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

Diagnosis: Severe Neck Pain.
Treatment: Magnetic resonance imaging of the cervical spine without contrast.

The insurer denied coverage for magnetic resonance imaging of the cervical spine without contrast.
The denial is overturned.

The patient is a woman who has severe pain in the neck radiating down to the left shoulder and into her arm and lower back.  The patient's treatment history includes steroid injections, non-steroidal anti-inflammatory drugs, and physical therapy. Her condition has failed conservative treatment, and she also has stiffness due to osteoarthritis. The pain has also been interfering with her activities of daily living. A magnetic resonance imaging (MRI) of the cervical spine was ordered to rule out any changes to pathology versus nerve root compression. 

Blanped et al (1) published clinical practice guidelines about evaluating neck pain.
"Patients with normal radiographs and with neurologic signs or symptoms should undergo cervical MRI that includes the cranial cervical junction and the upper thoracic region. If there is a contraindication to the MRI examination such as, but not limited to, a cardiac pacemaker or severe claustrophobia, computerized tomography (CT) myelography with multiplanar reconstruction is recommended. Magnetic resonance imaging is usually the preferred first imaging modality for patients with nonresolving radiculopathy or progressing myelopathy. Gadolinium contrast administration is preferred when oncological, infectious, inflammatory, or vascular causes of myelopathy are suspected." 

The American College of Radiology (2) similarly recommends an MRI in cervical radiculopathy: "Noncontrast MRI is usually appropriate for assessment of new or increasing radiculopathy due to improved nerve root definition."

The requested MRI is medically reasonable and necessary.

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

The insurer's denial of coverage for a magnetic resonance imaging of the cervical spine without contrast (code 72141) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent (at a dose of 300mg per week). 

The insurer denied the Dupixent (at a dose of 300mg per week). 
The denial is overturned. 

The patient is a male with atopic dermatitis, treated with topcial steroids, topical calcineurin inhibitors, Eucrisa and Dupixent 300 mg (milligrams) every other week. He continues to have flares and was increased to weekly dosing with improved control. 

The patient's provider requesting Dupixent 300 mg (milligams) every week. The health plan denied coverage of the request, as this is not the recommended dose. 

Yes, the requested weekly dosing of Dupixent is medically necessary. 

The study performed by Gao et al sought to characterize the real-world experience for recurrence of AD (atopic dermatitis) prior to the next dose of dupilumab and how patients on weekly dosed dupilumab did in the cohort, all of whom were inadequately controlled on the approved dosing. 

17 patients were found to have tried weekly dosing. It was observed that 12/17 patients (71%) reported recurrence prior to their next dupilumab dose, and all of them (100%) claimed that increasing EOW (every other week) dosing of dupilumab to EW (every week) dosing helped control their symptoms, this benefit was worth the effort of injecting oneself twice as often, and they planned to remain on weekly dosing. 

The study by Worm et al also examined dosing regimens for Dupixent. In this trial, continued response over time was most consistently maintained with dupilumab administered weekly or every 2 weeks. Longer dosing intervals reduced efficacy. This further supports that some patients may need weekly dosing. 

While limited, there is support in current peer reviewed medical literature that biologics often need dose adjustment in psoriasis, atopic dermatitis and other conditions. Therefore given the failure of this patient on every other week dosing and support in current literature, the request is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient is a female with no significant medical history. She presented to the emergency department (ED) as advised by her primary care physician due to anemia. Her hemoglobin was 6.1 and her hematocrit was 22.1 in the ED. Her iron saturation was 2% (percent). She was not symptomatic. Per clinical notes, "Last week was feeling a little week but this resolved". She received intravenous fluids and 1 unit of blood and was admitted to the hospital for anemia. She received post transfusion monitoring, further diagnostic testing, and repeat laboratory. 

The patient was asymptomatic and also transfused in the ER (emergency room). She was not bleeding and there was no indication of hemolysis. Her iron saturation was 2%, which suggests iron deficiency. This condition could have even been treated with oral or IV (intravenous) iron, without recourse to transfusion. Certainly, after the transfusion, she could have been discharged to outpatient follow-up. Therefore, the inpatient admission is not considered medically necessary for this patient.

DeLoughery T. G. (2017), "Beyond anemia, lack of iron has protean manifestations, including fatigue, hair loss, and restless legs. The most efficient test for the diagnosis of iron deficiency is the serum ferritin. Iron replacement can be done orally, or in patients in whom oral iron is not effective or contraindicated, with intravenous iron." 

Alexander, J., & Cifu, A. S. (2016), "More than 13 million units of RBCs (Red Blood Cells) were transfused in the United States in 2013.1 Transfusions are safe, with only 0.24% accompanied by an adverse reaction, and life-threatening transfusion reactions occur at a rate of only 15.1 per 1 million blood components transfused." 

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

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

Diagnosis: Mouth and Neck Pain. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He presented to the ED (emergency department) with a 3 day history of floor of mouth and neck pain with trismus and dysphagia. There was decreased oral intake. 

The patient's temperature was 101.2. ENT (otolaryngology) exam reported pharyngeal edema and erythema with FOM (floor of mouth) induration. WBC (white blood count) was 20.3. CT (computed tomography) reported a left floor of mouth located abscess. Flexible laryngoscopy noted edema on the lingual surface of the epiglottis. There was no sign of airway obstruction. 

The patient was started on IV (intravenous) antibiotics, steroids and pain medication. Inpatient admission was initiated. The patient was taken to the OR (operating room) for I&D (incision and drainage) of the abscess and extraction of tooth #17. He was discharged. 

The inpatient admission was previously denied coverage by the health plan as not medically necessary, and the denial is being appealed. 

No, the Inpatient admission was not medically necessary. 

All records were reviewed. The patient presented with a floor of mouth loculated abscess, leukocytosis and elevated temperature. There were no complaints of airway distress. An I&D (incision and drainage) was performed. The patient improved after the I&D (incision and drainage). The patient's pain was controlled. There were no intraoperative or postop complications. The patient was discharged. Based on the above, the medical necessity of the inpatient admission cannot be confirmed, as the patient's care could have been provided at an Observation level of care. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The inpatient admission was not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned


Diagnosis: Asthma
Treatment: Asmanex HFA (mometasone furoate)
The insurer denied Asmanex HFA (mometasone furoate). The health plan's determination is overturned. 

The patient is a female. Under review is Asmanex HFA (Hydrofluoroalkane) (mometasone furoate). This was denied because at least 3 of the preferred products were not tried and failed, and this decision is being appealed. The formulary alternatives are Arnuity Ellipta, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, and Qvar Redihaler.
The patient has asthma and has been well controlled on Asmanex HFA for the past few years.  She has tried and failed Flovent HFA (had adverse effect of nightmares). Due to her young age, she is unable to perform adequate technique to use Arnuity Ellipta, Flovent Diskus, Pulmicort Flexhaler, or Qvar Redihaler. She also had hyperactivity when Qvar was tried.

A formulary exception is indicated in this case.
There is currently no evidence in the medical literature demonstrating the superiority of one inhaled steroid over another with regards to efficacy or side effect profile. Any inhaled steroid should be considered as long as it is approved for that age, the child is able to properly use the device (they each require a different technique), and there is no history of prior adverse effects.
Arnuity Ellipta is Food and Drug Administration (FDA) approved for the treatment of asthma in patients aged 5 and older. The prescribing physician states that the patient isn't able to perform an adequate technique to use this inhaler.
Flovent Diskus is FDA approved for the treatment of asthma in patients aged 4 and older. The prescribing physician states that the patient isn't able to perform an adequate technique to use this inhaler.
Flovent HFA is FDA approved for the treatment of asthma in patients aged 4 and older. This medication has been tried and failed due adverse effects of sleep disturbances.
Pulmicort Flexhaler is FDA approved for the treatment of asthma in patients aged 6 and older. The prescribing physician states that the patient isn't able to perform an adequate technique to use this inhaler.
Qvar Redihaler is FDA approved for the treatment of asthma in patients aged 4 and older. The prescribing physician states that the patient isn't able to perform an adequate technique to use this inhaler.
Therefore, the formulary drugs would be expected to either be not as effective or cause adverse effects. Asmanex HFA (mometasone furoate) is indicated for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: atopic dermatitis
Treatment; Dupixent
The insurer denied Dupixent. The health plan's determination is upheld.

The patient is a male with moderate to severe atopic dermatitis of the arms, face, left hand, neck, nose, and trunk. The patient has previously tried and failed topical corticosteroids (triamcinolone, hydrocortisone, and fluocinonide) and tacrolimus, as well as oral corticosteroids with no signs of improvement. A dramatic improvement after a loading dose with Dupixent samples was noted.

The patient has insufficient to no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors and/or more potent topical steroids, and/or Eucrisa, and/or standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil) that would obviate the need for further topical therapies (despite these oral medications not be required step therapy for Dupixent).

Based on a review of the medical records, Dupixent appears to have been administered prior to any compliant, adherent, and comprehensive treatment regimen of topical medications and treatments (and/or the aforementioned first-line oral medications), so that Dupixent appears to have been used out of convenience instead of true medical necessity.

Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature, the requested Dupixent is not indicated for this patient. The patient can try the plan formulary drugs.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: palpitations
Treatment: Mobile heart monitor
The insurer denied Mobile Cardiac Electrocardiographic (Heartbeat Tracing) Recording in Real Time Services. 

The health plan's determination is upheld.

The patient is a man who was evaluated for occasional "fluttering" of his heart, which usually lasted a few seconds and sometimes lasted a few minutes. The frequency of these episodes was not specified. He also complained of occasional non-exertional chest discomfort. His past medical history was unremarkable. Ambulatory electrocardiographic monitoring with mobile cardiac outpatient telemetry (MCOT) was prescribed.  

Mobile Cardiac Electrocardiographic (Heartbeat Tracing) Recording in Real Time Services was not medically necessary for this patient. The mobile cardiac outpatient telemetry (MCOT) device that this patient wore are capable of continuously monitoring the patient's rhythm and immediately transmitting any detected abnormal rhythm to a remote station that is manned by technicians at all times. Their diagnostic yield compares favorably to that of other recording devices. For example, in the report by Rothman, et al, 266 patients, from 17 centers, with syncope, presyncope, or palpitations, were randomized to recording with either an MCOT device or a standard loop recorder. The diagnostic yield in the MCOT group was 88% (percent), significantly higher than the 75% yield in the loop recorder cohort. However, it should be noted that only a small percentage of patients in this study had event monitors that had an autoactivation function. There are no published reports directly comparing the yield of standard event monitors with an autoactivation function with monitors with MCOT function.

There is no documentation that this patient was at high risk for a potentially life-threatening arrhythmia, has had a stroke or has a history of atrial fibrillation. Thus, while ambulatory electrocardiographic monitoring was appropriate, MCOT was not medically necessary. Moreover, since the physician's note did not document the frequency of this patient's palpitations, it cannot be determined monitoring was necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations, shortness of breath
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history significant for coronary artery disease (CAD), 3-vessel coronary artery bypass graft (CABG), implanted loop recorder (ILR), stroke, diabetes mellitus type 2, and hypertension (HTN) who was brought to the emergency department (ED) by Emergency Medical Services (EMS) for evaluation of shortness of breath and palpitations. A review of the patient's vital signs demonstrated that she was hemodynamically stable. An electrocardiogram (ECG) showed normal sinus rhythm with right bundle branch block (RBBB) and no acute ST-T wave changes. She was minimally symptomatic complaining of generalized weakness and denied chest pain. Interrogation of the ILR showed no evidence of an arrhythmia. The patient was admitted under an inpatient level of care for evaluation of arrhythmia, interrogation of ILR, and rule out acute coronary syndrome (ACS). There was no evidence of ACS and no evidence of arrhythmia on ILR interrogation or telemetry. The patient was discharged home in stable condition. At issue is the medical necessity of an inpatient stay.

No, an inpatient level of care was not medically necessary in this case because there was no evidence of ACS,  The patient presented with palpitations and shortness of breath but remained hemodynamically stable and experienced quick resolution of her symptoms. She was ruled out for ACS and there was no evidence of arrhythmias on telemetry monitoring or ILR interrogation. According to the well validated HEART [history, EKG, age, risk factors, troponin] score pathway, a lower level of care would have been medically appropriate and safe in this case to rule out ACS (1). In addition, expert consensus guidelines on the evaluation of chest pain and non-ST elevation acute coronary syndromes also indicate that a lower level of care would have been medically appropriate and safe in this case for evaluation of her symptoms and rule out ACS (2, 3). An ECG was negative for ischemic changes, and cardiac troponins were negative. Therefore, a lower level of care would have been medically appropriate and safe in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Durable Medical Equipment (DME). 
The insurer denied Zoll life vest. 
The denial is overturned. 

The patient is a male who was admitted to the hospital with a subacute stroke, aspiration pneumonia and sepsis. An echocardiogram showed a left ventricular ejection fraction (LVEF) of less than 10%. There was extensive left ventricular thrombus. Subsequent coronary angiography showed normal coronary arteries. The patient had a prolonged and complicated hospital course with cardiogenic shock and acute kidney injury requiring mechanical ventilation and vasopressors. Repeat echocardiograms showed no improvement in his LVEF. Guideline directed medical therapy for heart failure was instituted and he was discharged with a LifeVest wearable cardioverter defibrillator (WCD). Medical necessity for the WCD is at issue.

The health plan's determination is overturned.

The Zoll life vest wearable cardioverter defibrillator was medically necessary for this patient.
This patient had a newly diagnosed nonischemic cardiomyopathy with marked left ventricular systolic dysfunction. Depressed left ventricular systolic function is a risk factor for, and powerful predictor of, sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients, such as this patient, with nonischemic cardiomyopathy and left ventricular ejection fractions of 35% or less. However, due to the possibility that left ventricular function may improve with time and/or treatment, it is recommended that device implantation be delayed for at least 90 days following the initial diagnosis of nonischemic cardiomyopathy. If, after 90 days of optimal medical therapy, the LVEF remains less than or equal to 35%, ICD implantation is then recommended. Given this patient's substantial risk for lethal ventricular arrhythmias, use of the WCD was appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Problems. 
Treatment: Home Health Care. 
The insurer denied personal care worker service hours 41 hours per week. 
The denial was upheld.

The patient is a female with a past medical history significant for osteoporosis, chronic obstructive pulmonary disease (COPD), constipation, dizziness, edema, hyperlipidemia, gait dysfunction, insomnia, joint pain, osteoarthritis, stress incontinence, asthma, the ptosis of the eyelids, and vitamin D deficiency. This review is for the medical necessity of reduction in personal care worker service hours from 41 hours a week to 38.5 hours a week. The patient is requesting additional services.

The health plan's determination is upheld.

The requested health service for personal care worker service hours of 41 hours per week is not medically necessary for this patient. The plan has approved 38.5 hours per week, a reduction from the previous 41 hours per week. 41 hours per week is not medically necessary.
Services were denied by the plan stating the following. Based upon your most recent assessment it demonstrated the ability to manage in the community effectively. The standardized time tasking tool use as a guide during this assessment shows 31 hours per week will meet your personal needs. The plan has instead authorized 38.5 hours a week of services. Your activities of daily living show you need extensive assistance. You still perform 50% (percent)  or more of the tasks needed with bathing and dressing lower body. You have strong community support.
Your most recent assessment states you are able to shift and change position in bed and do not require additional assistance throughout the day or overnight to assist with this function. Your daily needs can be met through specialized medical equipment.
Appeal from the patient's power of attorney states that the patient relies on an aid when to take medicines and drink water. She has frequent complaints of arthritic pains; she usually takes 2 naps and needs assistance to walk to her bed. She is unsteady when she walks. Recent diagnosis of the ptosis of the eyelid.
Uniform Assessment System (UAS) State of New York was reviewed. Noted that the patient is independent with bed mobility, limited assistance with toilet use and independent with eating. Patient uses a cane while indoors and uses contact guard.
Based upon information provided including the appeal from the patient's power of attorney. There are no medical reasons noted to as why the services being provided could not be provided with an allotted time.
The patient's current arthritis symptoms along with bilateral proptosis are of concern however, when approving services, there must be demonstrated need for activities of daily living (ADLs) or Instrumental activities of daily living (IADLs) beyond observation and preventing falls. Services for preventing falls and observation are typically included in the provided services allowed for under the evaluation. Specifically, the aide must be performing a service such as in ADL or IADL to be a covered service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits x12
The insurer denied Braces and monthly visits x12.
The determination is overturned.

The patient has a buccal (reverse) crossbite on teeth 3-5. She presents with a skeletal Class I malocclusion with maxillary and mandibular spacing. She is treatment planned for orthodontics; the treatment was denied due to lack of medical necessity.
At issue is the medical necessity of braces and monthly visits times (x) 12.

The requested treatment is medically necessary. Because teeth 3, 4, and 5 are in buccal crossbite, they have no antagonists. As a result, it is extremely likely that these teeth will overerupt. Once this overeruption occurs, it is very difficult to treat. (1) Buccal crossbite (also known as scissor-bite in the literature) can also negatively affect mandibular growth and should be treated as early as possible to eliminate the potential growth disturbance. (2)
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem.
For these reasons, the requested treatment is medically necessary.