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

Diagnosis: Atopic Dermatitis (AD)
Treatment: Dupixent Every Week Dosing
The insurer denied: Dupixent Every Week Dosing
The denial is: Overturned

The patient is a female with atopic dermatitis (AD), 20%(percent) body surface area (BSA), to the scalp, neck, trunk and arms. Prior treatments include topical steroids, Elidel and systemic steroids. She has been on Dupixent. The provider requested increased dosing interval to every week instead of every other week. This dose has improved her condition. The health plan denied the request as this dosing is not Food and Drug Administration (FDA) approved.

The study performed by Gao et al. published in 2021 sought to characterize the real-world experience for recurrence of AD prior to the next dose of dupilumab and how patients on weekly dosed dupilumab did in the cohort, all of whom were inadequately controlled on the approved dosing.
17 patients were found to have tried weekly dosing. It was observed that 12/17 patients (71%) reported recurrence prior to their next dupilumab dose, and all of them (100%) claimed that increasing every other week (EOW) dosing of dupilumab to every week (EW) dosing helped control their symptoms, this benefit was worth the effort of injecting oneself twice as often, and they planned to remain on weekly dosing.
The study by Worm et al. also examined dosing regimens for Dupixent. In this trial, continued response over time was most consistently maintained with dupilumab administered weekly or every 2 weeks. Longer dosing intervals reduced efficacy. This further supports that some patients may need weekly dosing.
While limited, there is support in current peer reviewed medical literature that biologic often need dose adjustment in psoriasis, atopic dermatitis and other conditions. Therefore, given the failure of this patient on every other week dosing and support in current literature, it is likely to be more beneficial for this patient than standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Per-oral endoscopic myotomy.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Stay.
The determination is upheld.

The patient has a past medical history of achalasia, hypertension (HTN), hyperlipidemia (HLD) who underwent a per-oral endoscopic myotomy (POEM) procedure. The patient tolerated the procedure well and was admitted for intravenous (IV) hydration, intravenous (IV) Protonix and post-surgical monitoring. The patient remained nothing by mouth (NPO) after the procedure and was given prophylactic levofloxacin and intravenous (IV) Zofran. The patient also received intravenous (IV) morphine. The patient was advanced to a clear liquid diet which they tolerated without issue. The patient was then discharged home. At issue is the medical necessity of the inpatient stay.

The requested health service/treatment of Inpatient admission was not medically necessary for this patient. There was no evidence of hemodynamic compromise, complications from surgery, significant electrolyte abnormalities, arrhythmias, sepsis, significant blood loss requiring frequent blood transfusions or the need for more frequent than every four hours of monitoring [1]. Furthermore, this procedure is the standard of care for achalasia and has shown promise compared to laparoscopic Heller myotomy [2]. Although both procedures are same day procedures, studies have shown that per-oral endoscopic myotomy (POEM) procedure is safe and if admission is indicated, the patient can be safely observed at a lower level of care [2,3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This patient is an adult female who presented to the emergency department with the complaint of abdominal pain of two-days duration. The patient reported chronic intermittent abdominal discomfort for the past one year. Prior evaluation has included upper endoscopy, magnetic resonance enterography and lab data that were reportedly normal. The patient's vital signs at the time of presentation were normal. The heart rate was 91 beats per minute. Her examination revealed abdominal tenderness in the periumbilical and right lower quadrant areas. The white blood cell (WBC) count was 11.2 thousand (K). The patient's liver enzymes were normal. Amylase and lipase were slightly elevated. Computed tomography (CT) scan on day #1 showed a 2.2-centimter pancreatic tail cystic lesion and a non-enhancing 3.5 by 3.0 by 3.4-centimeter lesion of the gastric fundus/pancreatic tail. Gastroenterology consultation was obtained. The patient was admitted to the hospital. 

The patient was evaluated with endoscopic ultrasound with biopsy of the pancreatic cystic lesion on day #2. Following this procedure, the patient's diet was advanced. Her vital signs included a heart rate of 114 beats per minute. Subsequent vital signs were normal with a heart rate of 85 beats per minute on day #3. The patient remained clinically stable following this procedure. She was discharged from the hospital on day #3. 

The health plan rationale for denial of inpatient care was based on the Milliman Care Guidelines (MCG) 25th edition, Abdominal Pain, Undiagnosed. 

The inpatient care was not medically necessary. 

The care and treatment provided during this time could have been rendered with an observation level of care and did not require an inpatient designation. This lower level of care would have provided for emergency department and gastroenterology assessment and follow up, lab and imaging, endoscopy as performed on day #2, and arrangements for outpatient follow up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left, Congenital below-elbow amputee (trans radial). 
Treatment: Hand Prosthesis (high definition silicone prosthesis). 

The insurer denied the hand prosthesis (high definition silicone prosthesis). 
The health plan's determination is overturned. 

The patient is a male with a congenital left trans-radial amputation for whom a high-definition silicone hand prosthesis was requested and denied. The medical records indicate that the patient suffers from anxiety and depression complicated by his feelings of his appearance due to his congenital left upper extremity amputation.
He also has impaired function due to his congenital amputation. The rationale with requesting a high-definition silicone prothesis as noted by the prosthetist and physician are for functional assist to improve the patient's overall quality of life functionally, socially and emotionally. 

At issue is the medical necessity for the hand prosthesis. 

The requested service and treatment of a hand prosthesis is medically necessary for the patient as detailed above. It will provide the patient with a medically necessary prosthetic to improve the functional use of his upper extremity. 
It is well documented in the literature that custom silicone prosthesis provide for functional use as a prosthetic, but also an improvement quality of life. 
It is well documented in the patient's medical record that he is suffering socially, emotionally and functionally in a large part due to his congenital limb amputation. The requested high-definition silicone prosthesis will provide him with medically necessary function for upper extremity amputees.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Postnasal Drip
Treatment: Budesonide 0.5 milligrams (mg) / 2 milliliter (ml) inhalation suspension
The insurer denied coverage for Budesonide 0.5 milligrams (mg) / 2 milliliter (ml)  inhalation suspension.
The denial is upheld.

This is an adult with multiple medical problems who complained of postnasal drip and from the history no other nasal symptoms. On repeated visits, the physical examination was constant and was noted as: "Nose: Internal Nose: Nasal mucosa is pink and moist. Adequate airway. Septum deviated to right. Nasal turbinates are normal in color and size. No nasal polyps noted." 

The medical history revealed that she was having minimal symptoms which were relieved by the use of other medications including Flonase. There was no indication from the information available that Budesonide 0.5 milligrams (mg) / 2 milliliter (ml) inhalation suspension would improve her health status. The peer reviewed literature supports that Budesonide for nasal congestion and chronic rhino sinusitis is not superior to other forms of medical intervention[1-3]. 

Budesonide 0.5 milligrams (mg) / 2 milliliter (ml) inhalation suspension is not considered medically necessary for this patient as there is no evidence that it would be any better than other interventions. 

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 Budesonide 0.5 milligrams (mg) / 2 milliliter (ml) inhalation suspension services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain
Treatment: MRI (magnetic resonance imaging) of knee
The insurer denied the MRI of knee.
The health plan's determination is upheld. 

The patient is a male with a complaint of right knee pain. He underwent prior anterior cruciate ligament (ACL) reconstruction in his right knee and had excellent, pain free function of the knee until recently. He began to experience medial sided right knee pain and stiffness. One office visit for this patient is documented. The patient complained of medial sided right knee pain without any recent injury, trauma or fall. 

The requested magnetic resonance imaging scan (MRI) of the right knee is not medically necessary for this patient. The provided records document that this patient was seen for one visit only for a complaint of right knee pain. There was no traumatic history reported in the progress note and there were no plain radiographs obtained of the affected right knee on that visit. Furthermore, the progress note does not document that the patient underwent any conservative treatments for his right knee pain, nor does the note state that the patient is experiencing mechanical symptoms such as catching or locking for which and immediate MRI scan of the knee would be indicated. The provider opted to send this patient for plain radiographs of the knee and an MRI at the same time, which is not supported by the current, peer-reviewed indications for a knee MRI scan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid arthritis, coronary artery disease and diabetes mellitus
Treatment: Increase to 7 days/week x 6 hours/day; 42 hours/week of personal care worker (PCW) services
The insurer denied coverage for the increase to 7 days/week x 6 hours/day; 42 hours/week of PCW services.
The denial is upheld.

This patient is an adult female with chronic medical problems including rheumatoid arthritis, coronary artery disease and diabetes mellitus. She lives with her spouse in a private home. The insurer approved personal care worker (PCW) 4 hours/day, 7 days/week for a total of 28 hours/week and the request is for PCW services 6 hours/day, 7 days a week for a total of 42 hours/week. 

The Uniform Assessment System (UAS) reported that the patient cognition is described as modified independent. She requires extensive assistance for bathing, lower body dressing and toilet transfer. Limited assistance is needed for personal hygiene, upper body dressing, eating and toilet use. She is frequently incontinent of bladder and continent of bowel. She is independent with bed mobility and uses a rollator for ambulation. Contrary to the assertions of her treating physician, according to the UAS report, the patient cognitive and functional ability have not significantly declined (if not slightly improved). The patient's condition and functional needs are not at a level or unpredictable as to require the requested increase PCW services 7 days/week, 6 hours/day. The patient's health and safety has been appropriately provided and maintained by the currently approved PCW 4 hours/day, 7 days/week, totaling 28 hours/week.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

The insurer's denial of coverage for the increase in personal care worker (PCW) services to 7 days/week x 6 hours/day; 42 hours/week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Vasospasm
Treatment: Inpatient hospital stay
The insurer denied coverage for the inpatient hospital stay.
The denial is upheld.

This is an adult female that presented to the hospital complaining of epigastric pain, palpitations and dyspnea. Past medical history was significant for a COVID (coronavirus disease) infection several months earlier and elevated serum troponin at that time. Upon arrival to the hospital, vital signs were stable [Blood Pressure 122/68 mmHg (millimeters of mercury), Pulse 92 bpm (beats per minute)]. Physical examination revealed no abnormality. A 12-lead electrocardiogram revealed normal sinus rhythm without acute ST (interval on electrocardiogram (EKG) or T (interval on EKG) wave abnormalities. Echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) of 55% [percent] without wall motion abnormalities. Serum blood testing revealed no elevation in troponin. The patient was admitted to the hospital for monitoring and treatment. She underwent cardiac catheterization that revealed spasm of the left anterior descending artery. No atherosclerotic coronary artery disease was noted. The patient was discharged on calcium channel blocking agents.

This patient presented with atypical chest pain and a past medical history COVID infection with elevated troponin. Utilizing the HEART (history, EKG, age, risk factors, troponin) score, she was considered low risk (Reference 1). She underwent an uncomplicated procedure and was diagnosed with coronary vasospasm. She was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference 2-5). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion, inpatient admission was not medically necessary. The patient could have been managed at a lower level of care.

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 inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Impinging Overbite. 
Treatment: D8080 braces and D8670 monthly visit x 12. 
The insurer denied coverage for D8080 braces and D8670 monthly visit x 12. 
The denial is upheld. 

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 deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 

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, and 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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index with a total of 11 points (4 points overjet, 5 points overbites, 2 points labiolingual spread). 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. 

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

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

The insurer's denial of coverage for the D8080 braces and D8670 monthly visit x 12 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prader Willi Syndrome

Treatment is continued acute rehabilitation (inpatient medical rehabilitation services)

The insurer denied coverage for continued acute rehabilitation (inpatient medical rehabilitation services)
 
The denial is overturned

The patient is a teenager with history of Prader Willi Syndrome. The patient has multiple medical problems including pneumonia, cellulitis of lower extremity, syncope, obstructive sleep apnea (OSA), status post (s/p) tracheostomy and on ventilator support, obesity, diabetes mellitus (DM), hypertension (HTN), and hypothyroidism. The patient was admitted to an Acute Rehab Facility for continuing care. The patient was receiving physical therapy (PT), occupational therapy (OT) and speech language pathology (SLP) therapies. In addition, the patient was requiring ventilatory support, respiratory treatments with Albuterol twice a day (BID), hypertonic saline BID, MetaNebs three times a day (TID) and also Flovent.

The patient was on ventilatory support with rate 14, FIO2 (fraction of inspired oxygen) 28 % and High PEEP (positive end-expiratory pressure) of 12 to prevent atelectasis.

This patient was cleared for discharge to a Long Term Care (LTC) for ongoing care. Multiple facilities refused to accept the patient due to a change in needs and ventilator requirements and complex medical needs. The patient's family was unable to take care of the patient due to access issues and complex medical needs and ventilator dependency which the family was unable to provide.

As per the last progress notes, the patient was receiving PT/OT and SLP therapies and was ventilator dependent.

There was no safe discharge plan in place. The patient needed to be placed in LTC, but no facility was available. The patient's family unable to care for the patient at home.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for continued acute rehabilitation (inpatient medical rehabilitation services) forward is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, colon cancer status post-surgery with colostomy status, urinary incontinence, type 2 diabetes.

Treatment is personal care services (PCS) 24 hours a day, 7 days a week, split-shift services.

The insurer denied coverage for personal care services (PCS) 24 hours a day, 7 days a week, split-shift services.
 
The denial is overturned.

The patient has several conditions including dementia, which taken into entirety have great effect on the necessary level of care. The patient has a colostomy. This requires daily cleaning, supplies and monitoring. The patient cannot perform this service independently. 

The patient has documented limitation to all activities of daily living. The patient is not ambulatory, cannot get out of bed without assistance, is incontinent of bladder and has limited bed mobility. The patient cannot prepare meals nor care for herself. There is no supportive family to assist. The patient has great risk for falls with reports of slipping from sofa to the floor. There is no system in place where the patient can call for assistance if necessary. Consultation by a psychiatrist has reported progression and worsening. There is little likelihood of improvement to an independent status. If this elderly patient is discharged to a home environment, 24/day, 7 days a week support would be required.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care services (PCS) 24 hours a day, 7 days a week, split-shift services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment: Dupixent 200 milligrams (mg) / 1.14 milliliter (ml) subcutaneous (SC) solution pen injection (SOPN)
The insurer denied coverage for Dupixent 200 milligrams (mg) / 1.14 milliliter (ml) subcutaneous (SC) solution pen injection (SOPN)
The denial is overturned.

This case involves a pediatric patient with a diagnosis of moderate atopic dermatitis affecting the arms and neck. The patient has failed topical steroids, but now requires systemic therapy. The request is for Dupixent 200 milligrams (mg) / 1.14 milliliter (ml) subcutaneous (SC) solution pen injection (SOPN). 

Dupixent is medically necessary for the treatment of the patient's diagnosis, atopic dermatitis. Pediatric patients have decreased systemic treatment options available which could safely be administered given their age. The patient has failed topical therapy with steroids and requires systemic intervention. Tacrolimus would be appropriate for mild localized disease and not sufficient for moderate to severe disease. Dupilumab is recommended as the first-line therapy in most adult and pediatric patients with moderate to severe atopic dermatitis that is not controlled by topical therapies (UptoDate). Dupixent is approved for use in the treatment of the patient's atopic dermatitis under close medical supervision and at an appropriate dosing schedule at the discretion of the treating physician.   

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Dupixent 200 milligrams (mg) / 1.14 milliliter (ml) subcutaneous (SC) solution pen injection (SOPN) is substantiated.