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

Diagnosis: Brief Resolved Unexplained Event (BRUE).
Treatment: Inpatient hospital stay.

The insurer denied coverage for inpatient hospital stay.
The denial is overturned.

This is the case of a female infant, 36 weeks gestation, with newborn admission for respiratory distress, hemolytic anemia, and hyperbilirubinemia presented to the emergency department (ED) with sudden-onset of choking and difficulty breathing followed by decreased responsiveness, appearing limp with pallor and cyanosis at home. Her father performed cardiopulmonary resuscitation (CPR) while her mother called emergency medical services (EMS) who found the infant to be pink, provided oxygen and documented an adequate oxygen saturation. In the ED, vital signs included a respiratory rate of 39 and a heart rate of 175.  She appeared congested, but in no acute distress. A chest x-ray was interpreted as possible mild respiratory distress or viral inflammation in the lungs. She was diagnosed with a Brief Resolved Unexplained Event (BRUE) and admitted to the pediatric intensive care unit for continuous cardiopulmonary monitoring "in the setting of a higher risk BRUE given prematurity and CPR event". She remained stable until discharge. 

The insurer denied coverage for an in-patient admission asserting the patient only required ED care.  

However, according to MCG (Milliman Care Guidelines): Apparent Life-Threatening Event (Brief Resolved Unexplained Event) (P-12): Admission is indicated for: Diagnosis of apparent life-threatening event (brief resolved unexplained event) appropriate, as indicated by ALL of the following: 1) Infant younger than 1 year of age, 2) Event is reported (eg, by observer) as having included 1 or more of the following: Cyanosis or pallor, Absent, decreased, or irregular breathing, Marked change in tone (eg, hypertonia, hypotonia), 3) Altered level of responsiveness (eg, loss of consciousness, lethargy), 4) Infant recovered fully to baseline state of health after event (eg, normal appearance, vital signs), 5) Event remains unexplained after history and physical examination, 6) Infant at increased risk for recurrence, serious underlying disorder, or unsafe discharge, as indicated by 1 or more of the following: Infant age younger than 60 days.

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

The insurer's denial of coverage for the inpatient hospital stay is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment inpatient substance abuse detox admission

The insurer denied coverage for inpatient substance abuse detox admission

The denial is overturned

This patient was admitted to this inpatient substance rehabilitation treatment for cocaine dependence and rehabilitation treatment. He reportedly was using $100 per day of cocaine for many years. He reportedly could not maintain abstinence despite past attempts and relapsed after a fire in his apartment. He reportedly had 5 past inpatient substance treatments including detoxification and rehabilitation treatment. He reportedly lacked coping skills and identification of relapse triggers, was temporarily staying with his brother and then was going to go to a shelter, and he lacked relapse prevention skills. He reportedly attended group and individual therapy with goals to improve coping skills, relapse prevention skills, and better identification of relapse triggers. He was reportedly discharged with referral to outpatient substance treatment.
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of cocaine daily including up to $100 per day with a long history of use and could not maintain any abstinence despite 5 past inpatient treatments including detoxification and rehabilitation. He reportedly had relapsed after a fire which rendered him homeless to the point of temporarily staying with his brother until he was to go to a shelter. He reportedly continued to use large amounts of cocaine putting him at high risk for medical consequences including cardiac arrest or stroke. He had a positive toxicology for cocaine. He reportedly lacked coping skills and had difficulty with identification of relapse triggers which put him at risk for continued cocaine use and relapse if not in a 24-hour inpatient therapeutic supervised and structured rehabilitation treatment setting. It was not likely that he could safely and effectively be treated in a less restrictive setting as he would have been exposed to cocaine and lacked the skills to try to rehabilitate while not in a 24-hour setting. It was not likely that he could maintain abstinence if not in a 24-hour therapeutic supervised and structured inpatient substance rehabilitation treatment setting then. 

It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the individual then.

The insurer's denial of coverage for an inpatient substance abuse detox admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrotic syndrome with minor glomerular abnormality.
Treatment: Acthar Gel.
The insurer denied the Acthar Gel.
The denial is upheld.

The patient is a male with nephrotic syndrome in the setting of minimal change disease. He has been treated with prednisone.

The health plan denied coverage of Acthar as there is no diagnosis of infantile spasms or multiple sclerosis. The physician is appealing the determination.

No, the requested Acthar Gel is not medically necessary.
As supported by current medical literature and standard of care, the requested Acthar Gel is not medically necessary, as is not considered safe, effective, or generally accepted national standard of medical practice; it cannot be confirmed that it is not provided primarily for convenience of the patient or the practitioner; and it is not the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient has a diagnosis of nephrotic syndrome from minimal change disease. He was on steroid monotherapy without induction remission.  KDIGO (Kidney Disease Improving Global Outcomes) recommends that corticosteroids be given for initial treatment of nephrotic syndrome. For patients with relative contraindications or intolerance to high-dose corticosteroids they suggest oral cyclophosphamide or Calcineurin inhibitors, to which there is no documentation of use, intolerance or failure in the current clinical scenario.

Acthar gel has not been shown in large multicenter randomized controlled trials to be safe or effective for the treatment of adult minimal change disease. It is not standard of care, and therefore it is not medically necessary in this patient's scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paraspinal mass.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.
The denial is upheld.

This case involves a child diagnosed with paraspinal mass and constipation. The patient was transferred from another hospital for an incidental finding of a paraspinal mass.  There were reports that the patient had flu-like symptoms 2 weeks prior which included fever, coughing, and nasal congestion.  Covid testing was negative.  The x-ray showed a suspicious lesion.  The patient was worked up further with a computed tomography (CT) scan with intravenous (IV) contrast which found a paraspinal mass.  The patient was then transferred following the finding of the mass.  There was an intermittent history of chest pain, dyspnea on exertion, and night sweats.  There was also constipation.  The patient had arrived in stable condition.  The examination documented a dilated anus with questionable anal wink.  Left lower extremity numbness after tripping at school was reported.  The patient was stable on arrival to the floor and abdominal x-ray showed large stool burden.  An MRI (magnetic resonance imaging) of the thoracic and lumbar spine showed a large thoracic left paraspinal soft tissue mass.  A neurogenic tumor was favored.  The patient was discharged home and was to follow-up with oncology.

According to the guidelines, this acuity of this case is considered to have required observation as the patient was being worked up for an unrelated finding. No other interventions were necessary. The patient was described as interactive and was able to be discharged. The patient did not require an escalated level of care.

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe/ persistent or there is evidence of hemodynamic instability. Within the documentation it was noted the patient presented with no neurological deficits. However, the submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The documentation detailed the patient was back at his baseline and was discharged. The requested inpatient admission would not be the most appropriate level of care.

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

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

Diagnosis: Malocclusion

Treatment D8080 braces and D8670 monthly visit (x (times)8),

The insurer denied coverage for D8080 braces and D8670 monthly visit (x8),

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, montage of extraoral and intraoral clinical images, narrative letters, as well as insurer correspondence, and NYS (New York State) Medicaid Dental guidebook, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to impacted permanent anterior among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anterior (#11) where extraction is not indicated. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of
impacted permanent anterior where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic. This reviewer concurs with the findings of the insurer of attaining 21 points on the HLD index (3 points overjet, 4 points overbite, 10 points anterior crowding, 4 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 the 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 clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit (x8) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal
Treatment: Pharmacy/Prescription Drugs (Remicade) 
The insurer denied Remicade. 
The denial is overturned. 

The patient is a male with Ulcerative Colitis (pancolitis). He has failed 5-aminosalicylates, azathioprine, 6-mercaptopurine, and methotrexate. He started Remicade and has been stable and in remission. A colonoscopy showed Ulcerative Colitis in remission; biopsies showed quiescent Ulcerative Colitis. He is recommended by his provider to continue Remicade 5 milligrams (mg)/kilograms (kg) every 8 weeks for the treatment of Ulcerative Colitis.

At issue is the medical necessity of Remicade.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Remicade is medically necessary for this patient.

Remicade is supported as medically necessary in this case. At issue in this case is a change from Remicade to a biosimilar in this patient with Ulcerative Colitis. Inflectra, Avsola, and Renflexis are United States Food and Drug Administration (FDA)-approved infliximab biosimilars for the treatment of Ulcerative Colitis. Support for the safety and efficacy of biosimilar medications in inflammatory bowel disease is provided by studies which either extrapolated safety and efficacy from patients with other diseases (such as rheumatoid arthritis), or from studies in patients who had controlled inflammatory bowel disease; many of these trials are underpowered to assess for noninferiority in inflammatory bowel disease patients. [1] Additionally, multiple studies have shown that patients who continued Remicade had a lower risk of disease worsening or treatment discontinuation, including a fivefold hazard of discontinuing treatment at 12 months, but these did not reach statistical significance. [1,2] Assumptions about switching patients from Remicade to a biosimilar should be made with caution, as lack of Ulcerative Colitis disease control can result in significant adverse events such as worsening flare, toxic megacolon, need for surgery such as colectomy, and need for hospitalization. [3-5] There is a lack of high-quality data or large studies to support the safety of a switch (in a patient in remission) from Remicade to a biosimilar in Ulcerative Colitis, as in this case. [6,7] For these reasons, the request for continuation of Remicade is supported in this case.

Therefore, the requested health service/treatment of Remicade is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Endosteal Implant for teeth 6 and 11.
 
The insurer denied Endosteal Implant for teeth 6 and 11. The health plan's determination is overturned. 

The patient is a male who presents for evaluation and treatment. Provided for review are previous letters of appeal and denial, letters explaining the list of the patient's medical conditions including diabetes, hypertension, blindness, asthma, bipolar disorder, and back pain. 

An Endosteal Implant for teeth 6 and 11 is medically necessary for this patient. 
Based on the provided documentation, the patient is missing all of his teeth. In addition, being that he is legally blind, the patient will have an additional challenge with a removable prosthesis. As he is missing teeth and missing teeth in the posterior region, the patient has the diagnosis of complete edentulism as well as diminished posterior support. With the diagnosis of complete edentulism as well as diminished posterior support, the only therapy capable of addressing both diagnosis is that of implant therapy as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis. Fixed partial dentures do not offer additional support and actually depend on the residual dentition to replace the missing tooth simply putting additional load on the residual teeth without replacing the loss (the patient no longer has teeth). Removable partial dentures are tissue supported prosthesis and do not offer any support to the dentition as they are designed to become passive upon load. The patient will have an implant assisted denture that will not be removed from the mouth and will be aided in retention support and stability from implants. After the implants have integrated they will require restorations. Hence the Endosteal Implant for teeth 6 and 11 is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbar Stenosis;
Treatment: Residential long-term care treatment.
The insurer denied Residential long-term care treatment.
The determination is upheld.


The patient has a past medical history significant for lumbar stenosis status post laminectomy, hypertension, hyperlipidemia, gastroesophageal reflux disease, benign prostatic hyperplasia (BPH) and edema. Services were denied by his insurance stating the following documentation submitted indicates that you are medically stable and are independent with your activities of daily living. You can use a wheelchair independently. Skilled need is for general debility/restorative rehabilitation. At issue is the medical necessity of residential long-term care treatment.

No, the residential long-term care is not medically necessary. A physician assistant's note dated states that he is doing well with therapy and the severe back pain has resolved.
A nursing note dated states that the patient is full weightbearing, independent with care, continent of bowel and bladder and able to self transfer to propel wheel chair independently. Patient had no complaints.
A physical therapy note notes that the patient is able to walk 300 feet with a 2 wheeled walker.
Occupational therapy (OT) evaluation noted that patient was able to complete tasks of ADLs.
Based upon the physician assessment, physical therapy assessment, occupational therapy assessment and nursing assessment the patient is able to most of his activities of daily living. Continued confinement in an inpatient facility is not medically necessary. He can continue with restorative physical therapy and occupational therapy at an alternate location. Other living arrangements may be more appropriate for this patient at this time. Therefore, the requested residential long-term care is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intermittent diarrhea
Treatment: Plenvu
The insurer denied the Plenvu.
The determination is overturned.

The patient has chronic intermittent diarrhea, amenorrhea, and positive celiac disease serology. She previously attempted Clenpiq, Trilyte, Gavilyte, and Suprep, but was unable to tolerate these. She used Plenvu in preparation for a colonoscopy. At issue is the medical necessity for Plenvu.

The request for Plenvu is medically necessary. The most recent American Society for Gastrointestinal Endoscopy guidelines for bowel preparation recommend that "bowel preparations be individualized by the prescribing provider for each patient based on efficacy, cost, safety, and tolerability considerations balanced with the patient's overall health, comorbid conditions, and preferences" [1].  In this case, the patient has failed multiple bowel preparations, including low-volume bowel preparations, due to inability to tolerate them.  Plenvu has demonstrated safety and efficacy for bowel preparation in high-quality clinical trials, and can be more tolerable than alternative bowel preparations (including the formulary alternatives Golytely and Nulytely, which are large-volume preparations, and less well tolerated than low-volume alternatives) [2-4].  Therefore, an attempt of Plenvu for bowel preparation is supported in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus, stage 4 chronic kidney disease, hypercholesterolemia, and hypertension (HTN).
Treatment: Farxiga

The insurer denied the Farxiga.
The determination is overturned.

The patient has a history of type 2 diabetes mellitus, stage 4 chronic kidney disease, hypercholesterolemia, and hypertension (HTN).
The patient's provider states the patient cannot take metformin or Jardiance due to her estimated glomerular filtration rate (eGFR) being less than 30. The provider would like to prescribe Farxiga which is a sodium-glucose co-transporter-2 (SGLT)-2 inhibitor in the setting of chronic kidney disease (CKD). Farxiga is indicated to reduce the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular (CV) death, and hospitalization for heart failure in adults with chronic kidney disease at risk of progression. It has also been shown to reduce the risk of hospitalization for heart failure in adults with type 2 diabetes mellitus and either established cardiovascular disease or multiple CV risk factors. The patient has a creatinine of 1.91, an eGFR of 29, and a hemoglobin A1c of 12.2. The health plan denied Farxiga as they require therapeutic failure (after a 3 month trial), contraindication of intolerance to Jardiance in order to approve an alternative such a Farxiga. At issue is the medical necessity of Farxiga.

The Farxiga is medically necessary. 
The formulary alternatives are Metformin [generic Glucophage, Glucophage XR] and Jardiance) 
The patient has an eGFR less than 30. Both metformin and Jardiance are not approved for use with an eGFR less than 30. Farxiga would therefore be medically necessary as the two alternative medications are both medically contraindicated.