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

Diagnosis: hyperbilirubinemia
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This is the case of a young male born by SVD (spontaneous vaginal delivery) at 35.5 weeks who was admitted to the hospital for phototherapy secondary to hyperbilirubinemia. The Bilirubin level was 15.3 at 62 hours old with phototherapy threshold of 15.8. He was reportedly breast and bottle feeding well with normal voiding and stooling patterns and typical activity level.

The inpatient hospital admission was not medically necessary.
Based on the 2022 American Academy of Pediatrics (AAP) Clinical Practice Guidelines, and noted in the admission records, this infant had a measured bilirubin level that was not at the phototherapy threshold. Although this infant's gestational age put him at higher risk for neurotoxicity related to hyperbilirubinemia, there was no indication of additional risk factors such as family history, blood type incompatibility, poor feeding or stooling. Additionally, there was no indication of rate of rise or the baby's bilirubin screen result during birth hospitalization. This baby was reportedly feeding well, both breast and bottle, in addition to doing and stooling typically. Therefore, it is very likely that this baby's bilirubin was naturally peaking and hospitalization may have been avoided by rechecking a bilirubin level upon presentation or 12 hours after the prior. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male with medical history of alcohol-induced pancreatitis, asthma, and chronic back pain. He presented to the emergency department with upper abdominal pain radiating to the back and dyspnea. Vital signs were notable for elevated blood pressure of 157/87. Physical examination was notable for uncomfortable appearance and soft, distended abdomen with diffuse tenderness, more in the epigastric area. Labs showed low hemoglobin of 10.6 and hematocrit of 30.5%, low potassium of 3.3, elevated lipase of 232, and elevated lactate of 2.66. Chest x-ray showed no active pulmonary disease. Abdominal x-ray showed nonobstructive bowel gas pattern. Computed tomography scan of the abdomen and pelvis showed limited pancreatic assessment without intravenous contrast, and mild peripancreatic infiltration which may be due to acute pancreatitis. 

The inpatient hospital admission was not medically necessary. The care provided could have been provided at a lower level of care. In this case, the patient presented with abdominal pain, somewhat elevated lipase (near but not quite three times the upper limit of normal), and imaging consistent with possible acute pancreatitis. His suspected alcohol-induced pancreatitis was uncomplicated, and there were no complications such as pancreatic necrosis, worsening pseudocyst, or abscess. No procedural interventions such as endoscopic ultrasound were necessary during the stay. He was appropriately treated with intravenous fluids, and his symptoms improved; his diet was advanced and discharge was then deemed appropriate. There was concern for alcohol withdrawal, but no complicated or severe acute alcohol withdrawal was documented; he was appropriately monitored. The interventions performed, including labs, monitoring, imaging, specialist consultations, and intravenous fluids with gradual advancement of diet, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.

Treatment: Braces and monthly visits.

The insurer denied coverage for braces and monthly visits.

The denial is upheld.

 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to impacted permanent anterior teeth among other findings. The orthodontist has completed the Handicapping Labiolingual Deviation Index (HLD) as required and has chosen the automatically qualifying condition of impacted permanent anteriors (#27) where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 15 points on review by internal reviewers.

Upon review of the submitted documentation, (study models were not provided for review), 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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. 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 this criterion is not met and the HLD index attains 15 points which is below the threshold of 26 or more points which is necessary for approval of orthodontic care. 

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 needs is a valid approach. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic needs. 

Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 braces, and D8670 Monthly Visits x 12 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female. An inpatient hospitalization is under review. There was history of hypertension and hyperlipidemia. The patient presented with chest pain. There were palpitations. The chest pain did not continue upon presentation. Blood pressure was mildly elevated. Other vital signs and oxygen saturation were essentially normal. The patient was in no distress. The electrocardiogram was reported as nonacute. The left ventricular ejection fraction (LVEF) was normal by echocardiography. She had a recent computed tomography (CT) calcium score of zero. Computed tomographic angiography was negative for coronary artery disease. A chest x-ray was not acute. Troponins were essentially negative. The patient remained stable and was discharged.

The requested health service was not medically necessary.

This patient presented with chest pain and remained stable. There was no congestive heart failure (CHF); respiratory distress; ongoing symptoms suggestive of treatment refractory angina or angina equivalent; severe arrhythmia; hemodynamic instability; another serious cause for chest pain, such as a pulmonary embolism (PE) or aortic dissection; need for prolonged intravenous medications or oxygen support; introduction of high-risk medications requiring ongoing in-hospital monitoring; need for invasive hemodynamic monitoring; need for vasopressor or mechanical cardiac support; or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal electrocardiogram. The setting of this case at an inpatient level of hospitalization rather than a lower level of care has not been established for care toward improved cardiac outcomes. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: atrial fibrillation.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male who was referred to the emergency department (ED) from the cardiology clinic where he was seen complaining of three days of dyspnea and chest pressure and was found to be in atrial fibrillation with a rapid ventricular rate. His medical history was remarkable for coronary artery disease, congestive heart failure (most recent left ventricular ejection fraction of 55%), atrial fibrillation with ablation, hypertension, hyperlipidemia, stroke, chronic hepatitis C, seizure disorder, and schizophrenia. In the ED, his blood pressure was 104/86 with a heart rate of 110. His respiratory rate was 20/minute with a room air oxygen saturation of 96%. On physical exam, his chest was clear. An electrocardiogram showed atrial fibrillation. 

Based on the documentation provided, an inpatient hospital admission was not medically necessary.
This man presented with atrial fibrillation (AF) with a rapid ventricular rate. He was hemodynamically stable, there was no evidence of acute ischemia, he was not in decompensated heart failure, had no evidence of structural heart disease, and was not at high short-term risk for thromboembolism. For patients presenting with acute AF, the safety of observation or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Psoriasis.

Treatment:  Taltz 80 milligram (mg) per milliliter (ml) autoinjector once every 3 weeks.

The insurer denied coverage for Taltz 80 milligram (mg) per milliliter (ml) autoinjector once every 3 weeks.  The denial is overturned.


The patient is an adult female with a diagnosis of psoriasis.  The patient has been treated with Taltz monthly injections for 2 years.  The results were not satisfactory, and as such the patient was switched to every 3-week dosing.  The request is for Taltz 80 mg every 3 weeks, as a dosing adjustment prior to changing to an alternative biologic. 

Based on the submitted documentation, the Taltz dosing adjustment is medically necessary.  The patient requires systemic therapy for control and management of her psoriasis and psoriatic arthritis diagnoses. Prior to switching to every 3-week dosing, the patient experienced joint pain and stiffness in the neck, back, and knees with psoriatic flares.   Prior to changing to an alternative biologic, it is reasonable and within the standard of care to attempt an adjusted dosing regimen.  Taltz is Federal Drug Administration (FDA) approved for treatment of psoriasis vulgaris and it is reasonable to attempt this dosing schedule.  Furthermore, a recent study by Wu et. al. found that dose escalation for Taltz was noted in 18% (percent) of patients being treated for psoriasis. 

The joint American Academy of Dermatitis - National Psoriasis Foundation (AAD-NPF) guidelines for psoriasis treatment with biologics states that Taltz is recommended for monotherapy in the treatment of psoriasis with a strength of recommendation of "A" -the highest recommendation.  Based on the submitted documentation, Taltz dosing every 3 weeks is approved based on the current evidence-based medical literature.

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 Taltz 80 milligram (mg) per milliliter (ml) autoinjector once every 3 weeks services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lung Cancer.
Treatment:  Imfinzi.

The health plan denied Imfinzi.  The determination is upheld.

The patient is a male with stage 3B squamous cell carcinoma of the left lower lobe. The patient has received two cycles of carboplatin+Abraxane as "induction therapy." He had an ambiguous response radiographically, but there was no clear evidence of progression, and he subsequently received chemo-radiation with carboplatin+paclitaxel. Adjuvant durvalumab has been recommended.
At issue is the medical necessity of Imfinzi (durvalumab).
The health plan's determination of medical necessity is upheld in whole.
The requested health treatment of Imfinzi is not medically necessary for this patient.
In a randomized phase III trial (PACIFIC), over 700 patients with unresectable, stage III Non-small-cell lung carcinoma (NSCLC) without progression after at least two cycles of platinum-based chemoradiotherapy were randomly assigned to up to 12 months of the programmed death-ligand 1 (PD-L1) antibody durvalumab every two weeks or placebo in a 2:1 ratio. At a median follow-up of 25 months, durvalumab increased the median progression free survival (PFS) (17.2 versus 5.6 months) and overall survival (OS). Subsequent reporting revealed five-year survival rates of 43 versus 33 percent, and median OS of 48 versus 29 months, with and without durvalumab, respectively. The benefit in PFS and OS with durvalumab was observed in both PD-L1 greater than (>) 25 or less than (<) 25 percent subsets. Further analysis observed that benefit with durvalumab was not evident in patients with PD-L1 expression < 1 percent. This patent's biomarker status is not available for review, and his imaging is ambiguous at best. In this clinical scenario, it is not clear durvalumab is supported in the literature or national guidelines, and thus, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion with protrusive maxillary incisors
Treatment: Braces and monthly visits
The insurer denied braces and monthly visits. 
The health plan's determination is overturned.

This is a male patient with a Class II malocclusion with protrusive maxillary incisors. He has a 7-millimeter (mm) overjet and a 5 mm deep bite. He has severe maxillary and mandibular crowding. Tooth number (#) 20 is impacted and unable to erupt due to crowding. He has treatment planned for orthodontics with extraction of four first premolars to correct this malocclusion.
At issue is the medical necessity of braces and monthly visits.

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

The requested health service/treatment of braces and monthly visits is medically necessary for this patient.
Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. Additionally, tooth #20 is impacted. Studies have shown almost 65 percent (%) of untreated impacted teeth will cause some kind of pathology. The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. [1] Given the proximity of #20 to the roots of the adjacent teeth there is already concern that the mandibular first molar may be damaged.
There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. [2] Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. Additionally, overjets greater than 6 mm are shown to negatively affect the oral health quality of life of patients. [3]
Therefore, the requested health treatment of braces and monthly visits is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-alcoholic steatohepatitis
Treatment: Mounjaro
The insurer denied: Mounjaro
The denial is upheld.

The patient is an adult male with non-alcoholic steatohepatitis. The request for Mounjaro is under review. The prior request was denied coverage by the health plan, as the patient does not have type 2 diabetes. The denial is being appealed, as the patient's provider is confident that non-alcoholic steatohepatitis will be an indication for use in the future, and if the use of Mounjaro is delayed for that date, then the patient will have irreversible cirrhosis.

The requested Mounjaro is not medically necessary.

This request is for Mounjaro for the treatment of a patient with nonalcoholic steatohepatitis. Mounjaro is not Food and Drug Administration (FDA)-indicated for weight loss or nonalcoholic steatohepatitis. Mounjaro is indicated for type 2 diabetes, which is not documented in this case. The Mounjaro prescribing information does not support the use of Mounjaro in this clinical situation. The Endocrine Society guidelines do not support the use of off-label medications for weight loss. A PubMed search did not reveal randomized clinical trials demonstrating safety and efficacy of Mounjaro for the treatment of nonalcoholic steatohepatitis in the absence of type 2 diabetes. Mounjaro has risks, including nausea and vomiting. Therefore, no, the requested Mounjaro is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Dry Eye Disease

Treatment: Tyrvaya

The insurer denied coverage for Tyrvaya.

The denial is upheld. 

The patient has a diagnosis of dry eye disease. The denial for Tyrvaya is upheld because the patient has not tried and failed, or has a contraindication or intolerance to, the formulary alternatives of cyclosporine, Restasis and Xiidra.  The current medical literature and practice guidelines do not support that Tyrvaya is more effective than the formulary alternatives.
The formulary drugs of Cyclosporine, Restasis and Xiidra are not likely to cause the patient an adverse reaction. These formulary drugs are approved for the treatment of dry eye disease.

The formulary drugs have not been ineffective based on the patient's clinical history.  There is no documentation provided that the patient has tried and failed any of the formulary drugs.

The requested drug would not be more effective than the formulary drug.  There is no evidence in the medical literature or clinical guidelines to suggest that Tyrvaya is more effective than the formulary drugs.

The carrier's denial of a request for a Formulary Exception for Tyrvaya to treat dry eye disease is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Type II achalasia 
Treatment: Peroral Endoscopic Myotomy (POEM) Procedure
The insurer denied Peroral Endoscopic Myotomy (POEM) Procedure
The health plan's determination is overturned.

The patient is a female provisionally diagnosed with possible Type 2 achalasia. Her main complaint is dysphagia. The patient has several other co-morbidities including schizophrenia. The patient had an esophagram which was interpreted as a lower esophageal stricture, however, there was no delay in emptying of the esophagus. An esophagogastroduodenoscopy (EGD) the following day was not consistent with achalasia as no resistance to passage of endoscope through the GEJ (gastroesophageal junction). A January 2023 HREM (High-resolution transmission electron microscopy) showed features suggestive but not diagnostic of Type 2 achalasia. 

Peroral Endoscopic Myotomy (POEM) Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
It can be difficult to diagnose achalasia and one needs to rely on the preponderance of clinical data. In this case, it appears that achalasia type 2 (due to pan-esophageal pressurization with absent contractility) is the correct diagnosis. Some data (EndoFlip) supports lower esophageal sphincter (LES) dysfunction. For achalasia type 2 the best treatment is a POEM procedure. The data supports that it is as effective as a laparoscopic Heller myotomy (LHM) if one looks at Eckardt symptom scores as the primary outcome. It is far less invasive and can be done as an outpatient endoscopic procedure that takes about an hour. For example, in a randomized trial of 221 patients with idiopathic achalasia, POEM and LHM were equally successful in controlling symptoms (Eckardt symptom score less than or equal to (<=) 3) at two years (83 versus 82 percent). Compared with LHM, POEM was associated with a lower rate of severe adverse events (2.7 versus 7.3 percent). POEM is far superior to pneumatic dilation or Botox injection into the LES. Both of these procedures tend to provide less improvement and are not a long-term solution as symptoms will recur over time.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Type II achalasia 
Treatment: Peroral Endoscopic Myotomy (POEM) Procedure
The insurer denied Peroral Endoscopic Myotomy (POEM) Procedure
The health plan's determination is overturned.

The patient is a female with achalasia type II, peptic ulcer disease, seizures, hypertension, hyperlipidemia, schizophrenia, asthma, and systemic lupus erythematosus. She has had progressive dysphagia with solids and a 30-pounds unintentional weight loss. Esophagogram showed a stricture in the lower esophagus, and intraesophageal stasis. Esophagogastroduodenoscopy showed no esophageal stricture or mass. Esophageal manometry showed absent peristalsis, pan-esophageal pressurization, inability to tolerate multiple rapid swallows, and incomplete bolus clearance. 

The peroral endoscopic myotomy (POEM) is likely to be more beneficial than any standard treatment or treatments for the treatment of the patient's achalasia.
The American Gastroenterological Association best-practice for peroral endoscopic myotomy states that "if the expertise is available, POEM should be considered guideline as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (Kahrilas, et al). The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, recommending POEM for the treatment of achalasia (Khashab, et al). Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available (Barbieri, et al; Schlottmann, et al). However, despite comparable efficacy, POEM is significantly less invasive than surgical intervention, resulting in less postoperative pain and a more rapid recovery (Docimo S, et al). The endoscopist who would perform the procedure does have expertise in performing POEM (Misra, et al; Kumta, et al).
In this patient with symptoms including dysphagia and unintentional weight loss, the use of POEM is supported by current medical literature and guidelines. For these reasons, POEM should be considered likely to be more beneficial than any standard treatment or treatments for the patient's achalasia.