Persius/imr-appeals huggingface dataset:
Diagnosis: Bilateral below the elbow amputations.

Treatment: Prosthetic Arm Additions (extra socket for left artificial arm).

The insurer denied coverage for Prosthetic Arm Additions (extra socket for left artificial arm).

The denial is upheld. 

This male patient has bilateral below elbow amputations of the arms. A request for bilateral myoelectric prostheses has since been approved. However, the request for prosthetic arm additions (extra socket for artificial arms), that was separately coded as L7499, has been denied.  

The insurer appropriately approved base code L6883 -Replacement socket, below elbow/wrist disarticulation, molded to patient mode, for use with or without external power.  However, the requested L7499 code- Skeletal contoured and dynamic below elbow socket- is an inappropriate unbundling code that should be incorporated into the base code of the replacement sockets (L6833).  Such unbundling of codes from the base code are inappropriate and have been previously adjudicated in case law.

The health plan acted reasonably, with sound medical judgement and in the best interest of the patient.  Including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies boards and associated were taken into consideration.  All decisions are evidenced based.

The medical necessity is not substantiated. The carrier's denial of coverage for prosthetic arm additions (extra socket for artificial arms), should be upheld.
Diagnosis: Dental Problems
Treatment: Dental/Orthodontic procedure

Diagnosis: Dental Problems-teeth spacing problem
Treatment: Dental/Orthodontic procedure-Braces and monthly visits
The health plan denied the treatment of Braces and monthly visits as not medically necessary. 
The reviewer has overturned in whole the health plan
determination.

The patient has maxillary and mandibular crowding. The orthodontist mentioned in the diagnosis that #27 is impacted. Tooth #11 is blocked out to the labial. The patient is treatment planned for 36 months of comprehensive orthodontics with extraction of first premolars to create room with possible canine exposure and ligation. 

It is in the best interest of patients to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered.1 Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology.2 The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth.2 If left untreated the damage that can occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason the treatment of braces and follow up visits is deemed medically necessary.
Diagnosis: Intractable back pain.

Treatment: Hospital admission.

The insurer denied coverage for the hospital admission.

The denial is overturned. 

This is a male patient with no significant past medical history who presented to the Emergency Department (ED) with intractable back pain. The patient also endorsed difficult ambulation and neck stiffness. In the ED, the patient received multiple pain medications including morphine without significant relief. The patient was unable to ambulate or sit up in the ED. Magnetic Resonance Imaging (MRI) of the lumbar spine was performed and the impression was: No acute fracture; no compression of the conus or cauda equine; annular bulge at L5-S1; transitional lumbosacral vertebra with lumbarization of S1; pseudoarthrosis of the transverse processes of the transitional vertebra with a sacral ala with bone marrow edema. It was noted that in the proper clinical setting, these findings could represent the initial presentation of Bertolotti syndrome. The patient was admitted to inpatient care for severe diffuse lower back pain bilaterally due to muscle spasm that resulted in the patient's inability to ambulate. Pain management was consulted and performed lumbar trigger point injection in the right lumbar paraspinal region, erector spinae and quadratus lumborum. The patient's pain improved but he experienced mild soreness in the lower back due to the injection. The patient was eventually able to ambulate on his own and was discharged with recommendations for outpatient Physical Therapy.

The patient was unable to sit up or ambulate. He was unable to perform his activities of daily living (ADLs) and received opiate medications for pain. These two factors are explicitly mentioned in the Milliman Care Guidelines (MCG) 24th Edition: Back Pain as criteria for admission.

Further, Joint Commission standards (2) require:
"The hospital reassesses and responds to the patient's pain though the following: ...
Progress toward pain management goals including functional ability (for example, ability to take a deep breath, turn in bed, walk with improved pain control."

The admission was required by the standard of care and was medically reasonable and necessary.

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

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.
Endocrine
Growth Hormone

Diagnosis: idiopathic short stature 
Treatment: Nutropin
The insurer denied Nutropin. The health plan's determination is overturned.

This is a female diagnosed with idiopathic short stature (ISS). This request is for Nutropin. Her growth hormone (GH) stimulation test with arginine and clonidine peaked at 13.10. Her genitourinary (GU) was at tanner 1. Her Insulin-like Growth Factor 1 (IGF1) was 184. Her height velocity is reported to be 3.4 centimeter (cm) /year. 

Nutropin is medically necessary for this patient. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS (standard deviation score) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient had a pretreatment height less than or equal to -2.25 SD (standard deviation). The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Ilumya 100 milligrams per milliliter (MG/ML). 
The denial is upheld. 

The patient is a male with psoriasis. He has tried and failed betamethasone for one year. He has been on Ilumya with great improvement; his body surface area affected is currently 0%. The subject under review is the medical necessity of the Ilumya 100 milligrams per milliliter (MG/ML).

The health plan's determination is upheld in whole.

The requested health treatment of Ilumya 100MG/ML is not medically necessary for this patient. There is no documentation that the patient has tried and failed, has an intolerance to, or contraindication to the preferred therapies, making Ilumya medically necessary.
There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Ilumya for this patient's condition as an accepted standard of practice in the U.S.
There are no comparative, controlled studies showing that Ilumya has a superior efficacy to the health plan's preferred alternatives, such as phototherapy and methotrexate.
Within the peer-reviewed literature, Racz et al. writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (2). Mehta et al. writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with greater than (>)10 % affected body surface area who have not responded to topical treatments...narrow band ultraviolet B (NB-UVB) ...effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile" (3).
Additionally, West et al. 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (4).
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the documentation provided, the request for Ilumya is not necessary. The patient has not tried and/or failed a preferred agent. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Ilumya medically more appropriate than the other options. Therefore, the administration of Ilumya is not strongly supported for this patient and is not medically necessary.
Diagnosis: Overbite.
Treatment: D8080 Comprehensive Orthodontic Treatment (Braces) and D8670 Periodic Orthodontic Treatment Visit, Pre-service.
The insurer denied the D8080 Comprehensive Orthodontic Treatment and D8670 Periodic Orthodontic Treatment Visit, Pre-service.
The denial is overturned.

The patient is a female. The request is for dental benefits for orthodontic treatment (Braces) and periodic orthodontic monthly visits.

Patient presents with skeletal Class I relationship, Class II Canines, moderate maxillary and mandibular spacing, moderately excessive overjet, deep impinging overbite with severe soft tissue damage.

The health plan denied the treatment because it states that it is not medically necessary. The provider appealed based on the conditions and diagnoses with which the patient presented.

Yes, the orthodontic therapy (Braces) and periodic orthodontic treatment visits are medically necessary.
The patient presents with a very deep overbite (greater than 50%). More than 50% of the anterior lower front teeth are covered by the upper teeth. In this case, the biting edge of the lower front teeth are biting into the gums of the upper front teeth when the patient closes their mouth. This is evident on the intra-oral photos of the upper anterior gum area.

A severe overbite like this can result in gum recession, and eventually gum disease and possible tooth loss. Difficulty with speech and chewing are also a possible consequence of this condition.

Therefore, given the above, the braces and visits are medically necessary.

As evidenced in the x-rays and the photos, the severity of the overbite and the other conditions of the patient's dentition warrants orthodontic treatment.

The long-term consequences of not treating these conditions would lead to more complications of the patient's dentition, and would thus affect the patient's overall health.
Diagnosis: Low Platelets
Treatment: T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing
The insurer denied the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing.
The denial is upheld.

The patient is a female.  She has a history of thrombocytopenia.  This had been present for one year.  She was noted to have positive antiphospholipid antibody titers.  It was noted that she had splenic lesions that felt consistent with splenic lymphangiomatosis.

Bone marrow biopsy was done and revealed mild fibrosis and normal hematopoiesis.  Flow cytometry revealed mild T-cell immunophenotypic changes.

The patient's CBC (complete blood count) was notable for normal white cell count, normal hemoglobin, and platelet count of 118.  CBC (complete blood count) testing prior was notable for mild leukopenia.

No treatment was recommended, but the patient's physician ordered a blood T-cell clonality study.

No, the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing was not medically necessary.

There is no evidence supporting the medical necessity of this test.  The patient had a bone marrow biopsy done that revealed "mild" T-cell immunophenotypic changes, but did not reveal clear evidence suggesting presence of T-cell lymphoma.  There is no abnormal white cell population noted in peripheral blood.  There is no neutropenia.  Cytopenias are a presenting finding in patients with T-cell large granular lymphocytic leukemia, but there is also no indication that this patient has been found to have an abnormal population of LGL (large granular lymphocyte) cells.  Also, LGL (large granular lymphocyte) leukemia is commonly associated with neutropenia, and CBC (comprehensive blood count) testing in this case is not notable for neutropenia.

Therefore, given the above, the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing was not medically necessary.
Diagnosis: Gastroesophageal reflux disease without esophagitis.
Treatment: Sucralfate suspension.
The insurer denied Sucralfate suspension.
The determination is overturned.

The patient is a male with gastroesophageal reflux disease (GERD) complicated by Barrett's esophagus, hiatal hernia status post Nissen's fundoplication, peptic ulcer disease with duodenal ulcer, and gastroparesis. He has had chronic dyspepsia and abdominal discomfort. He could not tolerate sucralfate tablets. Coverage is being requested for sucralfate suspension.

A formulary exception is indicated in this case. The submitted documentation reports that the patient attempted and failed sucralfate tablets in the past. Sucralfate (Carafate) is effective for the treatment of gastroesophageal reflux disease (GERD) symptoms. It is also effective for the treatment of peptic ulcer disease and dyspepsia associated with duodenogastric reflux. Sucralfate is available in tablet and liquid suspension forms, with similar reported efficacy and adverse effects, although the suspension has different physical characteristics which can result in easier traversion of the esophagus and different physical distribution in the stomach. As the patient has failed the tablet form, use of the suspension can be effective.
Diagnosis: Low Red Blood Cell Count (anemia).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with history of NSAID (nonsteroidal anti-inflammatory drug) use. He presented to the ER (emergency room) with anemia. As an outpatient, his Hgb (hemoglobin) was 7.3. He had recent black stool. He complained of some epigastric pain. He denied any NV (nausea and vomiting), hemetemesis, bright red blood per rectum or current melena.

The patient was hemodynamically stable. His Hgb (hemoglobin) was 7.4. He was transfused 2 units of PRBCs (packed red blood cells).

Day two, the patient's Hgb (hemoglobin) was 9.3. He was placed on PPIs (proton pump inhibitors) and seen by GI (gastroenterology). EGD (esophagogastroduodenoscopy) was scheduled.

On day two, three and four, there was no hemetemesis, melena or bright red blood per rectum.

On day five, Hgb (hemoglobin) was 10.7. EGD (esophagogastroduodenoscopy) revealed a duodenal ulcer, and the patient was discharged.

No, the Inpatient admission was not medically necessary.
The patient was hemodynamically stable, without evidence of active bleeding. He had no sepsis, coagulopathy, history of cirrhosis or any other significant co-morbidities. Therefore, treatment at a lower level care status was medically appropriate on day one. On day two, when his Hgb (hemoglobin) was up to 9.3, the patient was medically stable for discharge to outpatient care, or for EGD (esophagogastroduodenoscopy) at a lower level of care, and then discharged. Acute inpatient hospital stay was not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
As above, as a lower level of care status was medically appropriate, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying the acute inpatient hospital stay.
Diagnosis: Bilateral Lower Extremity Symptomatic Varicose Veins

Treatment: Sclerotherapy

The insurer denied coverage for sclerotherapy.

The denial is upheld.

The patient has been recommended to undergo bilateral sclerotherapy due to failure of conservative treatment.  The documentation indicated she has had a trial of conservative care.  This included over-the-counter medication in addition to elevation as well as compression without relief.  She continues to suffer from ongoing pain and has had treatment with the bilateral phlebectomy.  Later, she was seen with complaints of bilateral lower extremity symptomatic varicose veins.  The physical examination revealed there was mild edema bilaterally to the lower extremities.  Motor and sensation were intact.  Her bilateral leg incisions were well-healing and there were dense clusters of spider veins bilaterally.  The documentation indicated she had bilateral lower extremity symptomatic varicose veins despite compression in the absence of reflux and therefore it was recommended she undergo a bilateral sclerotherapy procedure.  A duplex revealed no evidence of venous reflux to the right lower extremity with evidence of focal venous reflux in the small saphenous vein to the left lower extremity.

The proposed sclerotherapy treatments bilaterally are not medically necessary.  There is no evidence of reflux in the right lower extremity.  There is reflux in the left lower extremity, but the degree and severity of reflux in the left sapheno-popliteal junction is not quantified on the venous reflux report.

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

Based on the above, the medical necessity for the sclerotherapy is not substantiated. The insurer's denial is upheld.
Diagnosis: Thyroid nodule.
Treatment: Thyroid Radiofrequency Ablation.
The insurer denied the Thyroid Radiofrequency Ablation.
The denial is overturned.

The patient is a female diagnosed with solitary right 6 cm (centimeter) thyroid nodule. This request is for Thyroid Radiofrequency Ablation.

As reported, the patient has history of indeterminate thyroid biopsies. Her most recent ultrasound showed normal cervical lymph nodes and no evidence of left nodule. Her FNA (fine needle aspiration) showed right nodule 6 cm (centimeters) (Bethesda category 3). Thyroseq was negative. Her FNA (fine needle aspiration) approximately two years ago showed right nodule 4 cm (centimeters); suspicious for follicular Neoplasm; hurthle cell (Bethesda category 4); Thyroseq was negative.

Yes, the Thyroid Radiofrequency Ablation is medically necessary.
The American Association of clinical endocrinologists guidelines [1] recommend radiofrequency ablation of solid thyroid nodules if they are large or symptomatic. This is grade A evidence. The solid component of the nodules should be sampled prior to ablation to show the absence of malignancy. This is supported by multiple studies including a meta-analysis [2].

The patient has a large nodule that was previously shown to be benign. She has a large and enlarging nodule that is now 6 cm (centimeters).

The request is not for the convenience of the patient or provider. It is not part of a study. It is clinically appropriate. The request for radiofrequency ablation of the nodule is consistent with generally accepted standards of medical practice and is therefore medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient, as the request is medically necessary as described above.
Diagnosis: Crohn's Disease
Treatment: Stelara (90 mg every 4 weeks)
The insurer denied Stelara (90 mg every 4 weeks). 
The health plan's determination is overturned.

The patient has Crohn's disease status post total colectomy with ileoanal pouch anastomosis. The patient has failed prednisone, antibiotics, cyclosporine, and Remicade. The patient was started on Stelara. Due to only partial improvement, the dose was escalated to every 4 weeks with good control of disease. The coverage is requested to continue Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease.

The request for Stelara to 90 mg every 4 weeks is supported as medically necessary by current medical literature. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease and pouchitis [1-3]. Guidelines for the treatment of Crohn's disease recommend the use of Stelara [4]. In this case, the patient has severe disease based on need for surgery. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response [5-7]. One study showed that dose escalation was required in approximately half of patients, and successful in 61.1% (percent) of dose escalation attempts [5]. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted [7]. Additionally, American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy" [4]. In this case, the patient has failed Stelara every 8 weeks, and has had disease control on Stelara 90 mg every 4 weeks; discontinuation of dosing every 4 weeks (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with moderate to severe disease. For all of these reasons, continuation of Stelara 90 mg every 4 weeks is supported to be more beneficial than any standard treatment or treatments in this case and is medically necessary by current medical literature.
Diagnosis: Multiple Sclerosis.
Treatment: Tecfidera DR 240mg.
The insurer denied the Tecfidera DR 240mg.
The denial is upheld.

The patient is a woman with relapsing remitting multiple sclerosis who is currently taking Tecfidera. She was previously on Copaxone and switched to Tecfidera due to breakthrough disease. She is currently stable on Tecfidera. The request for continued Tecfidera was previously denied as brand name Tecfidera is not in the plan formulary and it has not been documented that patient has tried and is intolerant of generic dimethyl fumarate.

No, the Tecfidera is not medically necessary.

The Tecfidera is not medically necessary, as no justification or rationale is provided as to why there is a medical exception for continuation of Tecfidera without trying generic dimethyl fumarate, which has been approved by the FDA (United States Food and Drug Administration). There is no available data comparing Tecfidera and generic dimethyl fumarate in regards to efficacy and safety.

Therefore, the Tecfidera is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Dimethyl fumarate in the generic form is the same ingredient as Tecfidera, and there is no evidence in the medical literature that supports the use of Tecfidera over generic dimethyl fumarate.