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

Diagnosis: Body Aches, Nausea, Diaphoresis, Anxiety and Tremors (detoxification from alcohol and drugs).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of polysubstance abuse. He presented to the ED (emergency department) requesting detox. His last detox was three weeks prior. He also had skin ulcers on his back and right finger.

The patient's VS (vital signs) were as follow: Temperature 98.2, pulse 87, respiration rate, 18, and blood pressure 113/63. His COWS (clinical opiate withdrawal scale) score was 9, and CIWA (Clinical Institute Withdrawal Assessment) score was 12. His exam was remarkable for quarter-sized ulcer on upper thoracic, throughout back, left neck, and right second finger. The patient's labs revealed WBC (white blood count) 4.67, H/H (hemoglobin/hematocrit) 11.3/37.1. Na (sodium) and BMP (basic metabolic panel) were normal.

The patient was admitted. Plan of care included CIWA (Clinical Institute Withdrawal Assessment) and COWS (clinical opiate withdrawal scale) protocol, methadone, and PO (oral) antibiotics.

Day two, the patient's vital signs were stable. His COWS (clinical opiate withdrawal scale) score was 0, and CIWA (Clinical Institute Withdrawal Assessment) 1. He did not require PRN (as needed) Ativan. The plan was to continue Methadone.

Day three, the plan was to continue current management. Discharge to rehab was being planned.

Day four, the patient's vital signs were stable. His COWS (clinical opiate withdrawal scale) score was 0, and CIWA (Clinical Institute Withdrawal Assessment) 0. He was cleared for discharge.

No, the Inpatient admission was not medically necessary.
This patient with a history of polysubstance use was admitted for detox. The patient was hemodynamically stable and afebrile. He did not have an arrhythmia. He did not have nausea, vomiting, tremor or perspiration. There were no physical signs of withdrawal. He did not have comorbid conditions that required intervention at an acute inpatient level of care. The patient was admitted with plan COWS (clinical opiate withdrawal scale) and CIWA (Clinical Institute Withdrawal Assessment) protocol and management with methadone. He remained hemodynamically stabled during hospital stay and did not have signs of severe withdrawal. He did not have symptoms or received intervention that required an acute inpatient level of care. He had not failed management in a lesser level of care. The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ingestion of foreign substance

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is the case of a male patient with a history of Autism. He presented to the Emergency Room (ER) as a transfer from another hospital with complaints of ingesting 10 milligrams (mg) of oral (PO) Amlodipine. He was given activated charcoal at the other facility. In the ER, the patient appeared to be active and in no apparent distress. Vitals were stable and the electrocardiogram (EKG) was within normal limits (WNL). There was no need for intravenous (IV) bolus and no reports of hypotension or hemodynamic instability while patient was in the hospital. 

Of note, the weight of the patient is 23 kilograms (kg) and the dose ingested is 10 milligrams (mg); the dose per kg is 10/23 which will be less than 0.5 mg/kg. The patient's EKG was WNL. The fatal dose is usually 2.5 mg/kg (lowest reported). This patient could have been observed for 23 hours in observation status. If there was any change in clinical status, the patient could have been moved to the Intensive Care Unit (ICU). This patient could have received care under observational status.

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

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

Diagnosis: Nausea, Vomiting and Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a female who presented to the facility with the complaints of nausea, emesis and inability to tolerate oral intake.  The patient had these symptoms prior to presentation. Her potassium was 2.8 on presentation. An ultrasound of the right upper quadrant was normal. She was admitted and received supportive care and intravenous hydration with potassium. An endoscopy showed gastritis. The patient's diet was advanced to full liquids and the patient was later discharged.

No, the proposed inpatient admission was not medically necessary.
While the care as provided was medically appropriate, the level at which the care was rendered was not medically necessary. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had emesis and nausea; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: seizures/infantile spasms.

Treatment: inpatient hospital stay.

The insurer is denied coverage for the inpatient hospital stay.

The denial is overturned. 

This female patient has a history of eczema and constipation.

Milliman Care Guidelines (MCG) recommends inpatient admission for recurrent seizure (ie, during ED or observation care) if the patient is not known to have a seizure disorder. This case involves a female that presented to the ED (Emergency Department). Per the patient's mother there was a history of abnormal movements for 2 weeks. The mother was concerned for seizures. It was reported that an ED provider witnessed an episode. Neurology consultation recommended an EEG (electroencephalogram) which revealed normal findings with no seizures. The patient was discharged. Given the recurrent episodes, no known history, and patient age, inpatient admission was supported for monitoring, consultation, and EEG.

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 inpatient hospital stay is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Joint Pain

Treatment Lidocaine Patch 5% (percent)

The insurer denied coverage for Lidocaine Patch 5%

The denial is upheld

The patient has ulcerative colitis and joint pain. She has been on multiple therapies including vedolizumab. The physician has requested Lidoderm patches as he states that non-steroidal anti-inflammatory drugs (NSAIDs) are contraindicated in inflammatory bowel disease (IBD). 

The American Journal of Gastroenterology 2009 Vol 104 p1298-1313 has an article titled "Do NSAIDs, Antibiotics, Infections or Stress Trigger Flares in IBD" the conclusion of the article was that there was insufficient evidence to warrant NSAID avoidance in IBD among those who really need them for joint pains.

The Journal of Clinical Gastroenterology 2016 Feb 50(2) 152-156 has an article titled "Role of Non-Steroidal Anti-Inflammatory Drugs in Exacerbations of Inflammatory Bowel Disease". The article states that use of NSAIDs in IBD is common. For ulcerative colitis, NSAIDs do not appear to impact disease activity.

This patient has joint pain from ulcerative colitis. NSAIDs are not contraindicated in patients with ulcerative colitis. The Lidoderm patch is used for several neuropathies. However in this case the literature supports the use of NSAIDs for IBD related joint pains. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for Lidocaine Patch 5% for joint pain is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intractable Migraines

Treatment Ajovy autoinjector 225 milligrams (mg)/1.5 auto injector

The insurer denied coverage for Ajovy autoinjector 225 milligrams (mg)/1.5 auto injector

The denial is overturned

The patient is an adult female with history of intractable migraines who has tried and failed treatments with ibuprofen and Ubrelvy. Her prescribing provider has started treatment with Ajovy. Since starting treatment, the patient has not had a headache for an entire month, whereas she normally has over 16 migraine headaches per month. She has had no adverse events to Ajovy. The prescribing provider is recommending continued treatment with Ajovy.

The current medical literature shows evidence of efficacy for preventive migraine treatment in patients with chronic migraine headaches utilizing the calcitonin gene-related peptide (CGRP) receptor blockers. Ajovy is a CGRP receptor blocker. 

Therefore, although the member has not tried and failed her insurance formulary alternatives, given the substantial beneficial response she has received from starting Ajovy, it would be medically unethical to stop this treatment in order to meet her carrier's step therapy guideline. 

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

The insurer's denial of coverage for Ajovy autoinjector 225 milligrams (mg)/1.5 auto injector is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: psoriasis

Treatment: Taltz (ixekizumab) 80 milligrams per millimeter (mg/mL)

The insurer denied coverage for Taltz (ixekizumab) 80 milligrams per millimeter (mg/mL)

The denial is upheld.

The patient has a diagnosis of psoriasis, and joint pains consistent with possible psoriatic arthritis.  The patient has failed topical triamcinolone, clotrimazole, and naproxen.  The requested medication is Taltz.  

There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Taltz for this patient's condition as an accepted standard of practice over alternative formulary medications.    

According to the joint American Academy of Dermatology - National Psoriasis Foundation (AAD-NPF) guidelines for the treatment of psoriasis, humira and enbrel have a strength of recommendation of "A" for monotherapy in adult patients with psoriasis vulgaris and are effective treatments for psoriatic arthritis.  

According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative safe and effective treatments for the management of psoriasis are available and appropriate for this patient.   A history of peptic ulcer disease and asthma are not contraindications to the use of any biologic.   

The preferred agents, humira and enbrel, are effective therapies for the treatment of the patient's psoriasis.  Similarly, in psoriatic arthritis Singh et al recommend the use of TNF [tumor necrosis factor] agents in this setting. The provided medical notes do not provide any evidence of an absolute contraindication for the use of these available alternatives.  Therefore, Taltz is not medically necessary for this patient based on the medical documentation provided. 

The insurer's denial of coverage for Taltz (ixekizumab) 80 milligrams per millimeter (mg/mL) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Eosinophilic Asthma
Treatment: Fasenra Pen 30mg/ml
The insurer denied the Fasenra Pen 30mg/ml.
The denial is overturned.

The patient is a female. She has a diagnosis of eosinophilic asthma. She is appealing denial of Fasenra. The request was denied due to lack of information detailing use and treatment. A statement from the provider notes the patient is immunocompromised with HIV (human immunodeficiency virus). Her current regimen includes albuterol, Allegra/singular/dupixent. Labs show eosinophil count as high as 6.7 (high normal 5.0).

A clinical note states the patient's symptoms are well controlled on albuterol, Breo and Spiriva. Notes an adverse effect to dupixent after initial improvement. The patient has latent TB (tuberculosis) and a history of pneumonia.

Yes, the requested Fasenra is medically necessary.
Fasenra is FDA (United States Food and Drug Administration)-approved for the add-on maintenance treatment of patients with severe eosinophilic phenotype asthma. This patient has eosinophilic pneumonia. Labs show eosinophilia. Her current treatment includes albuterol, Breo and Spiriva. She has tried and failed dupixent. Long term corticosteroids are contraindicated because the patient is immunosuppressed. Fasenra is medically necessary as add-on maintenance for this patient with eosinophilic pneumonia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurative
Treatment: Remicade
The insurer denied the Remicade.
The denial is overturned.

The patient is a male with severe hidradenitis, treated with antibiotics.  His provider requesting Remicade (Infliximab) continuation.  Per the appeal letter, he experienced good control of his disease on Infliximab.  The health plan denied the request, stating there was no documentation of improvement on Infliximab.

Yes, the treatment with Remicade is medically necessary.
This patient has responded favorably to Infliximab, thus making it medically necessary.

Discontinuing this medication places the patient at risk of worsening disease and morbidity, as well as infection.  The patient has improved and should be allowed to continue therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary and Mandibular Crowding and Deep Impinging Overbite

Treatment D8080 braces and D8670 monthly visit x (times) 12

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding and deep impinging overbite. The orthodontist has completed the Handicapping Labiolingual Deviation Index (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. 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 reaching only 12 points on the HLD index by internal reviewers. 

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, a Handicapping Labiolingual Deviation 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 claims an automatic qualifying condition of deep
impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care as on examination of the intraoral clinical images there is evidence of palatal gingival recession due to direct impingement of the teeth on the gingival soft tissues. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

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

D8080 braces and D8670 monthly visit x 12 is considered medically necessary
for this patient.

The insurer's denial of coverage for D8080 braces and D8670 monthly visit x 12 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class One Malocclusion.
Treatment braces and monthly visits.
The insurer denied coverage for braces and monthly visits.
The denial is upheld.

This is a request for comprehensive orthodontia. The documentation given for review shows the patient has a class one malocclusion. The orthodontist notes a Handicapping Labio-Lingual Deviation (HLD) score of 19.

There are several causes for malocclusion, including hereditary, tooth overcrowding, lost teeth, abnormal bite patterns, ill-fitting dental fillings, cleft lip and palate, tumor of mouth and jaw, and impacted teeth #4 Common conditions of malocclusion are upper protrusion (i.e., over jet), spacing or crowding problems, misplaced midline, open bite, overbite, cross bite, underbite, rotation and transposition#5 There are three major classes of malocclusion: Class 1 (i.e., upper teeth overlap the lower teeth, most common); Class 2 (i.e., severe overbite); Class 3 (i.e., severe underbite).1" (Tran, K. & Picheca, L.).

"Several studies have investigated the effects of orthodontic treatment on oral health related quality of life (OHRQoL) between treated patients and untreated control groups [8]. de Oliveira and Sheiham studied the impact of orthodontic treatment on oral health-related quality of life in Brazilian adolescents and found better oral health-related quality of life in adolescents who had completed orthodontic treatment [9]. However, Taylor et al. [10] did not find any significant association between orthodontic treatment of malocclusion and oral health related quality of life despite the improvement in the health, appearance, social well-being and oral function of the patients." (Jamilian, A. et al.).

To determine the need for braces the HLD index is utilized. Unless there is an automatic qualifying condition a score of 26 is required for coverage. The treating provider does not claim and auto qualifier and scored the index at 19. This reviewer calculated the HLD as 5. The patient doesn't meet the criteria for coverage.
                                                     
The insurer's denial of coverage for braces and monthly visits is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic migraines.

Treatment: Nurtec orally dissolving tablet (ODT) 75 milligrams (mg).

The insurer is denied coverage for Nurtec orally dissolving tablet (ODT) 75 milligrams (mg).

The denial is overturned. 

This female patient has a history of chronic migraines.

Lipton, et al. (2019), "Treatment of a migraine attack with the oral calcitonin gene-related peptide receptor antagonist rimegepant resulted in a higher percentage of patients who were free of pain and free from their most bothersome symptom than placebo."
Croop, et al. (2019), "Between Feb 27 and Aug 28, 2018, 1811 participants were recruited and assessed for eligibility. 1466 participants were randomly assigned to the rimegepant (n=732) or placebo (n=734) groups, of whom 1375 received treatment with rimegepant (n=682) or placebo (n=693), and 1351 were evaluated for efficacy (rimegepant n=669, placebo n=682). At 2 hours post-dose, rimegepant orally disintegrating tablet was superior to placebo for freedom from pain (21% vs 11%, p<00001; risk difference 10, 95% confidence interval [CI] 6-14) and freedom from the most bothersome symptom (35% vs 27%, p=00009; risk difference 8, 95% CI 3-13). The most common adverse events were nausea (rimegepant n=11 [2%]; placebo n=3 [<1%]) and urinary tract infection (rimegepant n=10 [1%]; placebo n=4 [1%]). One participant in each treatment group had a transaminase concentration of more than 3  the upper limit of normal; neither was related to study medication, and no elevations in bilirubin greater than 2  the upper limit of normal were reported. Treated participants reported no serious adverse events... Interpretation: In the acute treatment of migraine, a single 75 mg dose of rimegepant in an orally disintegrating tablet formulation was more effective than placebo. Tolerability was similar to placebo, with no safety concerns."
Peters & Hennessey, (2021), "Rimegepant is one of these newly approved agents for acute migraine treatment in adults with or without aura. Rimegepant has been found to decrease pain and symptoms associated with migraine attacks and is generally well-tolerated."                                                         
The patient suffers from migraine and had failed triptans and NSAIDs(non-steroidal anti-inflammatory drugs). The use of Nurtec is medically appropriate for this patient. Nurtec can be used for both prevention and as an abortive medication. It is being used here as abortive because the appeal letter does talk about failure of triptans and Celebrex as these are abortive medications and not preventative. There is no contraindication to use an abortive calcitonin gene-related peptide (CGRP) blocker while using another one as preventative. Therefore, Nurtec is medically necessary for this patient.

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 Nurtec orally dissolving tablet (ODT) 75 milligrams (mg)  is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: asthma exacerbation.

Treatment: inpatient admission.

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This male patient has a history of asthma and immunocompromised status.

This patient did not need acute inpatient hospitalization. He was stable to have been kept in observation status while diagnostic testing and treatment initiated. Observation period can last up to 48 hrs. The patient was afebrile and hemodynamically stable. The attack was precipitated by non-compliance with prescribed meds. The patient was not in any distress. Asthma was mild. The patient was tolerating oral intake, was ambulating freely with oxygen saturations at 95-99% on room air. The patient could have been discharged home after a period in observation on oral medication with close follow up (F/U) in the outpatient setting.

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

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.