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

Diagnosis: Psoriasis

Treatment: Taltz

The insurer denied coverage for Taltz.

The denial is upheld.

The patient has a diagnosis of psoriasis and joint pains consistent with possible psoriatic arthritis.  The patient has failed topical steroid therapy and stelara.  Tremfya did not relieve the patient's joint pains.  Cosentyx, an IL(interleukin)-17 inhibitor, led to injection site reactions; the physician is requesting Taltz, also an IL-17 inhibitor.  

There is no medical or scientific literature and/or evidence-based clinical practice guidelines that strongly support the administration of Taltz for this patient's condition as an accepted standard of practice over alternative formulary medications.    

According to the joint American Academy of Dermatology (AAD) - National Psoriasis Foundation (NPF) guidelines for the treatment of psoriasis, humira and enbrel have a strength of recommendation of "A" for monotherapy in adult patients with psoriasis vulgaris and are effective treatments for psoriatic arthritis.  

According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, alternative safe and effective treatments for the management of psoriasis are available and appropriate for this patient.  A history of peptic ulcer disease and asthma are not contraindications to the use of any biologic.   

The preferred agents, humira and enbrel, are effective therapies for the treatment of the patient's psoriasis.  The provided medical notes do not provide any evidence of an absolute contraindication for the use of these available alternatives.  In addition, there are no head to head trials using these agents.  Therefore, Taltz is not medically necessary for this patient based on the medical documentation provided.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the Taltz is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease with anxiety

Treatment: Personal care aide (PCA) services of 24 hours per day (split shift)

The insurer denied coverage for personal care aide (PCA) services of 24 hours per day (split shift).

The denial is overturned.

This case involves an elderly male with a history of Alzheimer's disease with anxiety, depression, coronary artery disease (CAD), atrial fibrillation, benign prostatic hyperplasia (BPH), presence of cardiac pacemaker, bilateral hearing loss, insomnia, gastroesophageal reflux disease, abnormality of gait and mobility and vitamin D deficiency. The documentation indicated the patient is often confused and disoriented, as well as anxious and agitated. The patient's daughter also indicated sometimes he will develop severe generalized weakness up to the point of inability to turn himself in bed. The patient completely depends on caregivers in all his activities of daily living and needs supervision 12 hours a day, as well as 12 hours a night, 7 days a week. He requires turning every 2 hours with repositioning and frequent diaper changes to prevent bedsores, as well as pressure ulcers and infection. He has also sustained multiple falls attempting to get up and down on his own. He has a deteriorating physical condition which causes greater limitations in activities of daily living and has become more dependent upon caregivers. The physician indicates he requires assistance at home to prevent a health or safety crisis from developing.

The patient requires total care. He has a high frailty index due to his advanced age and multiple comorbidities. He also has functional quadriplegia in the sense that he requires help even to turn in the bed and he is bedbound. He cannot ask for help because of his cognitive impairment from advanced dementia. He is at high risk for adverse events such as fractures if he falls.

Due to all of the above-mentioned issues, he should qualify for care 24 hours a day, seven days a week. One person alone cannot provide this care because of the total care the patient requires. This care cannot be given by one person because of the patient's needs and it is reasonable to have a 24 hour split shift. The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

Based on the above, the medical necessity for the requested personal care aide (PCA) services of 24 hours per day (split shift) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: B-acute lymphoblastic leukemia
Treatment: Hospital admission for chemotherapy
The insurer denied the hospital admission for chemotherapy.
The denial is overturned.

The patient is a male with a history of acute lymphoblastic leukemia who is receiving chemotherapy. The provider is recommending acute care hospitalization for chemotherapy with high dose methotrexate and intravenous hydration.

Yes, the requested hospital admission for chemotherapy is medically necessary.

The five-year overall survival of children with newly diagnosed acute lymphoblastic leukemia (ALL) exceeds 90% with multiagent chemotherapy. However, a subset of patients remains at very high risk (VHR) for relapse and includes older patients and patients with unfavorable cytogenetics, a poor initial response to therapy, and/or central nervous system leukemia. Although targeted therapy has proven effective for patients with Philadelphia chromosome positive ALL, many patients lack an actionable target. Intensification of conventional chemotherapy has remained the main therapeutic option and has proven effective, but the outcome for VHR patients is still inferior. After remission is achieved, children with ALL receive six to eight months of intensive therapy. Treatments are typically delivered in one- to two-month phases that use a variety of non-cross-resistant chemotherapy agents. Delayed intensification with PEG-asparaginase (polyethylene glycol-conjugated asparaginase), vincristine, dexamethasone, cytarabine, doxorubicin, thioguanine and methotrexate, is the most widely used strategy in ALL protocols and is beneficial to all patients. The methotrexate is given as an extended infusion over 24 hours then drug level and electrolyte monitoring is required.

The administration of 24 hours of IV (intravenous) methotrexate meet the MCG (Milliman Care Guidelines) Chemotherapy, Pediatric (24th edition) guideline as it is, "Chemotherapy regimen that requires aggressive or prolonged support (need for intravenous fluid or medications given to you through your veins or high risk chemotherapy that would increase your risks of variety of infections)." The infusion cannot be given as on outpatient basis.

Therefore, given the above, the hospital admission for chemotherapy is medically necessary for this patient.

The health care plan applied national guidelines (MCG [Milliman Care Guidelines] Chemotherapy, Pediatric [24th edition]). The patient requires a prolonged infusion of methotrexate, which cannot be administered in an ambulatory setting. Methotrexate is given as an extended infusion over 24 hours, then drug level and electrolyte monitoring is required.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Over-bite.
Treatment: D8080 Braces and D8670 Monthly Visit x12, Pre-service.
The insurer denied the D8080 Braces and D8670 Monthly Visit x12, Pre-service.
The denial is upheld.

The patient is a male. The request is for dental benefits for orthodontic treatment (braces) and monthly visits, pre-service.  Orthodontic records have been created, and include clinical consultation, x-rays and photos.  Per the attending physician, the patient presents with a class II skeletal relationship, mild maxillary and mandibular crowding, moderately excessive overjet, deep impinging over-bite with severe soft tissue damage.

The provider appealed the claim because of the deep impinging over-bite with soft tissue damage.  The health plan denied the claim because the patient did not score a 26 - the score needed to qualify for orthodontic treatment (braces) per the Handicapping Labio-Lingual Deviation (HLD) Index Report.

No, the proposed treatment of orthodontic therapy (braces) and monthly visits is not medically necessary.
The documentation submitted does not support a deep impinging over-bite with soft tissue damage.  More specifically, the photos reveal a 50 percent overbite - meaning that the maxillary (upper) teeth cover about half of the mandibular (lower) teeth when the mouth is closed.  The photos do not show any soft tissue damage to the maxillary palatal /gum area.

The patient does not meet criteria because the deep impinging overbite must produce soft tissue damage to qualify for orthodontic treatment.  This soft tissue damage is not evident on the photos or any documentation submitted.

The patient did not exhibit soft tissue damage arising from a severe over-bite.  Therefore, the decision to not approve orthodontic therapy in this case is reasonable. Orthodontic therapy is an invasive therapy to correct certain malocclusions; it should be performed when indicated based on the clinical conditions.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Crisis. 
Treatment: Inpatient admission. 

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

The patient in this case is a woman with sickle cell anemia.  She presented to the emergency department with complaints of pain in her left arm and right leg that had been present for a few hours. She had no other symptoms.  On initial evaluation, blood pressure and heart rate were normal. Physical exam was notable for tenderness of the left arm and right leg and no other significant findings. Laboratory studies were notable for a hemoglobin level of 8.8 grams/deciliter. Otherwise labs were unremarkable. 

The patient was treated with narcotic pain medication in the emergency department with some improvement in pain.  She was admitted and during her hospital stay treated with intravenous (IV) Dilaudid and intravenous (IV) fluids. Repeat hemoglobin after admission was 7.1 grams/deciliter and she was transfused with one unit of packed red blood cells.  Hemoglobin rose after that, but day three was down to 7.2.  She was discharged that day. 

No, the proposed acute inpatient hospital admission was not medically necessary. 
This patient did not require acute care inpatient admission and could have been managed at a lower level of care such as observation.  She was treated for uncomplicated pain crisis and was also given one until of blood.  She had no hemodynamic instability, no active infection and no respiratory insufficiency.  Given lack of any significant medical complications, there was no indication for acute care inpatient hospitalization in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: D8080 Braces; D8670 Monthly Visit x12; Pre-service.
The insurer denied the D8080 Braces; D8670 Monthly Visit x12; Pre-service.
The denial is overturned. 

The patient is a female.  The request is for dental benefits for orthodontic treatment (braces) and monthly visits.  Orthodontic records have been created, and include clinical consultations,-x-rays, and photos taken.  The patient presents with a class I skeletal relationship, class II canine, mild maxillary and mandibular crowding, anterior crossbite with gingival attachment loss (maxillary and mandibular left canine).

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index Report - the score necessary to be approved for orthodontic treatment.  The provider appealed because the patient has a crossbite on the left canines.

Yes, the proposed treatment of orthodontic therapy, braces and monthly visits, is medically necessary.
The patient presents with an anterior crossbite on the left maxillary and mandibular canines with attachment loss.  The degree of the crossbite (maxillary canine sits palatal [inside] the mandibular canine) is evident on the photos. The normal position is for the maxillary canine to be buccal (just in front) of the mandibular canine.
The gum tissue around the maxillary canine is beginning to show some detachment from the tooth due to the position of the tooth. The long term prognosis, if left untreated, could potentially affect the patient's ability to chew effectively, have proper speech and maintain good hygiene.

The health plan denied the claim because they stated that the criteria were not met for approval; however the documents submitted, particularly the photos, support the existence of the crossbite with attachment loss.  Per the Handicapping Labio-Lingual Deviation (HLD) Index, a crossbite with attachment loss is an automatic qualifier for orthodontic treatment (braces) approval.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: D8080 Comprehensive Orthodontic Treatment; D8670 Periodic Orthodontic Treatment Visit x 12.
The insurer denied theD8080 Comprehensive Orthodontic Treatment; D8670 Periodic Orthodontic Treatment Visit x 12.
The denial is overturned. 

The patient is a female requesting dental benefits for orthodontic treatment (Braces), monthly visits. Orthodontic records were created, clinical consultation was performed, and x-rays and photos taken.

The patient presents with a class I skeletal relationship, class II canines, mild maxillary and mandibular crowding, impacted third molars, anterior crossbite with gingival attachment loss (Maxillary and mandibular left canine).

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index Report--the score necessary for orthodontic therapy approval or meet the criteria for any of the auto qualifiers on the same index for orthodontic therapy.

The provider appealed because of the presence of the presence the crossbite on the patient's mandibular left canine.

Yes, the requested orthodontic therapy (Braces) and monthly visits are medically necessary.
As supported by the documentation submitted, particularly the photos, the patient presents with an anterior crossbite on the left maxillary and mandibular canines with attachment loss. The patient also exhibits an anterior crossbite on the left maxillary canine and lateral incisor.

The normal position for the maxillary canine is to sit just buccal (in front) of the mandibular canine, but in a crossbite the maxillary canine sits palatal (inside) the mandibular canine. A crossbite can potentially affect the patient's ability to chew effectively, maintain proper hygiene and speech.

The long term prognosis is poor if left untreated, as it can lead to more complications with the overall dentition.

Per the HLD (Handicapping Labio-Lingual Deviation) Index Report, a crossbite is an automatic qualifier for orthodontic treatment (Braces) approval.

This criterion was met by the documentation submitted for this patient; therefore the treatment is needed and should be performed to correct the patient's condition.


Therefore, given the above, the orthodontic treatment and visits are medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Insomnia.
Treatment: Belsomra.
The insurer denied Belsomra.
The denial is upheld.

The patient is an adult male with a history of insomnia. The patient's physician, prescribed him Belsomra. No medical records were provided for review with this request. A letter from the health plan stated that the patient had a prior trial of zaleplon.  According to pharmacy claims information provided by the patient, he had prior prescription fills for zolpidem 10 mg (milligrams), and zolpidem 5 mg (milligrams). He had a prescription filled for zaleplon 10 mg (milligrams). A request has since been made of the health plan for coverage of Belsomra.

The request was initially denied by the health plan for the following reason: The patient has not had a serious side effects or drug failure with both zolpidem and eszopiclone.

No, the health plan should not cover the Formulary exception for Belsomra.

It cannot be determined from the information provided that the remaining formulary drug which has not been trialed to date (eszopiclone) has been or would be ineffective in the management of the patient's insomnia. There were no medical records provided for review with this request to permit such a conclusion.

There have otherwise not been any direct comparison studies completed to date between the non-formulary drug and the formulary drug to permit a conclusion that the requested agent would be more effective than the formulary drug. The guidelines from the AASM (American Academy of Sleep Medicine) on the use of pharmacotherapy in insomnia graded both drugs equally ("weak for") (Sateia et al).

Nor can it be concluded that the patient would experience adverse effects from the use of the remaining formulary agent that would not be present on the non-formulary drug. Again, there was a lack of patient-specific information provided (in the form of medical records) that would have permitted such a conclusion to be made.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Kidney Disease (CKD).

Treatment: Jardiance 10 milligram (mg) tablet.

The insurer denied coverage for Jardiance 10 milligram (mg) tablet.

The denial is overturned.

The patient is a female with diabetes, and chronic kidney disease (CKD). The patient had a low glomerular filtration rate (GFR) of 36. The treating provider has requested therapy with Jardiance.

According to Packer et al., "During a median of 16 months, a primary outcome event occurred in 361 of 1863 patients (19.4% [percent]) in the empagliflozin group and in 462 of 1867 patients (24.7%) in the placebo group (hazard ratio for cardiovascular death or hospitalization for heart failure, 0.75; 95% confidence interval [CI], 0.65 to 0.86; P [probability] <0.001). The effect of empagliflozin on the primary outcome was consistent in patients regardless of the presence or absence of diabetes. The total number of hospitalizations for heart failure was lower in the empagliflozin group than in the placebo group (hazard ratio, 0.70; 95% CI, 0.58 to 0.85; P<0.001). The annual rate of decline in the estimated glomerular filtration rate was slower in the empagliflozin group than in the placebo group (0.55 vs. [versus] 2.28 ml [milliliter] per minute per 1.73 m2 [measure of money] of body-surface area per year, P<0.001), and empagliflozin-treated patients had a lower risk of serious renal outcomes. Uncomplicated genital tract infection was reported more frequently with empagliflozin."

According to Wanner et al., "Incident or worsening nephropathy occurred in 525 of 4124 patients (12.7%) in the empagliflozin group and in 388 of 2061 (18.8%) in the placebo group (hazard ratio in the empagliflozin group, 0.61; 95% confidence interval, 0.53 to 0.70; P<0.001). Doubling of the serum creatinine level occurred in 70 of 4645 patients (1.5%) in the empagliflozin group and in 60 of 2323 (2.6%) in the placebo group, a significant relative risk reduction of 44%. Renal-replacement therapy was initiated in 13 of 4687 patients (0.3%) in the empagliflozin group and in 14 of 2333 patients (0.6%) in the placebo group, representing a 55% lower relative risk in the empagliflozin group. There was no significant between-group difference in the rate of incident albuminuria. The adverse-event profile of empagliflozin in patients with impaired kidney function at baseline was similar to that reported in the overall trial population."   

The use of Jardiance 10 mg tablet is considered medically necessary for this patient.

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

This patient has a diagnosis of diabetes, and CKD. The GFR threshold, which this medication is deemed to be ineffective, is 30. With a GFR of 36 this individual would be expected to get benefit from this therapy, Jardiance. Therefore, Jardiance is medically necessary.

The insurer's denial of coverage for Jardiance 10 milligram (mg) tablet is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee pain
Treatment: Joint surgery
The insurer denied the joint surgery
The denial is upheld.

The patient is an adult female with right knee pain and grinding.  She also reported catching.  She reported some benefit from an injection.  The physical examination was significant for grinding, crepitus and full motion.  The patient's MRI (magnetic resonance imaging) report was significant for chondromalacia to her patella (full thickness defect).  The patient's physician recommended arthroscopic surgery.  He provided an additional injection of corticosteroid.  She was also referred to PT (physical therapy).

No, the requested joint surgery is not medically necessary.

The patient has evidence of catching and crepitus, as well as osteophytes and chondral loss.  However, the records do not describe the duration of the patient's non-surgical management.  The clinical records do not document at least three months duration of non-surgical treatment.  As such, the joint surgery would not be indicated at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Protein Losing Enteropathy

Treatment Cuvitru

The insurer denied coverage for Cuvitru.

The denial is overturned.

This is the case of a teen male who has protein losing enteropathy secondary to his congenital heart surgery. He has had symptoms of diarrhea and low immunoglobulin G (IgG). His physician has prescribed Cuvitru. 

According to the telemedicine notes with nurse practitioner, the patient was scheduled for home intravenous immune globulin (IVIG) infusion and had a recent IgG level of 216. A letter of medical necessity states that the patient received IVIG Gammagard and developed reactions. He also states that the patient has poor venous access and will achieve better IgG levels with subcutaneous gammaglobulin.

The plan states that the patient must fail or have a contraindication to Gamunex C or Gammaked, which are both IV (intravenous) gammaglobulin products. 

Given the patient has a known lymphatic and hypoalbuminemia conditions, it would be expected that his venous access would be poor (see reference below). Given these conditions, subcutaneous gammaglobulin administration would be preferable. Cuvitru is one of the subcutaneously administered gammaglobulin products.

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

The insurer's denial of coverage for Cuvitru is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seropositive rheumatoid arthritis

Treatment: Humira 40 milligrams

The insurer denied coverage for Humira 40 milligrams.

The denial is overturned. 

This female patient has a history of seropositive rheumatoid arthritis (RA) involving multiple sites.

In comparing the patient's RA status at the time Humira was begun there is documentation of substantial improvement, more than 20%. Joint count has gone from multiple to none. Stiffness is reduced to less than 15 minutes. The patient's assessment is that she is doing well.

There is sufficient documentation to establish that the addition of Humira to MTX (methotrexate) has provided substantial benefit and it is appropriate to continue the medication.

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

The carrier's denial of coverage for Humira 40 milligrams is overturned. The medical necessity is substantiated.