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

Diagnosis: Congenital total anomalous pulmonary venous return
Treatment: 93303 Transthoracic Echocardiography (TTE), Pre-service
The insurer denied the 93303 Transthoracic Echocardiography (TTE), Pre-service.
The denial is upheld. 

The patient is a male with a history of congenital total anomalous pulmonary venous return status post (s/p) surgical correction, as well as obesity, sleep apnea and asthma. The patient was seen by a cardiologist and an echocardiogram was done. The patient was found to have calcified posterior mitral leaflet with trace mitral regurgitation. Due to the history of congenital heart disease, the patient was referred to an adult congenital heart disease specialist and a repeat echocardiogram was requested. Repeat study was denied, as there was documentation of a recent echocardiogram performed and no new symptoms or signs were reported.

No, the proposed 93303 Transthoracic Echocardiography (TTE) is not medically necessary. The medical necessity of the proposed treatment is not established.

As per the provided medical records, the patient had a documented echocardiographic study performed, with findings as documented in the report. There have been no new symptoms or change in clinical condition reported. There is no documentation that the recent echocardiogram was incomplete or of poor quality. Therefore the medical necessity of repeat echocardiogram could not be established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Areata
Treatment: Xeljanz XR 10mg Tab, Pre-service
The insurer denied the Xeljanz XR 10mg Tab, Pre-service.
The denial is overturned. 

The patient is a female with severe alopecia areata and vitiligo. She has severe eye irritation from lack of eyelashes and eyebrows. She has failed topical, intralesional, and systemic steroids, as well as topical calcineurin inhibitors. She has been on tofacitinib ten milligrams (mg), twice daily, for six weeks and continues to lose hair.

Yes, the proposed Xeljanz is medically necessary.

The current literature reflects Xeljanz as being more effective than other treatments.

Alopecia areata (AA) is a relatively common disease, but no satisfactory treatment has yet been developed. Recently, research progress has been made in the pathogenesis of alopecia areata, revealing that autoreactive cytotoxic T cells are important and that the Janus kinase (JAK) pathway is involved. Therefore, the potential of Janus kinase (JAK) inhibitors as therapeutic agents for alopecia areata is attracting attention. There have been a number of case reports and small clinical trials reporting promising outcomes of Janus kinase (JAK) inhibitors tofacitinib, ruxolitinib and baricitinib for alopecia areata. The majority of the literature to date is based on small volume data, with a lack of definitive evidence or guidelines. 

A retrospective study of 90 adults with severe alopecia areata (at least 40 percent scalp hair loss, alopecia totalis, or alopecia universalis) who had stable or worsening disease for at least six months and received oral tofacitinib (five to ten milligrams [mg] twice daily) for at least four months (with or without adjuvant prednisone) supports benefit. Of the 65 patients with a duration of the current disease episode of ten years or less, 77 percent had a clinical response (at least six percent improvement in the Severity of Alopecia Tool [SALT] score) and 58 percent achieved greater than 50 percent improvement in the Severity of Alopecia Tool (SALT) score over four to 18 months of treatment. Patients with a disease episode longer than ten years appeared less likely to respond to treatment; the clinical response rate in this population was 32 percent (eight of 25 patients). No serious adverse effects occurred during treatment.

Therefore, given the above, Xeljanz is the best treatment option for this patient at this time.

Treatment  with Xeljanz is currently the best treatment option for this patient at this time. Given this patient's diagnosis and history, treatment with Xeljanz would be considered to be reasonable and consistent with the current standard of care in the dermatology community.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque psoriasis.

Treatment: Cosentyx to treat psoriasis.

The insurer denied coverage for Cosentyx to treat psoriasis.

The denial is upheld. 

This is a male patient with plaque psoriasis. The patient has failed treatment with topical steroids. The letter of appeal states that the patient's plaques are severe on his extremities and trunk. It further states that cyclosporine is contraindicated for this patient due to his autoimmune hepatitis. The request is for Cosentyx.

As per Colombo, et al. (2013), "Cyclosporine A (CsA) is one of the most effective systemic drugs available for the treatment of psoriasis, as evidenced by the results of several randomized studies and by a prolonged experience in dermatological setting. In clinical practice, CsA is usually used for the induction of psoriasis remission at a daily dose included in the range of 2.55mg/kg [milligrams per kilogram] and with intermittent short-term regimens, lasting on average 36 months." Sciveres et al. (2004) found that cyclosporine may be considered as a safe treatment for all autoimmune liver diseases and as an effective alternative for front-line therapy. This study included patients with autoimmune hepatitis, autoimmune cholangitis, and giant cell hepatitis. 

According to the 2018 American College of Rheumatology and National Psoriasis Foundation guidelines Phototherapy and oral agents for psoriasis (i.e., acitretin, cyclosporine) may be used first-line in various clinical situations. Cyclosporine may be effective long-term, but is normally reserved for intermittent use (up to 12 weeks) to control a flare so the patient can transition to another drug for long-term maintenance.  When used intermittently, a course of cyclosporine can induce an average decrease of > 75% in psoriasis severity.  Cyclosporine has been used successfully to avoid high steroid doses in both adult and pediatric patients. 

In this case, the patient does not have kidney disease or uncontrolled hypertension. The patient also does not have a history of skin cancer. The patient has not tried and failed conventional options of phototherapy or systemic agent of cyclosporine. Literature does not support that use of cyclosporine is contraindicated for patients with autoimmune hepatitis. Thus, there is no exception for Cosentyx for this patient at this time. Cosentyx 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.  

Based on the above, the medical necessity for Cosentyx to treat psoriasis is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II occlusion and moderate overbite
Treatment: braces
The insurer denied braces. The health plan's determination is upheld. 

The patient in question is a female with a Class II occlusion and moderate overbite. The maxillary and mandibular arches are both crowded. Teeth 11 and 21 are ectopic and blocked out to the labial. She is treatment planned for 24-30 months of orthodontics with the extraction of tooth 12 to correct her malocclusion. 

Comprehensive Orthodontic Treatment of the Adolescent Dentition: Braces is not medically necessary for this patient.
The patient has crowding which leads to the position of teeth 11 and 21. Her bite is deep but there is no indication of damage to the incisors or the palate in the photographs, and her cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided there is severe soft tissue damage (or any soft tissue damage) on this patient.
The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another. Furthermore, deep bites may be corrected in adulthood, so it is not as if she will lose the ability to correct her malocclusion should she choose to do so as an adult.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is overturned.

The patient is a male who was admitted for left forearm cellulitis. He was well until several days prior to admission when he developed a small, red, painful bump on his wrist. The bump grew in size and he also developed a rash on his lower forearm. He was seen by his primary doctor and was given a topical medication, but his mother noted that the forearm swelling rapidly increased within several hours. He also developed fatigue, rhinorrhea, and congestion. They called the primary doctor again and were sent to the emergency department for further care.

In the emergency department he was noted to have erythema extending the full length of the left forearm with a single, raised lesion on the palmar aspect of the wrist. Laboratory values as well as a blood culture were obtained. He received a dose of intravenous clindamycin and was admitted for further care.
At the time of admission, the erythema was noted to extend further than the demarcation from the emergency department. He was continued on intravenous clindamycin as well as ibuprofen and acetaminophen as needed. The blood culture was pending. He did well overnight, and the erythema improved and did not spread further. By the following day, he was able to tolerate oral intake and was felt to be stable for discharge to home to complete treatment with oral antibiotics and with follow-up as an outpatient.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The requested health service/treatment of inpatient stay was medically necessary for this patient. Due to the rapid progression of cellulitis, outpatient treatment would not have been appropriate for this patient.
This is a patient who presented with rapidly spreading cellulitis. He had been seen previously as an outpatient and was prescribed topical treatment, but his symptoms were not improving. At the time of presentation in the emergency department he had erythema extending up the full length of his forearm. He required prompt initiation of parenteral treatments and close monitoring. In fact, by the time he was admitted to the hospital the erythema had extended even further.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 24th edition, Cellulitis, Pediatric: Hospital admission is indicated for patients with a clinical presentation that requires the intensity of patient monitoring that cannot be provided at other than inpatient level of care, Including rapidity of progression. This patient had cellulitis with rapidly progressing erythema that required parenteral treatment.
The decision-making at the time of admission for this patient was consistent with the patient's age, the presence of rapidly spreading cellulitis, and the need for treatment with parenteral therapies and close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

The patient is a female who presented to the hospital emergency department (ED)with upper abdominal pain, nausea, and vomiting of 2-days duration. Her comorbid health conditions included gastroesophageal reflux disease (GERD) and migraines. At the time of presentation, the patient was without fever and her vital signs showed a heart rate of 80beats/minute and blood pressure of 131/84 millimeters of mercury (mmHg). She was tender in the upper abdomen. The white blood cell (WBC) count was normal at 6.9 K. The complete metabolic panel identified normal serum transaminases and her bilirubin was normal. The ultrasound showed gallstones and a sonographic Murphy sign.
She was initially treated with intravenous (IV) fluid and antiemetics. A surgical consultation was obtained. The patient underwent laparoscopic cholecystectomy. The submitted records indicate an uncomplicated surgical procedure. The patient was treated with post-surgical monitoring, IV fluid, and IV analgesia. The immediate post-surgical recovery was uncomplicated.
Following the operation, the patient had stable vital signs. The diet was advanced. She was discharged from the inpatient setting.
At issue is the medical necessity of the Inpatient stay.
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of Inpatient stay was not medically necessary for this patient.
This patient is a female who presented to the ED with abdominal pain. Evaluation identified gallstones. She was hemodynamically stable at the time of presentation. The WBC count was normal. Serum chemistries were normal. An uncomplicated cholecystectomy was performed. The patient remained hemodynamically stable during the period of pre-surgical care, during surgery, and during the period of post-surgical monitoring. There was no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. There were no peri-operative complications or other clinical issues that mandated an inpatient care. Based on nationally recognized and generally accepted standards of care, the inpatient level of care was not medically necessary.
Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Norditropin Flexpro for medical necessity. The denial was overturned. 

This patient is a male diagnosed with growth hormone deficiency (GHD). His growth hormone (GH) stimulation test with arginine and clonidine peaked at 8.03. His magnetic resonance imaging (MRI) scan was normal.
His genitourinary (GU) is at tanner 1.
His mid parental height is 167 centimeters (cm) (-1.37 standard deviation score (SDS)). His recent height velocity is reported to be 2.84 cm/yr, -3 SD (standard deviation).
At issue is the medical necessity of the Norditropin Flexpro 15/1.5 milliliters (ML) injectable (INJ).
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Norditropin Flexpro 15/1.5 ML INJ is medically necessary for this patient.
Classic GH deficiency criteria are outlined in the guidelines for the treatment of GH deficiency, [1] the Lawson Wilkins Pediatric Endocrinology Society, [2, 3] and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists. [4]  The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year (yr) more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. 
This patient met biochemical criteria. His GH stimulation testing peaked at less than 10ng/ml. The patient met height criterion 3 as his height is more than 2 SD below the mean and height velocity is more than 1 SD below the mean. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency. 
Therefore, the requested treatment of Norditropin Flexpro 15/1.5 ML INJ is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/musculoskeletal
Radiology services

Diagnosis: back pain.
Treatment: MRI.
The insurer denied an MRI of the lumbar spine. 
The health plan's determination is upheld.

The patient is a male with a past medical history significant for chronic lower back pain and hepatitis C. The back pain was treated symptomatically with anti-inflammatory medication. The patient was evaluated in the office and it was recommended that the patient get a magnetic resonance imaging (MRI) of his back for further evaluation.

Magnetic Resonance Imaging (MRI) of the Lumbar Spine, without Contrast is not medically necessary for this patient.
The patient has had at least a 4-year history of lower back pain. He had x-rays done which were noted to be normal. He presented to his physician with complaints of chronic lower back pain. He had exam findings consistent with lower back pain without any neurological deficits. MRI without contrast was recommended for further evaluation.
A recent notes chronic lower back pain, of at least one year's duration. Physical exam notes generalized tenderness in the lower back with no focal neurological deficits. No new x-rays were noted.
An MRI of lumbar spine for the treatment of mild to moderate nontraumatic lumbar back pain without neurological deficits is not medically necessary. Standard of care typically would be for repeat x-ray films of the back plus or minus physical therapy evaluation, and reevaluation subsequent to these treatment modalities.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, gait ataxia, hypertension,
depression/anxiety and dizziness. 
Treatment: Increase Home Care/Personal Care HHC Level II Personal Care Services, per 15 Minutes to 40 Hours per Week. 

The insurer denied the Increase Home Care/Personal Care HHC Level II Personal Care Services, per 15 Minutes to 40 Hours per Week. 
The denial is upheld. 

The patient is a female with a history of coronary artery disease, gait ataxia, hypertension, depression/anxiety and dizziness. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). An appeal review was requested for potential approval of 40 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support. 

No, the proposed treatment of 40 hours/week Personal Assistance Services is not deemed medically necessary. 

The patient is a female with a history of coronary artery disease, gait ataxia, hypertension, depression/anxiety and dizziness. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). However, an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that the currently approved plan of 30 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. 

Specifically, this assessment revealed no changes with the patient's ability to perform bed mobility, bathing, personal hygiene, dressing, walking, eating, meal preparation, housework and medication management. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment 40 hours/week Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Dupixent SC Injection for medical necessity.
The denial was upheld.

The patient is a male with atopic dermatitis affecting his hands, feet, trunk, and face. The patient has tried and failed multiple topical corticosteroids, tacrolimus, and oral steroids. Infections (in particular, eczema herpeticum) have placed the patient in the hospital. Methotrexate and cyclosporine are being avoided because of the pandemic.
At issue is the medical necessity of Dupixent subcutaneous (SC) Injection.
The health plan's determination of medical necessity is upheld in whole.
No, the requested health service/treatment of Dupixent SC Injection is not medically necessary for this patient. 
Dupixent is but one form of systemic therapy, and with severe patients such as this one, the incidence of worsening head/neck and ocular symptoms and/or worsening of atopic disease is not insignificant. Oral methotrexate has been used for years for rheumatologic and dermatologic diseases for patients as young as age 4 and sometimes younger. Concurrent use of oral immunomodulators is not an uncommon occurrence, and although prednisone and cyclosporine may be contraindicated during the pandemic, methotrexate is not, as methotrexate has been demonstrated to help prevent the cytokine storm observed in severe coronavirus 2019 (COVID-19) infections.
The patient has no documented treatment failure with, or medical contraindication to first-line standard oral medications such as Methotrexate, Azathioprine, and/or Phototherapy, that are used for pediatric patients [3-5] as well as for adult patients. Some pediatric patients are so severe that both Dupixent and the oral immunomodulators will be needed for concurrent use. Dupixent is not proven to be superior to all other formulary alternatives (oral immunomodulators) as per comparative, controlled studies as only topical therapies were compared to Dupixent used with topical therapies.
Therefore, the requested Dupixent SC Injection is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male. He has a history of HTN (hypertension) and HLD (hyperlipidemia). He presented with the complaints of progressive left-sided abdominal pain. The patient noted fever and abdominal distension.

The patient's presenting vital signs were a temperature of 98.1, pulse 72, and respiratory rate of 18. The BP (blood pressure) was 117/78, and the pulse oximetry was 96 on room air. The white count was 15.4. The physical examination showed LLQ (left lower quadrant) isolated localized tenderness with mild guarding.

An Abdominal CT (computed tomography) scan showed colonic diverticulosis. Wall thickening and inflammatory changes at the sigmoid colon consistent with acute diverticulitis were noted. Extraluminal air at the pericolonic fat adjacent to the sigmoid colon consistent with contained perforation was documented.

No, the inpatient admission was not medically necessary.

While the care as provided was medically appropriate, the level at which this care was provided 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 diverticulitis with contained microperforation; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (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.