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

Diagnosis: Hyperlipidemia
Treatment: Lipoprotein (a) Testing.

The health plan's determination is overturned.

The patient is a female with a history of hyperlipidemia and a family history of premature atherosclerotic cardiovascular disease. The patient is on Atorvastatin 80 milligrams (mg) daily her most recent low density lipoprotein (LDL) cholesterol level was 95 milligrams per deciliter (mg/dl). Her Lipoprotein(a) level is 31 mg/dl.

The proposed health service or treatment Lipoprotein (a) Testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has hyperlipidemia and a family history of premature coronary artery disease, which increases her risk for atherosclerotic disease.
Lipoprotein(a) is a well-recognized, independent risk factor for atherosclerotic cardiovascular disease (ASCVD), with elevated levels estimated to be present in 20 percent (%) of the population. High quality evidence supports a link between Lipoprotein(a) levels and a variety of cardiovascular related outcomes. The 2019 scientific statement from the National Lipid Association supports measurement of Lipoprotein(a) levels in patients with a personal history of, or a first-degree relative with, premature ASCVD. Per this document, testing in these patients helps to further define their risk beyond traditional risk factors, inform clinical decision-making regarding risk management and may trigger escalation of lipid-lowering therapy. Likewise, the 2018 American Heart Association (AHA)/American College of Cardiology (ACC)/American Black Cardiologists (ABC)/American College of Preventive Medicine (ACPM)/American Pharmacists Association (APhA)/American Society of Preventive Cardiology (ASPC)/Preventive Cardiovascular Nurses Association (PCNA) Guideline on the Management of Blood Cholesterol considers a family history of premature ASCVD a relative indication for measurement of Lipoprotein(a) levels.
Standard risk assessment tools, such as the Pooled Cohort Equation or the Framingham score, may underestimate risk in patients with a family history of premature ASCVD. The addition of Lipoprotein(a) levels to these tools can be used to better refine risk and identify appropriate treatment goals.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hyperlipidemia
Treatment: Lipoprotein (a) Testing.

The health plan's determination is overturned in whole.

The patient is a female with a past medical history significant for asthma, Graves' disease, hyperlipidemia, and premature family history of coronary artery disease (CAD) (Father with premature CAD status/post (s/p) coronary artery bypass graft (CABG)). Review of this patient's records indicate the patient is currently treated for hyperlipidemia with Atorvastatin 80 milligrams (mg) a day. The patient's treating provider has recommended checking a lipid panel and Lipoprotein (a) test for additional cardiovascular risk assessment.

Yes, measurement of Lipoprotein (a) (Lp(a)) would be considered more beneficial than the current standard of care cholesterol level testing for this patient at increased risk for cardiovascular events. The current body of published medical literature indicates that Lp(a) is associated with increased cardiovascular risk and events including acute myocardial infarction (AMI), stroke, cardiovascular mortality, and elevated levels are an established independent and causal risk factor for atherosclerotic heart disease due to increased atherogenesis, inflammation, and thrombosis (1). According to the 2018 American Heart Association (AHA)/American College of Cardiology (ACC) guideline on the management of blood cholesterol, measurement of Lp(a) levels is reasonable for further cardiovascular risk stratification in women treated for hyperlipidemia with a family history of premature atherosclerotic cardiovascular disease (ASCVD) or personal history of ASCVD not explained by traditional major risk factors (2). In addition, the National Lipid Association published a scientific statement in 2019 on the use of Lp(a) in clinical practice stating measurement of Lp(a) level is reasonable to provide further risk stratification for atherosclerotic cardiovascular events in adults with first-degree relatives with premature cardiovascular disease and/or patients with primary severe hypercholesterolemia or suspected familial hypercholesterolemia(3). For these reasons, measurement of Lp(a) level is both medically necessary and appropriate to provide additional cardiovascular risk assessment in this patient at increased risk for future cardiovascular events.
Appeal type: Experimental/Investigational
Decision: Overturned

Endocrine/Metabolic/Nutritional
Lab Work/Blood Tests

Diagnosis: Hyperlipidemia
Treatment: Lipoprotein (a) Testing.
The insurer denied the Lipoprotein (a) Testing.


The health plan's determination is upheld in whole.

The patient is a female with hyperlipidemia (HLD) and a family history of premature coronary artery disease (CAD). She has no history of hypertension (HTN) or diabetes mellitus (DM). Her total cholesterol was 222, high density lipoprotein (HDL) 113 and low density lipoprotein (LDL) was 95. She was taking Atorvastatin 80 milligrams (mg) daily. Lipoprotein (a) Testing was ordered.

Lipoprotein (a) testing is not likely to be more beneficial than any standard treatment for the patient's hyperlipidemia. Current American Heart Association (AHA)/American College of Cardiology (ACC) guidelines (1) indicate that LDL is the primary target for lipid lowering. The health plan policy considers Lipoprotein (a) testing as investigational and not medically necessary for cardiovascular disease risk assessment and management (2). Despite the association of Lipoprotein (a) with atherosclerotic cardiovascular disease, as noted in reference 3 below, universal guidelines for diagnosing and providing risk assessment based on Lipoprotein (a) and targeted treatments to lower Lipoprotein (a) are lacking.
For these reasons, the test is not likely to be more beneficial than standard treatments for this patient with hyperlipidemia.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Juvenile idiopathic arthritis. 
Treatment: Humira 40 milligram every 10 days. 
The insurer denied: Humira 40 milligram every 10 days. 
The denial is overturned. 

This patient is a teenage female who has juvenile idiopathic arthritis (JIA) and has been on Humira every 14 days. The medication was prescribed every 10 days because the patient has not had a complete response to every 14 day dosing. The medication was denied because the patient does not meet criteria for every 10 day dosing. 

The health plan should cover the proposed treatment. 

This is considered standard of care for this condition. The requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease. This medication is Food and Drug Administration (FDA) approved for rheumatoid arthritis (RA) every 7 days. The other autoimmune conditions such as ankylosing spondylitis, psoriatic arthritis, juvenile arthritis, and uveitis are approved every 14 days however some patient either lose response or do not have complete response to the treatment and therefore require every 7 to 10 day dosing. This is considered standard of care for this diagnosis. There is a limited number of medications approved for juvenile idiopathic arthritis, so it is best to use this medication at its highest dose prior to switching treatments. 
Per reference #1: 
Escalation to weekly adalimumab dosing demonstrated clinical benefits for patients who lost response to therapy and may be beneficial for patients not initially responding to induction therapy. No new safety risks were identified with weekly dosing. 
Per reference #2: 
By 12 weeks after dose escalation, one-quarter achieved substantial clinical improvement. Safety results were similar between patients who dosage-escalated and those who did not. 
Per reference #3: 
Some patients with rheumatoid arthritis not receiving methotrexate may benefit from increasing the frequency to 40 milligrams every week. 
Per reference #4: 
This study suggests that over 3 years of treatment, adalimumab is more efficacious than infliximab in maintaining remission of chronic childhood uveitis. 
Per reference #5: 
Adalimumab is described as being well tolerated and helpful in decreasing inflammatory activity in refractory uveitis and may reduce steroid requirement.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Juvenile idiopathic arthritis. 
Treatment: Humira 40 milligram every 10 days. 
The insurer denied: Humira 40 milligram every 10 days. 
The denial is overturned. 

This case involves a teenage female with juvenile idiopathic arthritis being treated by a pediatric rheumatologist. The patient has already tried and failed non-steroidal anti-inflammatory drugs (NSAIDs) and standard dose Humira therapy. Her physician is requesting to start weekly Humira therapy. The patient's insurance company denied the request because the requested dose is above the quantity limit policy. The patient's physician is appealing this decision. 

The health plan should cover the proposed treatment. 

There are multiple articles in the literature to support the use of a weekly increased frequency dosing of adalimumab in patients with juvenile idiopathic arthritis (JIA) (articles #1-4). It is considered standard of care in the pediatric rheumatology community to attempt to escalate therapy by increasing the frequency of dosing if the patient had an initial positive response to adalimumab. The requested treatment is more beneficial than standard treatment for the patient's condition. 
The patient has already tried and failed standard therapy with Humira 40 milligrams every two weeks. Weekly Humira therapy has been used successfully in multiple studies to treat patients with juvenile idiopathic arthritis. It is standard of care to use weekly Humira in patients with juvenile idiopathic arthritis that do not respond to standard therapy. It is standard care to use every other week dosing first, and if that is not successful, then use every 7 to 10 day dosing.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Reaction to food. 
Treatment: Acute Inpatient Hospital Admission. 
The insurer denied: Acute Inpatient Hospital Admission. 
The denial is overturned. 

The patient is an adolescent male. He presented to the hospital after experiencing a reaction to food. Acute Inpatient Hospital Admission is under review. The patient developed symptoms of shortness of breath, throat itchiness, and emesis after ingesting chickpeas. The patient was given epinephrine and albuterol by his mother and was taken to the emergency department (ED). In the ED (emergency department), the patient was in respiratory distress and received another epinephrine 0.3 mg (milligrams), Decadron, Benadryl, Zofran. After 30 minutes, the patient had episodes of hyperventilation, ongoing throat tightness, dizziness, lightheadedness, vomiting, abdominal pain. The patient was admitted to the inpatient pediatric floor. 

The Acute Inpatient Hospital Admission was medically necessary. 

The patient developed symptoms of shortness of breath, throat itchiness, and emesis after ingesting chickpeas. The patient was given epinephrine and albuterol by his mother and was taken to the emergency department (ED). In the ED (emergency department), the patient was in respiratory distress and received another epinephrine 0.3 mg (milligrams), Decadron, Benadryl, Zofran. After 30 minutes, the patient had episodes of hyperventilation, ongoing throat tightness, dizziness, lightheadedness, vomiting, abdominal pain. The patient was admitted to the inpatient pediatric floor. The patient had symptoms concerning for anaphylaxis refractory to multiple doses of epinephrine. Given the life-threatening nature of anaphylaxis and concern for refractory or rebound anaphylaxis, the patient required inpatient hospitalization admission for close monitoring and further management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: McCune Albright syndrome

Treatment: Embryo freezing

The insurer denied coverage for embryo freezing

The denial is upheld.

 
The patient is an adult with a history of McCune Albright syndrome. The patient presented to the Reproductive Endocrinologist's office for a review of the most recent in-vitro fertilization (IVF) cycle. The patient underwent multiple IVF cycles. Embryo freezing was recommended. 

This patient does not have a diagnosis of infertility.  She has not tried and failed to conceive. According to the provider's progress note, "The patient may try to conceive on her own. If she decides to try to conceive then no more IVF. If delay trying to conceive then do 1 more IVF cycle".

While the patient has decreased ovarian reserve, this does not translate into a diagnosis of infertility. She is young and may conceive spontaneously when she tries. Scientific studies have shown that Serum Anti-Mullerian Hormone (AMH) levels have poor predictive value for natural pregnancy. The predictive value of AMH was poor in the younger and older subgroups suggesting that low serum AMH levels are not associated with reduced fertility.

The patient already has 2 embryos frozen. It is unclear how many embryos she would like to bank. Note that if the patient is interested in having children, she can try conceiving when she is ready and if unable to she can transfer her 2 embryos and if not enough then she can undergo further infertility treatment at that time. Note that the aim of infertility treatment is to have children not to collect embryos.

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 embryo freezing services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mal-positioned Teeth
Treatment: Braces
The health plan denied Braces.
The determination is Overturned.

The patient is a female. She has a Class II malocclusion with moderate crowding and protrusive maxillary incisors. She has a 6-millimeter (mm) overjet and a 5-mm overbite. She is treatment planned for 24-30 months of orthodontics to correct the crowding and protrusion.
At issue is the medical necessity of braces.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of braces is medically necessary for this patient. Teeth # (number) 8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma.[1] Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with overjets 6-mm (millimeter) and greater, which this patient has.[2] For these reasons, orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal/Stomach Pain
Treatment: Inpatient emergency admission
The health plan denied Inpatient emergency admission.
The determination is Overturned.

The patient is a male with chronic alcohol abuse and a known history of ascites from cirrhosis. He was admitted with progressive abdominal distention with pain. He had new onset exertional shortness of breath (SOB). There were no fevers and no gastrointestinal (GI) bleeding. The patient was on propranolol for variceal bleeding prophylaxis. On exam, his vital signs were stable, and he was afebrile. He had icteric sclerae. The abdomen had distention from ascites and was mildly tender diffusely. On admission, his aspartate aminotransferase (AST)/alanine aminotransferase (ALT) were 291 and 63. The total bilirubin was 9.3. His Model for End-Stage Liver Disease (MELD) score was 23. The ultrasound (US) on admission showed moderate ascites. A GI (gastrointestinal) consult was called, and he was started on empiric antibiotics. He underwent an interventional radiology (IR) guided paracentesis with 5.1 liters (L) removed. He received albumin post-procedure. He was still complaining of abdominal pain of 6/10 but was hungry and wanted to eat. He was started on intravenous (IV) Lasix and spironolactone.
At issue is the medical necessity of the inpatient emergency admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient emergency admission is medically necessary for this patient. The patient presented with apparent alcoholic hepatitis on top of underlying cirrhosis leading to decompensation. He had marked volume overload and needed a large-volume paracentesis, as well as IV diuretics. His admission MELD (Model for End-Stage Liver Disease) score was 23. With that MELD score, his 90-day mortality is expected to be approximately 20 percent (%). He needed the paracentesis urgently in order to treat his abdominal pain and SOB, as well as to provide fluid for cell count and culture. He needed a Clinical Institute Withdrawal Assessment (CIWA) protocol in light of his drinking history. This patient was too ill and complex to manage at a level lower than inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male who presented to the emergency department (ED) complaining of epigastric/chest pain that was worsened with breathing, palpation and position change. He also reported nausea and an episode of vomiting. He had no significant past medical history. In the ED his blood pressure was 154/87 millimeters of mercury (mmHg) with a heart rate of 70 beats per minute. His room air oxygen saturation was 97 percent (%). An electrocardiogram showed sinus rhythm with nonspecific ventricular repolarization (T) wave changes. His serum troponin level was normal. The chest x-ray showed no acute pathology. The patient was treated with Aspirin, Ondansetron and Ketorolac and was admitted to the hospital. His troponin level remained normal. A cardiology consultant opined that his symptoms were likely due to pericarditis or costochondritis and recommended treatment with Colchicine and Naproxen. The patient was discharged.

Based on the documentation provided, an inpatient level of care was not medically necessary. This patient presented with atypical chest pain that was thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under an alternate level of care.
This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non- segment (ST)-Elevation Acute Coronary Syndromes.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: pulmonary embolism.
Treatment: inpatient stay.
The insurer denied an inpatient stay. 
The health plan's determination is overturned. 

The patient is a female with a medical history of obesity, sleeve gastrectomy, gastroesophageal reflux disease, history of COVID-19 infection, and recent cesarian section childbirth who presented with symptoms of chest pressure exacerbated with breathing, coughing, laughing, and dyspnea on exertion for a few days prior to admission. She was found to have bilateral pulmonary emboli on computed tomography (CT) chest angiogram. She was initiated on a Heparin infusion and transitioned to Lovenox.

Inpatient Hospital Admission was medically necessary for this patient.
This patient presented with symptoms of chest pressure exacerbated with breathing, coughing, laughing, and dyspnea on exertion for a few days prior to admission. In the emergency room, she was afebrile, hemodynamically stable, her heart rate was 91 beats per minute, she had an oxygen saturation of 99% on room air and was in no acute distress. On physical exam, she had no documented jugular venous distension, had a normal work of breathing without accessory muscle use, clear breath sounds on auscultation of the chest but had moderate respiratory discomfort on exertion. On computed tomography (CT) chest angiogram she was found to have bilateral pulmonary emboli. Her echocardiogram did not demonstrate right ventricular dysfunction/strain or diminished cardiopulmonary reserve and her electrocardiogram (EKG) did not demonstrate ST-segment elevation.
However, she was at a high risk for complications upon initiation of anticoagulation due to recent surgery (cesarian section) that could increase the risk of catastrophic bleeding. Therefore, an Inpatient Hospital Admission was medically necessary for this patient.