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

Diagnosis: Left knee pain

Treatment: Physical therapy

The insurer denied coverage for physical therapy

The denial is upheld.

The patient is an elderly adult with a right above knee amputation and status left tibia fracture. She has been receiving physical therapy for approximately six months. Under review is additional physical therapy (2 visits).  

The physical therapy treatment notes provide insufficient clinical information to support the medical necessity of continuing treatment. The Physical Therapy progress notes were reviewed. The patient has no complaints of pain (0/10), full left knee range of motion and essentially 4/5 strength. The clinical records do not demonstrate the medical necessity of continuing a structured out-patient physical therapy treatment program from beyond the physical therapy visits that were previously approved. The treatment notes fail to demonstrate evidence of significant ongoing impairment which could not be addressed via a home exercise program (after several months of physical therapy). Continued improvement would be anticipated via a home exercise program.    

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, additional physical therapy (2 visits) was not medically necessary.  

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the physical therapy, 2 visits is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional/Short Stature/idiopathic short stature
Treatment: Pharmacy/Prescription Drugs/Humatrope 12 mg cartridge 0.9 subcutaneously injected daily 
The health plan denied the requested Humatrope 12 mg cartridge 0.9 subcutaneously injected daily as not medically necessary. The health plan's determination is upheld.

The patient is a male who is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). His mother's height is 5 feet 3 inches and father's height is 5 feet 10 inches. His growth chart shows his height around 10% (percentile) since the age of 5 years. He is being followed in the pediatric endocrinology clinic. His initial evaluation was unremarkable (results not available). 

At a follow up visit, his height was 115.1 centimeters (cm) (-1.38 standard deviation (SD)). His growth velocity was calculated as 5.9 cm per year. 

Based on his bone age, his adult height prediction was calculated as 65.2 inches. He underwent GH stimulation testing and his peak GH response was 13.1 nanograms/milliliter (ng/ml) after Arginine and 17.9 ng/ml after Clonidine. Treatment with GH is requested under the indication of idiopathic short stature (ISS).
At issue is the medical necessity for the requested health service/treatment of Humatrope 12 milligram (mg) cartridge 0.9 subcutaneously injected daily.

I uphold, in whole, the health plan's determination of medical necessity.

No. This patient is seeking GH treatment under the indication of ISS. In 2003, the US Food and Drug Administration (FDA) approved injectable somatropin for the treatment of ISS, also called non-GH-deficient short stature, defined by height standard deviation score (SDS) <=-2.25 and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients for whom diagnostic evaluation excludes other causes of short stature that should be observed or treated by other means.
Consensus on the definition of ISS and on the management of children with ISS was published in 2008. In that statement, ISS was defined as an individual with a height more than 2 SD below the mean without findings of any disease.
This patient is relatively short for his age and genetics but growing normally. His height was 1.38 SD (not 2.25 SD) below the mean for age and 1.16 SD below his genetics (mid-parental height +/- 1 SD 69+/-2''). His growth velocity was 5.9 cm per year which is normal (56% (percentile) for age). He clearly does not meet the criteria for the diagnosis of ISS.
The Pediatric Endocrine Society Guidelines for Growth Hormone and Insulin-Like Growth Factor-1 Treatment in Children and Adolescents recommend GH treatment for idiopathic short stature (height -2.25 SD) on a case-by-case basis after assessment of physical and psychological burdens, and discussion of risks and benefits. This patient clearly does not meet the definition of ISS. 
As this patient's height is not 2.25 SD below the mean for age and he is growing normally, he does not qualify for growth hormone treatment under ISS indication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Cholesterol
Treatment: Praluent
The insurer denied Praluent.
The denial is upheld.

The patient is an adult male with history of coronary artery disease (CAD) including coronary artery bypass grafting (CABG) and percutaneous coronary intervention. The patient has risk factors of hyperlipidemia and hypertension. Medications include atorvastatin, metoprolol, Lisinopril/hydrochlorothiazide (HCTZ), and aspirin. Allergies are denied.

The patient's exam was normal. His electrocardiogram (EKG) was consistent with ischemia. The patient's lab showed a low-density lipoprotein (LDL) of 79. The treating physician set a goal LDL of 75 and requested Praluent to be added. Formulary alternatives of Crestor and Zetia were offered as alternatives. In response to the denial, the attending physician stated the patient had intolerance to statins including Crestor. The denial was upheld as there is no documented evidence of use of those formulary drugs or that statin intolerance was present.

The proposed treatment is not medically necessary.

The patient's documented history does not support the use of proprotein convertase subtilisin/kexin type nine (PCSK9) therapy. No reason was presented why Zetia could not have been added to the patient's regimen, and there would have been a reasonable expectation of lowering LDL below 75. Also, literature has little evidence to support that lowering LDL from 79 to 75 would lead to an improved outcome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Issues
Treatment: The insertion of braces and the adjustment of braces
The insurer denied the insertion of braces and the adjustment of braces.
The health plan's determination is upheld.

The patient is a male with a Class I occlusion with appropriate overbite and overjet. He has mild maxillary and mandibular spacing. The following teeth were previously extracted: tooth number 5, tooth number 12, tooth number 20 and tooth number 29. The following teeth are in his crossbite: tooth number 14 and tooth number 15. He has treatment planned for orthodontics to correct his malocclusion, but his insurance company rejected the claim on the basis that treatment is not medically necessary. 
The subject under review is the medical necessity for the insertion of braces and the adjustment of braces.

The health plan has acted in the best interest of this patient. The patient has some minor spacing. His overbite is appropriate and there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows he does not have a traumatic deep bite. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient.

The insertion of braces and adjustment of braces is not medically necessary for the patient. There is no medical reason to correct his malocclusion with braces. There is no evidence of wear or periodontal recession. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male toddler who presented to the emergency department with cough and stridor. He was well until a few days prior to presentation when he developed a runny nose. The night prior to presentation he awoke with a bark-like cough. That night his mother felt that his breathing did not sound right. She woke him up and brought him to the shower to see if the steam would provide relief. He did not improve, so she called emergency medical services (EMS). The EMS team arrived and he received 2 Albuterol treatments in transit.
In the emergency department he was found to be tachypneic with mild retractions, stridor, accessory muscle use, and an oxygen saturation of 95 percent (%). He received intramuscular (IM) Dexamethasone and 2 doses of Racemic Epinephrine. However, he continued to have stridor at rest after these treatments, so he was admitted to the hospital for further care.

Upon admission he initially continued to have accessory muscle use with retractions and stridor at rest. His heart rate was 140 beats per minute (bpm) and his respiratory rates was 34. He was placed on humidified oxygen with Racemic Epinephrine as needed. His stridor quickly resolved, and by later that day he was felt to be stable for discharge with follow up as an outpatient.

The health plan, in its determination of medical necessity, has not acted reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service and treatment of an inpatient hospital admission was medically necessary for the patient. The patient is a toddler who presented with respiratory distress from croup. He had retractions and accessory muscle use upon presentation with stridor at rest. He received intensive and appropriate treatment both in transit and in the emergency department, with bronchodilators, Racemic Epinephrine, and Dexamethasone, however he continued to have stridor at rest. Therefore, he required a hospital admission for ongoing treatment as needed and close monitoring for potential deterioration of his clinical status.
Children with croup may be discharged home after treatment if they have no stridor at rest. Indications for inpatient admission include moderate to severe croup symptoms that recur or persist after initial treatment (consisting of glucocorticoids and one to two nebulized Epinephrine treatments). The patient received appropriate treatment including glucocorticoids and nebulized Epinephrine and he continued to have moderate croup with stridor at rest. He therefore required an inpatient hospital admission for ongoing care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.


The patient is a previously healthy male who presented to the hospital with a history of progressively worsening abdominal pain for 1 day. Evaluation included a physical exam, labs, and a computed tomography (CT) scan. He was without a fever at the time of presentation. A CT scan yielded the diagnosis of appendicitis (hyperemic non-filling appendix). Treatment was initiated with intravenous (IV) fluid and antibiotics.

The patient underwent a laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. He was provided IV fluid and perioperative antibiotics. His vital signs remained normal throughout the hospitalization without a fever. The diet was advanced and pain management was converted to oral medications. He was discharged home.

At issue is the medical necessity of an inpatient hospital stay.

An inpatient hospital stay was not medically necessary as the care and treatment provided could have been appropriately rendered with a lower level of care. The evaluation with examination, lab data, and CT scan established the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and an appendectomy. The early post-surgical course was uncomplicated and the patient was clinically stable for discharge from the hospital following surgery.

The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have provided for presurgical assessment, operative treatment, and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring.

The Milliman Care Guidelines (MCG) indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction, or surgical complications, the procedure may be performed without inpatient admission. In this case, the patient tolerated oral hydration, a diet and medication and the pain was well controlled. A lower level of care would have appropriately provided for presurgical assessment, laparoscopic appendectomy, and post-surgical monitoring. Inpatient care was not required or medically necessary in this case per the referenced MCG or generally accepted medical standards.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, dementia, coronary artery disease (CAD), hypertension (HTN), type II diabetes mellitus (DM), chronic pain, and unsteady gait
Treatment: Personal care assistance (PCA) services: 10 hours per day, 7 days per week, for a total of 70 hours per week
The insurer denied coverage for PCA services: 10 hours per day, 7 days per week, for a total of 70 hours per week
The denial is overturned

This is an elderly patient with chronic medical problems including Parkinson's disease, CAD and DM.  He lives alone in a 1st floor 2-bedroom apartment.  The insurer PCA 8 hours/day, 7 days/week and the request is for PCA 10 hours/day - 7 days/week - a total of 70 hours/week, which is under review.

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Severely Impaired-Never or rarely makes decisions."  He requires extensive assistance for bathing, personal hygiene, dressing and toilet transfer/use.  He is frequently incontinent of bladder and occasionally incontinent of bowel.  Limited assistance is needed for locomotion and ambulation.  He is at the supervision level for bed mobility and eating.  His cognitive status (previously moderately impaired) and functional ability have declined compared to the previous UAS, as has his functional mobility.  His condition and functional capacity continue to decline, are at a level and unpredictable as to require the requested PCA services 70 hours/week.  Given his continued decline and based on the enclosed documents reviewed, the patient's health and safety is more appropriately provided and maintained by increasing PCA services 10 hours/day, 7 days/week, totaling 70 hours/week.  

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 an increase in personal care assistance (PCA) services: 10 hours per day, 7 days per week, for a total of 70 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abscess. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

Patient is an adult with past medical history significant for schizoaffective disorder with auditory hallucinations, who was referred to the emergency department with complaints of left neck swelling and sore throat. 

Vitals on presentation included: Temperature 97.6 degrees Fahrenheit, Blood Pressure 114/80, Pulse 65, Respiratory Rate 19, Oxygen saturation 100% on room air. Laboratory values were notable for the following: White Blood Cells (WBC) 7.6, Hemoglobin 12.3, Hematocrit 36, Glucose 129, Creatinine 1.08, Erythrocyte Sedimentation Rate 21, C-Reactive Protein 7.7. 

The patient was empirically started on intravenous antibiotics (Unasyn and Zosyn) for possible neck abscess. Computerized Tomography (CT) scan with contrast showed soft tissue of the neck revealing cervical lymphadenopathy with tonsillitis with a mass the size of 6 centimeters (cm) by 6 cm. Patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (Augmentin) as an outpatient. 

According to documentation, the patient presented with upper respiratory illness-like symptoms. Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. Based on above findings, the patient met criteria for observation level of management not acute inpatient admission. 

Based on the above, the insurer's denial is upheld. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Dental
Dental procedure

Diagnosis: teeth decay
Treatment: Crowns for Teeth #s 7, 18 and 30 
The insurer denied Crowns for Teeth #s 7, 18 and 30. The health plan's determination is overturned. 

The patient is a male who presents for evaluation and treatment of teeth # (number) 7,18 and 30. Provided for review are previous letters of appeal and denial, full mouth panoramic radiographic image, one page of American Dental Association (ADA) claim forms and health plan language. In question is the medical necessity of the crowns for teeth #7, 18 and 30 (D02751).

Crowns for Teeth #s 7, 18 and 30 are medically necessary for this patient. The teeth involved have an overall fair prognosis from the information provided and will be able to continue to provide form and function if restored with crowns. The rationale for extraction would lead the patient to having diminished posterior support and would be detrimental from a medical/dental perspective as tooth loss increases the load and strain on the remaining dentition. Dentures to not provide support and depend completely on the soft tissue for support, retention and stability, eventually leading to further tooth loss. As the teeth involved have decay and require full coverage restorations, the requested treatment is medically necessary.
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 severe atopic dermatitis (AD). Body surface area affected is 20%(percent). She has tried and failed clobetasol, fluocinonide, Elidel, and dexamethasone 3 milligrams (mg) weekly. The medication under review is Dupixent weekly.

The proposed health treatment Dupixent is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease,
Based on the current peer-reviewed literature, Dupixent weekly is appropriate for this patient. The patient has tried and failed biweekly Dupixent. There are limited other systemic therapies approved for use in atopic dermatitis. In 2019, Thibodeaux et al. published "A review of dupilumab in the treatment of atopic diseases" in which they demonstrated that weekly dosing of Dupixent had significant efficacy (1). Beck et al. also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to 3 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis" (2).
Deleuran et al. writes "This first-step analysis of a long-term, open-label study of dupilumab 300 mg weekly in patients who previously participated in randomized, double-blinded, placebo-controlled clinical trials of dupilumab is, to our knowledge, the longest published study with a systemic drug in adults with AD to date and the first report of dupilumab safety and efficacy beyond 52 weeks of treatment...he safety and efficacy profile from this study supports the role of dupilumab as continuous long-term treatment for patients with moderate to severe AD." (3) Therefore, it is likely based on the patient's clinical findings and refractory disease, that weekly Dupixent will be more beneficial for this patient than standard treatment.
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: Upheld

The patient is a female with moderate to severe atopic dermatitis of the scalp, neck, trunk, and bilateral upper extremities (20%[percent] body surface area involvement). This condition has been present since childhood, and prior failed treatments include topical clobetasol, fluocinonide, Elidel, and both oral dexamethasone and prednisone. The patient is currently being treated with topical dexamethasone and clobetasol, as well as weekly Dupixent (300 milligrams [mg]). The subject under review is whether every week dosing of Dupixent is likely to be more beneficial for this patient than standard dosing.

Although safety and relatively increased efficacy can potentially be beneficial in patients who do not sufficiently respond to the standard, Food and Drug Administration (FDA)-approved dosing of 300 mg every two weeks [1-3], the denial of coverage of weekly Dupixent goes beyond health plan policy restrictions of coverage to the FDA-approved dosing.
Although weekly Dupixent is potentially helpful to patients with severe, treatment-resistant atopic dermatitis who do not sufficiently respond to the FDA-approved dosing, other FDA-approved medications such as the interleukin (IL)-13 inhibitor Adbry and the two Janus Kinase inhibitors Rinvoq and Cibinqo allow other treatments to be successfully used in patients with severe atopic dermatitis [4-8]. For weekly Dupixent to be appropriate for this patient, no other reasonable or viable alternatives would have to be available, but such is not the case with the patient at this time.
In particular, higher dosing of Rinvoq and Cibinqo--both now FDA-approved at those higher doses--have been compared to Dupixent at the FDA-approved every other week dosing and are superior with respect to visual and tactile/pruritus-related metrics compared to Dupixent.
The patient therefore has other literature-supported options than weekly Dupixent, and the request for weekly Dupixent is not more beneficial than other standard treatments for this patient's severe atopic dermatitis.