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



Diagnosis: atrial septal defect.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a girl with a history of prematurity at 34 weeks, pulmonary stenosis status post valvuloplasty and a moderate secundum atrial septal defect. She was taken to the cardiac catheterization laboratory and had a transcatheter closure of her ASD (atrial septal defect) under general anesthesia. She was admitted for observation overnight and had an electrocardiogram (ECG) and echocardiogram the following day. She was subsequently sent home. Under review is the inpatient stay.

The inpatient hospital admission is medically necessary. This patient had a major cardiac procedure, requiring general anesthesia. Moore et al describe an up to 5.8% major adverse event rate in transcatheter ASD device closures. Standard of care for these patients is an overnight stay with further imaging in the morning to monitor for these major events in the first 24 hours after ASD closure.

The health plan's determination is overturned.
Appeal type: Medical necessity
Decision: Overturned

Documentation:  Central Nervous system/Neuromuscular Disorder-Migraine.
Treatment:  Pharmacy/Prescription Drug (Botulinum Toxin A [Botox 800 Units]).

The health plan denied the treatment of Pharmacy/Prescription Drug (Botulinum Toxin A [Botox] 800 Units) as not medically necessary.  The reviewer has overturned in whole the health plan's determination.

This is a patient, who is being treated with Botox.  She is receiving treatment on approximately every three month basis.  She has received a total of 200 units on multiple occasions.

According to an office note from the neurologist, she had a very good response, and had one very small migraine over the previous three months.  At that time, she received a total of 200 units.

On a later visit she received an additional 200 units, and was also placed on Requip, noting continued benefit from Botox.  Three months later she received 200 units of Botox, noting continued stability and no evidence of any side effects of Botox.  It was also noted that her back pain had improved significantly, and she was on gabapentin.  She received 200 units of Botox, and headaches had been reduced by at least 60% since being on Botox.

Note that the note indicates that the patient had a reduction of 60% from baseline.  She was receiving Botox every 12 weeks.

A prior authorization form from the provider requested Botox 100 unit vials quantity of two every 12 weeks with 4 refills.

The patient has been receiving Botox 200 units every 12 weeks.  She had a 60% reduction of migraines.  As per the documentation from the treating neurologist, she has benefited from the current dose of Botox 200 units.  While United States Food and Drug Administration (FDA) guidelines use 155 units as standard dosing, generally accepted neurological practice supports the safety of dosing up to 200 units.  There was no documentation at any time that the patient is receiving 800 units of Botox per dose.  The patient has benefited from Botox with a 60% reduction in migraines, and, given the accepted dosing of 200 units every three months, the continued use of Botox 200 units per dose every three months is medically necessary.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis:  Rosacea.
Treatment:  Azelaic Acid 15% Gel.

The insurer denied the Azelaic Acid 15% Gel.  The denial is overturned. 

The patient is a woman with mild to moderate rosacea for whom azelaic acid 15% gel is requested.  She has tried and failed metronidazole gel and is allergic to sulfa medications, so she cannot use sodium sulfacetamide.

Yes, the treatment with Azelaic Acid 15% gel is medically necessary.

Topical azelaic acid - Azelaic acid is a naturally occurring dicarboxylic acid with anti-inflammatory and antioxidative properties.  Similar to metronidazole, azelaic acid improves papular and pustular lesions, and may also reduce erythema.  The mechanism of action for azelaic acid in rosacea is not well understood.  Reductions in messenger RNA (ribonucleic acid) for cathelicidin and kallikrein 5, potential contributors to the development of rosacea, have been detected following treatment with topical azelaic acid in patients with rosacea.  Azelaic acid-induced modulation of the inflammatory response via activation of peroxisome proliferator-activated receptor-gamma is an additional potential mechanism of action.

Azelaic acid is available as a 20% cream or lotion, or as a 15% foam or gel.  The cream, foam and gel formulations are available in the United States.

The utility of azelaic acid for rosacea is supported by a systematic review of randomized trials performed primarily in patients with papulopustular rosacea that found high certainty evidence to support this therapy.  Azelaic acid was a more effective treatment than placebo (RR [risk ratio] 1.40, 95% CI [confidence interval] 1.28-1.53). 

The patient has failed metronidazole gel and cannot use sodium sulfacetamide due to a sulfa allergy.  She has mild to moderate rosacea, and oral antibiotics (doxycycline) are not indicated.  She should first exhaust topical therapies in attempt to control her disease.  Therefore, azelaic acid 15% gel is medically appropriate and necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite.
Treatment: Comprehensive orthodontic treatment.
The insurer denied the Comprehensive orthodontic treatment. The denial is overturned. 

The patient is a male. The request is for dental benefit coverage for comprehensive orthodontic treatment.

A patient exam and records indicated that the patient has a Class II, Division I deep overbite due to a retrognathic lower jaw creating a severe overjet of approximately 10mm (millimeters) with lip incompetence

Yes, the Comprehensive orthodontic treatment is medically necessary.

A patient with a Class II, Division I with a deep overbite and an overjet of 10mm (millimeters) and lip incompetence (inability to maintain the lips together) of this severity tend to have substantial speech impediments, compromised masticatory function. The teeth are more prone to trauma due to the degree of protrusion. The teeth can cause significant trauma to the surrounding soft tissue structures (lips and cheeks); sleep apnea is also more likely. All these conditions will have a profound effect on the patient's quality of life.

Comprehensive Orthodontics will be necessary to provide some corrective remedy for this patient's condition. Of particular concern is the speech therapist's report that states that this patient's dental anatomy is dictating and limiting any further progress for normal speech. Restoration of normal speech, normal masticatory function can only be achieved with orthodontic treatment which is indicated to reposition the teeth to some semblance of the normal anatomy and thereby restoring normal function.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperhidrosis
Treatment: Botox
The insurer denied the Botox.
The denial is overturned. 

The patient is a female with hyperhidrosis for whom Botox injections are requested. She has tried and failed topical Drysol and over the counter (OTC) clinical strength antiperspirant. She has been receiving Botox injections for a couple of years with great results and no side effects.

Yes, the proposed treatment with Botox injections is medically necessary.

The patient has been treating her severe axillary hyperhidrosis with prescription Botox for three years with excellent results and it is medically appropriate and necessary for her to continue with this treatment.

Individuals with primary focal hyperhidrosis typically have excessive sweating of the palms, soles, and axillae and can suffer significant psychological, social, educational, and occupational consequences. Patients with axillary, palmar, or plantar hyperhidrosis should initially be treated with topical antiperspirants such as 20% aluminum chloride hexahydrate or 6.25% aluminum chloride hexahydrate. Skin irritation is a common side effect that may be reduced with proper application technique or a low-potency topical corticosteroid. Second-line treatments for axillary hyperhidrosis include botulinum toxin injection, microwave thermolysis, and topical glycopyrronium.

Botox injections are appropriate and medically necessary to maintain the excellent response the patient has had to this treatment with no side effects for the past three years and they are a continuation of therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Malocclusion
Treatment: Dental/Orthodontic Procedure/Braces
The health plan denied the requested dental treatment plan. The health plan's determination is overturned.

The patient in question is a male with a Class I malocclusion and anterior crossbite of #7. Tooth #27 is showing some recession, and there is wear on #7 due to its position relative to #27. Teeth #20 and #29 are congenitally missing, and baby teeth K and T remain. He is treatment planned for 30-36 months of orthodontics to correct his malocclusion. His insurance company rejected the claim on the basis that treatment is not medically necessary.
At issue is the medical necessity of the requested dental treatment plan.

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

The health plan has not acted in the best interest of this particular patient. This patient presents with an anterior crossbite and significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.[1,2,3] These problems are much more time consuming and costly to correct than the patient's current orthodontic problem.
The patient has significant maxillary anterior crowding with #7 in crossbite. This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. It is already being worn due to its position relative to #27. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, [4] which will make treating this occlusion at a later time more difficult. Tooth #27 already has slight recession, and further movement of #27 will likely lead to the need for future for periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class I, maxillary and mandibular crowding, deep bite, excessive overjet and impacted maxillary incisor)

Treatment: Braces and treatment visits

The insurer denied coverage for braces and treatment visits.

The denial is upheld. 

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary and mandibular crowding, deep bite, excessive overjet and impacted maxillary incisor. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. 

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, the 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 anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. This reviewer concurs with the findings of the insurer of attaining 11 points on the HLD index (3 points overjet, 6 points overbite, 2 points labiolingual spread).
 
Regarding the validity of the HLD 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. Peer reviewed articles conclude 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 healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. Braces and treatment visits are not considered medically necessary for this patient.

The carrier's denial of coverage for braces and treatment visits is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyponatremia

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a female patient with a history of diabetes, epilepsy, diverticulitis, nicotine abuse, and bipolar disorder. The patient presented to the Emergency Room (ER) with complaints of generalized weakness and dizziness for the past 2 weeks. In the ER, the patient's vital signs were: temperature 98.4, blood pressure 105/55, pulse 84, respiratory rate 18 and oxygen saturation of 98% on room air. The patient was hemodynamically stable with normal oxygenation. As per the patient's bloodwork, she did not have significant electrolyte disturbances other than mild hyponatremia (sodium of 129). The patient did not have significant change in kidney function, did not have cardiac arrhythmias, and no altered mental status or persistent nausea and vomiting with dehydration. There is also no documentation of refractory pain. The patient was able to tolerate an oral diet and did not need total parenteral nutrition (TPN). The patient's condition responded to intravenous fluid and oral fluid restriction within 24-hours of treatment. 

As per literature review, there is no evidence-based clinical finding for this patient's case to warrant an inpatient level of care. The patient's care could have been safely provided in the ER and/or observation with close follow-up as outpatient. Thus, the inpatient hospital admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's Disease
Treatment: Rivastigmine 1.5 mg #24 capsules per day (36 mg per day)
The insurer denied Rivastigmine 1.5 mg #24 capsules per day (36 mg per day)
The determination is upheld.


The patient has a past medical history significant for Alzheimer's type dementia. Rivastigmine 1.5 milligrams (mg), #24 capsules per day for total of 36 milligrams (mg) a day was requested. This was denied by the plan stating the following: The dose is not within the plan's quantity limit of 2 capsules a day. Clinical resources do not support the use of 36 mg daily. At issue is the medical necessity of the Rivastigmine 1.5 mg #24 capsules per day (36 mg per day).

The requested health service is not medically necessary for this patient.
This is a patient with a past medical history significant for Alzheimer's dementia. There were limited medical records provided. The rationale for treatment was continuation of medical care. Rivastigmine 1.5 mg, #24 capsules per day for total of 36 mg a day is requested.
Rivastigmine is an acetylcholine esterase inhibitor indicated for the treatment of mild to moderate Alzheimer's disease. Dosing regimens approved by the Food and Drug Administration (FDA) include a topical patch along with capsules. Capsules are indicated from dosage range of 1.5 mg twice a day up to 6 mg twice a day as a maximal dose. There is no FDA indication for a dose greater than a total of 12 mg a day and there is no FDA indication for multiple doses, greater than 2 a day. This is supported by the package insert referenced below. Dosing regimens of Rivastigmine greater than 12 mg a day are not supported by a Medline search. Based upon the provided information, there is limited data to support a dosing regimen that is more frequent than the FDA recommended dosing regimen or add an increased total dosing amount. There was a paper submitted for review, however, there was no significant other medical literature to support a supratherapeutic dosing regimen.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism spectrum disorder (ASD).
Treatment: Applied Behavioral Analysis (ABA) Therapy.

The insurer denied Applied Behavioral Analysis (ABA) Therapy. The health plan's determination is overturned. 

The patient is a boy with multiple behavioral deficits. These include poor social interactions, poor language skills, behavioral rigidity, and aggression. Based on this combination of deficits, he has been diagnosed with autism spectrum disorder. He also displays poor attention and anxiety, for which he has been diagnosed with attention deficit hyperactivity disorder (ADHD) and anxiety disorder. For his ADHD, he is being treated with Vyvanse and Intunive, and for his anxiety disorder, he is being treated with Prozac. For his autism spectrum disorder, his pediatrician has suggested that he be treated with Applied Behavioral Analysis (ABA). The health plan has denied coverage of the ABA therapy on the basis that it is not medically necessary because of the presence of possible comorbid conditions that have not been addressed.

ABA therapy has been shown to improve the behavior and intelligence quotient (IQ) of children with autism spectrum disorder (ASD). It is an effective and widely used therapy for ASD. Child psychiatrists and pediatric neurologists consider ABA therapy to be customary and necessary treatment for children with ASD.
Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder, usually of unknown etiology, that is marked by impaired social interactions, impaired communication skills, and restricted behavioral repertoire. This patient has all of these symptoms and has been properly diagnosed with ASD. Applied Behavioral Analysis (ABA) is the process of applying behavioral interventions that are based on principles of learning and that have been derived from experimental psychology research. These interventions are applied to increase and maintain desirable adaptive behaviors and to minimize maladaptive behaviors. ABA is recognized as an effective treatment for ASD. It is customary and appropriate for children with ASD to receive ABA therapy.
Many children with ASD have ADHD and anxiety as comorbid conditions, and these are not considered contraindications to treatment with ABA therapy. Furthermore, this patient's s anxiety and ADHD have been evaluated and are being addressed through treatment with Prozac, Vyvanse, and Intunive.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and orthodontic treatment visits. 
The denial is upheld.

The patient is a female with Skeletal Class I occlusion. The patient has moderate maxillary crowding and moderate mandibular crowding. She has mild overjet and moderate overbite. The subject to be determined is the medical necessity for braces.

Treatment of braces and periodic orthodontic treatment visits are not medically necessary for this patient. Using the standard Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 16 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9mm or greater and underbite 3.5 millimeter (mm) or greater. The malocclusion in question does not meet the standard of care criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces are not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Pharmacy/Prescription Drugs (Dupixent)
The health plan denied the requested prescription drug (Dupixent). 
The health plan's determination is upheld.

The patient is a male with atopic dermatitis that is generalized and is worse on the back and the legs. The patient has tried and failed topical Halobetasol, Betamethasone, Triamcinolone, and Tacrolimus. The patient is documented to have severe atopic dermatitis and has a history of Crohn's disease and is on Infliximab infusions.
Dupixent is under review for medical necessity.

The health plan's denial of the medical necessity of Dupixent is upheld, in whole.

No. Although some form of systemic therapy is indicated for this patient, the risks of using Dupixent are entirely unknown when used with Iinfliximab (brand name Remicade). Dupixent is an anti-Interleukin 4/13 antagonist, and Remicade is a Tumor Necrosis Factor antagonist, and there is little to no evidence to support the enhanced benefit and ensured safety of the use of the two of them in combination for any given clinical scenario. Alternative oral/systemic therapies, and/or light therapy, are more appropriate and literature-supported [1-4] treatments acceptable for the treatment of this patient's atopic dermatitis. Accordingly, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient in denying coverage of Dupixent as not medically necessary.
The patient has no documented treatment failure with, or true medical contraindication to, either phototherapy and/or one of the standard, first-line oral medications such as Methotrexate, Azathioprine, or Mycophenolate Mofetil. These oral/systemic therapies have also been utilized in the treatment of gastrointestinal autoimmune diseases such as Crohn's disease. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature reviews [1-4], the requested Dupixent is not medically necessary.
Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. This review focuses on the use of systemic treatments in adult AD patients analyzing published literature. [2]