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

Diagnosis: Left cerebral dysfunction and transient ischemic attack (TIA)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This case involves a patient diagnosed with left cerebral dysfunction and transient ischemic attack (TIA). The patient was admitted to the hospital regarding transient right-sided weakness. The patient is under the care of an oncologist and had probable ovarian cancer. There were reports of visual disturbance and headache. The patient had an episode of right upper and lower extremity weakness. The visual disturbance lasted 5 minutes. Symptoms had improved and she was recommended to go to the emergency room for further evaluation. The patient was scheduled to undergo an oophorectomy. Upon arrival to the emergency room, vital signs were blood pressure 136/70, oxygen saturation was 98% (percent), and blood glucose was 90. There were reports of occipital headaches. Laboratory tests revealed a white blood count of 11.3. X-ray showed no active pulmonary disease and electrocardiogram (EKG) showed sinus bradycardia. The computed tomography (CT) of the head showed no evidence of hemorrhage, mass-effect, or acute infarction. The patient was admitted to telemetry for further evaluation as the physician was concerned for TIA-CVA (transient ischemic attack cerebrovascular accident) versus metastases. The patient was later discharged.

The patient presented to the emergency department (ED) for transient visual disturbances lasting for five minutes coupled with an episode of right-sided upper and lower extremity weakness. She was evaluated in the ED and admitted to the hospital. Neurology was consulted. CT of the head, along with magnetic resonance imaging (MRI) of the brain with magnetic resonance angiography (MRA) were performed and showed no acute process. Electroencephalogram (EEG) was performed, showing no evidence for seizure proclivity. Care provided, including diagnostic testing and imaging, specialty consultation, as well as medical management, all could have been performed at an outpatient or observation level of care. The inpatient hospital admission was not medically necessary.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, hypertension, mitral regurgitation, benign prostatic hypertrophy (BPH), coronary artery disease (CAD). 

Treatment: Personal care aide (PCA) level 2 services: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week. 

The insurer denied coverage for personal care aide (PCA) level 2 services: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week. 

The denial is overturned. 

This is a patient with chronic medical problems including diabetes, hypertension and mitral regurgitation. He currently lives with a roommate in a nursing home. The insurer approved PCA level 2; 8 hours/day- 7 days/week for a total of 56 hours/week. Under review is the request for PCA level 2 services: 12 hours/day- 7 days/week; 12 hours/day- 7 days per week (split shift) for a total of 168 hours/week. 

According to the Uniform Assessment System (UAS) report, the patient's cognitive status is described as "minimally impaired" and oriented to person and place. However, the patient requires maximal assistance for dressing, bathing, and hygiene. He is incontinent of bowel and bladder. Bed mobility and transfers also require maximal assistance, and he is non-ambulatory. The patient was recently hospitalized and transferred to a skilled nursing facility due to a fall at home. According to the treating ophthalmologist, the patient has "severe glaucoma to both eyes. Retinal vein occlusion to the left eye. He is legally blind. The combination of the patient's progressive functional decline with recent falls necessitating hospitalization as well as maximal assistance for activities of daily living and mobility, support the requested increase PCA level 2 services: 12 hours/day- 7 days/week; 12 hours/day- 7 days per week (split shift) for a total of 168 hours/week as medically necessary, in order to allow him to resume living safely at home. 

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

The insurer's denial of coverage for personal care aide (PCA) level 2 services: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, hypertension, mitral regurgitation, benign prostatic hypertrophy (BPH), coronary artery disease (CAD). 

Treatment: Personal care aide (PCA) level 2 services: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week. 

The insurer denied coverage for personal care aide (PCA) level 2 services: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week. 

The denial is overturned. 

This is a patient with chronic medical problems including diabetes, hypertension and mitral regurgitation. He currently lives with a roommate in a nursing home. The insurer approved PCA level 2; 8 hours/day- 7 days/week for a total of 56 hours/week. Under review is the request for PCA level 2 services: 12 hours/day- 7 days/week; 12 hours/day- 7 days per week (split shift) for a total of 168 hours/week. 

According to the Uniform Assessment System (UAS) report, the patient's cognitive status is described as "minimally impaired" and oriented to person and place. However, the patient requires maximal assistance for dressing, bathing, and hygiene. He is incontinent of bowel and bladder. Bed mobility and transfers also require maximal assistance, and he is non-ambulatory. The patient was recently hospitalized and transferred to a skilled nursing facility due to a fall at home. According to the treating ophthalmologist, the patient has "severe glaucoma to both eyes. Retinal vein occlusion to the left eye. He is legally blind. The combination of the patient's progressive functional decline with recent falls necessitating hospitalization as well as maximal assistance for activities of daily living and mobility, support the requested increase PCA level 2 services: 12 hours/day- 7 days/week; 12 hours/day- 7 days per week (split shift) for a total of 168 hours/week as medically necessary, in order to allow him to resume living safely at home. 

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

The insurer's denial of coverage for personal care aide (PCA) level 2 services: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypogammaglobulinemia, functional natural killer (NK) cell deficiency, and recurrent viral and ear infections

Treatment: Cuvitru

The insurer denied coverage for Cuvitru

The denial is overturned 

The patient has a history of hypogammaglobulinemia, functional NK cell deficiency, and recurrent viral and ear infections. He has been treated with Cuvitru successfully for years. The insurer has denied the request for Cuvitru coverage and states that coverage is contingent on a trial of the preferred immunoglobulin preparation Cutaquig. Furthermore, the denial letter states that there is no evidence that Cuvitru is superior to Cutaquig. The provider argues that the patient has done well on Cuvitru, and that tapering would be complicated if the immune globulin preparation is changed.

UpToDate (Ballow & Shehata) lists subcutaneous immunoglobulin products. (1) Furthermore, the authors of this article state, "..Once a patient has found a well-tolerated
intravenous immune globulin (IVIG) product, it is advisable not to change products without a compelling reason;...

Selection of product - IVIG is produced from pooled plasma donated by several thousand screened donors. Numerous quality control procedures and manufacturing standards are in place to ensure highly purified and stable solutions, although slight differences exist among products. Choice of product depends on patient and disease factors and clinical judgment. Individuals who require a specific type of hyperimmune globulin should receive a product intended for this purpose rather than IVIG. Once a patient has found a well-tolerated IVIG product, it is advisable not to change products without a compelling reason; administration of alternative products should only be done with the clinician's approval. (1)

This concept is reasonable to apply to subcutaneous immune globulin as well, especially given the circumstances described by the provider.

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 the medication Cuvitru is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right foot pain.

Treatment: Magnetic resonance imaging (MRI) of the right foot (visits/units requested: 1).

The insurer denied coverage for magnetic resonance imaging of the right foot (visits/units requested: 1).

The denial is overturned.

The patient is a female who sustained an injury to the right foot and ankle. The patient continued to have pain and was started on a custom orthotic, possible need for surgery was discussed with the patient and she was subsequently sent to PT (physical therapy). On initial PT evaluation the patient noted continued burning pain to the right foot and instability of the ankle. While undergoing PT the patient noted some relief but also stated orthotics made her worse. PT notes made available to me reveal continued 9/10 pain (on a pain scale of 1-10) with only a decrease to 7/10. The patient visited her doctor and noted that she was using the orthotics previously dispensed, but she continues to use it in hopes it will help. A visit note reveals that the patient has significant posterior tibial tendon dysfunction with pain along the plantar fascia medially, at the posterior tibialis tendon insertion on the navicular, and has significant pes planus deformity. X-rays taken on this visit revealed no fractures. At this point the patient had essentially completed all possible conservative measures and was sent to get and MRI of the foot and the ankle with the doctor citing specific reasons for each including evaluation of the soft tissue, tendon and ligaments around the midfoot as well as the PT (posterior tibial) tendon which comes down from the ankle to the midfoot. PT with no relief. The patient's doctor wrote an appeal on behalf of the patient citing medical necessity and offering to do a peer-to-peer review. An MRI is a very useful tool when it comes to ongoing foot and ankle pain. "MRI has the unique capability to evaluate osseous, ligamentous, tendinous, and muscular injuries about the foot and ankle, with a single imaging study"1. In the case of this patient this is exactly what is needed as the patient has out done all other conservative measures. Furthermore, even though other imaging can be used, "magnetic resonance imaging (MRI) provides high levels of sensitivity and specificity for articular and soft-tissue injuries" 2 and in this case, it appears there is definite soft tissue involvement.

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

Magnetic resonance imaging of the right foot (visits/units requested: 1) is considered medically necessary for this patient.

The insurer's denial of coverage for magnetic resonance imaging of the right foot visits/units requested overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension.
Treatment: Brand name Bystolic.
The insurer denied brand name Bystolic. 
The health plan's determination is upheld. 

The patient is a man with a history of hypertension, obstructive sleep apnea and morbid obesity. He was previously treated with a combination of valsartan and hydrochlorothiazide, which did not adequately control his blood pressure. In addition, he developed renal dysfunction with the valsartan; this improved with drug discontinuation. He is currently treated with a combination of amlodipine and Bystolic. The medication list provided includes one entry for nebivolol (which is generic Bystolic).

Brand name Bystolic is not medically necessary. The three formulary alternatives in this case, metoprolol, atenolol and bisoprolol, are all beta-blockers. Thus, nebivolol would be expected to be better tolerated and similarly or more effective than the formulary alternatives. However, the question asked is whether brand name Bystolic is medically necessary. Based on the information provided there is no reason to believe that Bystolic would be more effective or better tolerated than generic nebivolol. The Food and Drug Administration (FDA) standards for bioequivalence for generic drugs are rigorous and multiple reports confirm the bioequivalence of generic and brand name cardiovascular drugs, including different beta-blocker formulations.
In summary, brand name Bystolic is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, atherosclerotic heart disease, hypertension, gastroesophageal reflux disease (GERD), and hyperlipidemia. 

Treatment: Consumer directed personal assistance program (CDPAP): live-in per diem: 24 hours per day- 7 days per week. 

The insurer denied coverage for CDPAP: live-in per diem: 24 hours per day- 7 days per week. 

The denial is overturned. 

This patient with chronic medical problems including hypertension, atherosclerotic heart disease and Alzheimer's disease. He currently has CDPAP: 5.5 hours per day- 7 days per week- a total of 38.5 hours per week. Under review is the request for an increase in CDPAP: live-in per diem: 24 hours per day- 7 days per week. 

According to the Uniform Assessment System (UAS) report, the patient's cognitive status is described as "severely impaired." According to his daughter "one night, member went outside in the middle of the night alone and was escorted back to his home. Member is reported to have episodes of paranoia." He has fallen in the past 90 days and tends to wander at night. He is totally dependent for meal preparation, housework and managing medications. He requires limited assistance for bathing, dressing and personal hygiene. He is occasionally bladder and infrequently bowel incontinent. Given the progression of the patient's severe dementia (as supported by his treating primary care physician and neurologist) as well as functional impairments, increasing the CDPAP: live-in per diem: 24 hours per day- 7 days per week, is medically necessary, in order to allow him to continue living safely at home. 

From a physical medicine and rehabilitation perspective, increasing CDPAP: live-in per diem: 24 hours per day- 7 days per week, is medically 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 consumer directed personal assistance program (CDPAP): live-in per diem: 24 hours per day- 7 days per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dementia
Treatment: personal care assistant
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift). The health plan's determination is upheld. 

The patient is a female with past medical history of atherosclerotic heart disease, atrial fibrillation with chronic anticoagulation, congestive heart failure, end-stage renal disease on hemodialysis, hypertension, hyperlipidemia, aortic insufficiency, gout, hypertension, dementia, anxiety, and depression who had been assigned PCA (personal care assistant) services based on telephonic assessment performed that assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, and shopping while maximum assistance with tasks of managing medication and transportation. With tasks of phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with task of bed mobility. The patient was assessed at independent with task of eating. There was a request to increase PCA services and the patient underwent a telemedicine assessment that assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, and transportation while maximum assistance with tasks of managing medication and phone use. With tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with task of bed mobility. The patient was assessed at supervision only with task of eating.

Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift) are not medically necessary for this patient.
Although there is documentation of worsening cognitive and functional status as well as lack of formal and informal care, there is no documentation that the patient has overnight care needs that would not allow a live-in PCA to obtain 5 hours of uninterrupted sleep. There are no overnight care logs documenting the overnight care needs of the patient. There is no documentation of a need for turning and repositioning every 2 hours. The patient does have unscheduled and unpredictable care needs but again there is no documentation that these care needs would not allow a PCA to obtain less than 5 hours of uninterrupted sleep. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift) are not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Eliquis (apixaban). 
The denial is upheld. 

This patient is a male with a history of persistent atrial fibrillation with prior ablations currently being treated with apixaban (Eliquis) for prevention of stroke. According to the patient's provider, he has not been treated with other anticoagulants. The patient's health plan has denied prescription benefit exception request for apixaban on the grounds the patient has not met prescription benefit exception criteria including treatment failure, intolerance or adverse effects to the other formulary anticoagulants, warfarin and Xarelto. The patient's provider is appealing this denial.
At issue is whether the formulary drugs, warfarin, Xarelto, will be or have been ineffective, would not be as effective as the non-formulary drug, Eliquis, or would have adverse effects.

The health plan's determination is upheld in whole.

Based on the patient's records provided for review of this case, there is no documented reason why the patient would have adverse effects to the formulary anticoagulant, Xarelto. Xarelto is an appropriate anticoagulant to prevent stroke in this patient with persistent atrial fibrillation as recommended by the 2019 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. (1)
There is no clear documented reason that the patient would have an adverse effect or treatment failure to the formulary anticoagulant Xarelto, that Xarelto would be ineffective, or would not not be as effective as Eliquis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Myfembree. 
The denial is upheld.

In this case, the patient is noted to be a gravida (G)1 para (P) 0 abortion (A)1 (ectopic) female who underwent prior treatment with medroxyprogesterone and had a reported adverse effect. She is stated to have tried samples of Oriahnn and reported adverse effect but did not have a prescription for this and this is not accepted as a trial and failure of formulary alternative as a sample. Review of the pharmacy claims noted prior prescription for Motrin 800 milligrams (mg) tablets, Naproxen 500 mg tablets and medroxyprogesterone 100 mg tablets. The patient also reports she has a fibroid, menorrhagia, irregular periods, adenomyosis and pelvic pain. The patient underwent ultrasound that noted a normal uterine size and a solitary 4.4 centimeter (cm) intramural left sided fundal fibroid. There was a possible intrauterine polyp in that appears to be 7 millimeter (mm) in size. The patient has bleeding off and on for two years. This is also noted with left lower quadrant (LLQ) pain. The endometrium had a 2.4 cm polyp. The subject under review is the medical necessity for Myfembree.

The health plan's determination is upheld.

Based upon a review of the medical records in this case, there would not be a medical necessity or indication for the use of Myfembree 40-1-0.5 mg oral tablets for the indication of heavy menstrual bleeding. In this case, the patient is noted to have a single fibroid but has a large intrauterine polyp that is within the endometrium. There is a large polyp within the endometrium, and this should be treated with removal. There is no indication for the use of Myfembree 40-1-0.5 mg oral tablets when the causation of bleeding is a large polyp in the endometrium. This would represent a mechanical cause of bleeding.

Based upon a review of the indication of heavy bleeding for the plan of Myfembree, this would not be supported by the recommendations of the Food and Drug Administration as this medication is not a first line agent for the treatment of heavy bleeding when an endometrial polyp is present. The recommendations of the American College of Obstetricians and Gynecologists have not recognized the use of Myfembree in the management of anatomic bleeding and there have been no reported trials or failures of standard therapy with oral contraceptives, oral progesterone, or non steroidal anti-inflammatory drugs (NSAIDs) for treatment. In addition, there is no reported management of the large polyp in the uterus based upon ultrasound evaluation. Thus, the medication would also not be indicated by lack of this diagnosis being present and considered.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal malocclusion. 
Treatment: D8080 Comprehensive Orthodontic Treatment, D8670 Monthly Visits,  
D8680 Orthodontic Retention. 

The insurer denied the D8080 Comprehensive Orthodontic Treatment, 
D8670 Monthly Visits, D8680 Orthodontic Retention. 

The denial is overturned. 

The patient is a male with a class I skeletal malocclusion. He has severe upper and lower crowding and a deep bite. The prior denial was because of a score of 15 on the Handicapping Index scale. 

Yes, the proposed treatment is medically necessary. 

The patient has an impacted permanent anterior tooth (#11, upper left canine), where extraction is not indicated. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.