.6, hemoglobin 9.2, blood urea nitrogen (BUN) 53, creatinine 4.3, sodium 138, potassium 4.6, chloride 100, bicarbonate 17, and troponin 0.206.  She was treated with intravenous (IV) saline, morphine, and dexamethasone, with subsequent laboratory test results: BUN 52, creatinine 3.6, and troponin 0.101.  Troponin level was 0.068.  Electrocardiogram (EKG) is interpreted as sinus rhythm with non-specific T wave abnormalities.  Chest x-ray revealed borderline cardiomegaly, evidence for prior right upper lobectomy, and minimal bibasilar atelectasis.  Nuclear stress testing revealed no ischemic perfusion defects nor areas of infarction.  She was treated with Bicitra for renal tubular acidosis, remained hemodynamically stable, and had no chest discomfort or symptoms suspicious for angina.  Discharge medications included albuterol, epoetin alfa, vitamin D, megestrol, nifedipine, tiotropium, amitriptyline, atorvastatin, calcitriol, hydromorphone, and oxycodone. 

There is no evidence that this patient required an acute inpatient level of care to evaluate her symptoms, treat her acute on chronic renal failure, or determine that her mildly elevated troponin level was not related to acute coronary syndrome.  This should have been completed in the ED or at an observation level of care. 

The health care plan acted reasonably, with sound medical judgement, and in the best interest of the patient. 

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

Diagnosis: Overjet, open bite, and anterior mandibular crowding
Treatment: Orthodontic Care - D8080 braces
The insurer denied coverage for D8080 braces
The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, 3-d representation of study models as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including overjet, open bite, and anterior mandibular crowding and has recommended orthodontics.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 27 total points to support orthodontic care. 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 having attained a score of 16 points on the HLD index.  The patient's mother is appealing the decision.

Upon review of the submitted documentation, 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, an HLD index is utilized.  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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 27 points to justify orthodontic care.  This reviewer concurs with the HLD index completed by the insurer attaining a total of 16 points (i.e., 3 overjet, 1 overbite, 4 anterior open bite, 5 anterior crowding, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

The coverage for D8080 braces is not considered medically necessary for this patient.

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

The insurer's denial of coverage for D8080 braces should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male.  The patient has a past medical history significant for ischemic cardiomyopathy status post heart transplant, with prior complications including transplant rejection, pericardial tamponade, extracorporeal membrane oxygenation (ECMO), bradycardia requiring pacemaker implantation, hypertension (HTN), and chronic kidney disease.  The patient presented to the emergency room with hypertension and abdominal pain at the site of his pacemaker. The patient had an argument with his wife and subsequently presented to emergency room with blood pressure (BP) level over 200 millimeters of mercury (mmHg) systolic. The patient was found to have mild elevation in troponin and was monitored in observation with a plan for repeat troponin level and management of blood pressure elevation. 

Repeat troponin level was trending up and a decision was made to admit him for medical optimization. The patient's blood pressure responded to treatment and he was seen by social work in consultation. He was discharged home with a plan for outpatient follow-up.

Yes, the proposed treatment, inpatient admission, was medically necessary.

The patient with multiple risk factors and extensive cardiac history, including heart transplant with multiple prior complications,, presented with severe blood pressure elevation, consistent with hypertensive urgency and troponin release, consistent with myocardial injury. Given the presentation, uncontrolled hypertension, as well as evidence of myocardial injury, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission. The denial is overturned. 

This is the case of a male who presented to the emergency department (ED) by Emergency Medical Services (EMS) transport with a chief complaint of wheezing. The patient was in his usual state of health until shortly before presentation when he began to complain of trouble breathing and mother heard intermittent audible wheezing. 

ED vitals were temperature (T) 98.8 Fahrenheit (F), heart rate (HR) 134, respiratory rate (RR) 24, blood pressure (BP) 130/82, oxygen (O2) saturation of 98%. Physical exam notes an obese male in no acute distress. Head, eyes, ears, nose, throat (HEENT) exam is unremarkable except for a small incidental foreign body in the left ear canal. Respiratory effort was normal without distress or retractions; there was a productive cough and scattered wheezes on the right. COVID, respiratory syncytial virus (RSV), and influenza testing was negative. Complete blood count (CBC) and electrolytes were within normal limits. Chest x-ray showed minimal blunting of the right costophrenic angle suggesting a small pleural effusion. The patient was given ceftriaxone and the patient was admitted to the hospital. 

Respiratory panel came back positive for Rhinovirus and Enterovirus. He was treated with albuterol nebulizers every two hours, dexamethasone, ceftriaxone, and clindamycin. Repeat decubitus x-rays of the lungs showed fibrosis of the right lower lobe. The patient did well overnight and was able to be discharged home the following day. 

At issue is whether the inpatient hospital admission hospitalization is considered medically necessary. 

The health plan's determination is overturned. 

Yes, the requested hospitalization is considered medically necessary for this patient. This patient had a significant history of extended pediatric intensive care unit (PICU) stay due to sepsis and pleural effusion with chest tube. He presented to the ED with difficulty breathing and chest x-ray suggestive of small right pleural effusion. The patient was started on albuterol prior to arrival in the ED; initial vital signs showed tachycardia and hypertension. 

Given this patient's past medical history and presenting symptoms, combined with the medical information gathered in the ED, there was significant concern for re-accumulation of pulmonary effusion so that inpatient hospitalization with close monitoring and treatment was medically appropriate.