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

Diagnosis: Abdominal pain
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

This is an adult patient who was hospitalized with vomiting, diarrhea, abdominal pain, and inability to eat or drink for 24 hours. The patient was feeling weak and dehydrated. Emergency medical services (EMS) noted that patient had tachycardia to 113 beats per minute and hypoxia (92-93 percent on room air). The patient had a fever of 101.7. Computed tomography (CT) of the abdomen/pelvis showed extensive diverticulosis of the sigmoid colon. The patient was thought to have suspected acute gastroenteritis with sepsis. The patient was treated with intravenous (IV) fluids (1 liter of normal saline), IV acetaminophen, IV ketorolac, IV Zofran, IV Zosyn, IV fentanyl, and IV vancomycin. Upon admission, the patient was treated with IV hydration, IV ciprofloxacin and Flagyl, liquid diet, IV Zofran, IV hydromorphone, IV magnesium sulfate, and Pamelor.

On day # (number) 2, IV ciprofloxacin and Flagyl were continued. IV fluids were continued. The patient required IV hydromorphone times two doses. The patient had 
vomiting overnight. The diet was advanced to full liquid. As the patient had epigastric burning, IV pantoprazole was administered.

On day #3, IV ciprofloxacin and Flagyl were continued. The patient received hydromorphone times three doses. IV magnesium sulfate was administered twice for 
repletion. The diet was advanced to soft mechanical diet.

On day #4, the patient was discharged.

The proposed treatment was medically necessary.

The patient was thought to have suspected acute gastroenteritis with sepsis. An inpatient admission was required as the patient required IV pain medication, IV antibiotics to treat sepsis, slow advancement of diet, and electrolyte replacement intravenously. The medical records do support that the acute inpatient admission was medically necessary. The patient did require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would have been threatened by providing the care given in a lower level of care setting. Therefore, based on review of the submitted medical records, the requested inpatient level of care was medically necessary for the dates of service in question as it required the intensity of the level of care necessary to provide safe, adequate, and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned in Part

Orthopedic
Surgical Services

Diagnosis: lower extremity edema
Treatment: Lipectomy and Panniculectomy 
The insurer denied Lipectomy and Panniculectomy. The health plan's determination is overturned in part. The Lipectomy is medically necessary. The panniculectomy is not medically necessary.

This is a female with history of lower extremity lipedema. She started with symptoms after puberty which got worse after her pregnancies. She has been seen by vascular surgery with an appropriate and negative workup for venous insufficiency. She has had disproportionate heaviness in her thighs which has not changed with weight lass (despite 30 lb (pounds) weight loss recently). She also has a symptomatic abdominal pannus after her weight loss. This includes symptoms of rash under her abdomen and difficulty with personal hygiene.

The Lipectomy is medically necessary. The panniculectomy is not medically necessary.
Liposuction is medically necessary. This female has failed medical treatments, and liposuction is an effective treatment for lipedema. This patient's vascular surgeon has diagnosed her condition as lipedema, and she has failed to improve with conservative treatments. Liposuction is the treatment of choice for her condition and is medically necessary.
The panniculectomy is not medically necessary. The medical records do not provide documentation in the form of PCP (primary care provider) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.


The patient is an adult female with adenomyosis on oral contraceptive and developed acute chest pain. The patient was diagnosed with acute pulmonary embolism and was admitted to acute hospitalization. The patient was started on low molecular weight heparin. The patient also had nausea and vomiting in the emergency room due to pain medications. The acute inpatient hospitalization was denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment was not medically necessary.

The patient had chest pain due to acute pulmonary embolism. At the time of admission, the patient was hemodynamically stable. The patient's testing did not show right heart strain. The patient's nausea and vomiting were improving. The patient was medically stable to be discharged within 24 hours of admission. The patient did not receive any treatment that could not have been provided at a lower level of care. The proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

This patient is an adult female. She presented to the ED (emergency department) with compliant of 3 days of nausea, vomiting, and cough. She had undergone laparoscopic roux en Y gastric bypass approximately three months earlier. The patient's vital signs at presentation included a normal temperature, BP (blood pressure) of 106/76 mmHg (millimeters of mercury) and pulse of 93. Oxygen saturation was 97%. She was evaluated with physical exam and lab data. The electrolytes were normal, BUN (blood urea nitrogen) and creatinine were normal. The WBC (white blood cell) count was normal (6.6 thousand). The patient was admitted to the hospital with the diagnosis of dehydration secondary to nausea and vomiting related to an upper respiratory infection. The patient was treated with IV (intravenous) fluid and antiemetic medications. A subsequent temperature was elevated at 102.9 Fahrenheit but had normalized two hours later to 99.9 Fahrenheit after a single dose of Tylenol. She received four IV (intravenous) fluid boluses overnight. She was started on a post-bariatric diet. She was able to tolerate a diet without nausea or vomiting. Vital signs were normal the next day. The patient was discharged from the hospital. The health plan rationale for denial of coverage of the inpatient admission is that there is no documentation of a significant medical condition that required hospital admission. 
Per the denial letter from the Plan, there were not abnormal vital signs that persisted despite appropriate treatment. There was not a serious cause of dehydration, severe electrolyte abnormalities, or inability to maintain oral hydration. The criteria for full hospital admission were not met, and the patient's medical needs could have been satisfied with an observational level of care. This letter references MCG (Milliman Care Guidelines).

The Inpatient admission was not medically necessary.

The records do not support that inpatient admission was medically necessary. The care and treatment provided to this patient could have reasonably been administered with an observational level of care (rather than acute inpatient admission). This patient is an adult female. She presented to the ED (emergency department) approximately three months following bariatric surgery with complaints of nausea and vomiting and cough. The patient was clinically stable at the time of presentation and remained stable throughout the hospitalization. The initial WBC (white blood cell) count was normal. Liver enzymes were normal. BUN (blood urea nitrogen) and Creatinine were normal at presentation. The etiology of her symptoms was attributed to an upper respiratory illness. She was treated with IV (intravenous) fluid with appropriate response. She was tolerating an appropriate post-bariatric diet on day #2 and was considered to be stable for discharge from the hospital. While she did have one episode of fever, this promptly normalized with a single dose of IV (intravenous) Tylenol.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Ozempic
The insurer denied coverage for Ozempic.
The denial is overturned.
 
The patient has sarcoid, cardiac disease, and pulmonary disease. He has a diagnosis of heart failure. He has obesity with a Body Mass Index (BMI) of 34.6 and has not been able to lose weight on his own. His physician has advised that he start Ozempic for weight loss. 

UpToDate has an article titled "Obesity in adults: Drug therapy." The article states that a number of medications are approved by the FDA (Food and Drug Administration) for the treatment of obesity. These medications should be used in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those individuals with a BMI (Body Mass Index) of 30 or a BMI of 27 in patients with weight-related comorbidities. Semaglutide is a Glucagon Like Peptide (GLP)-1 receptor agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction as well as improvement in glycemia and lipids. 

This patient has obesity with comorbid conditions. The recommendation from UpToDate is that Semaglutide is beneficial for a patient with a BMI of 30. There is no requirement that the patient also has to have diabetes. 

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 Ozempic (semaglutide) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Periodic Paralysis. 
Treatment: Keveyis 50 MG (milligram) OR (oral) Tabs. 

The insurer denied coverage for Keveyis 50 MG (milligram) OR (oral) Tabs. 

The denial is overturned. 

This case involves an adult patient regarding the denial of coverage for Keveyis 50 MG (milligram) OR (oral) Tabs.  The final adverse determination denial notice stated the patient did not meet the criteria for the medication as there was no record of the patient having taken or having a poor response to medications on the preferred drug list to include acetazolamide at the maximum tolerated dose.  Records stated the patient only used acetazolamide for a 7-day duration at 700 mg per day when it was last filled. The physician responded with a statement that it was believed that Keveyis is essential for management of the patient's medical condition of paretic paralysis.  The patient has failed Diamox, which was filled, which the patient trialed for 2 weeks.  The patient's insurance required the patient to be on another increased dosage of Diamox.  However, the patient failed Diamox to 50 mg 2 tablets twice a day for another 2-week trial.  The patient has been experiencing left-sided weakness for years, which had worsened within the past 6 months.  The patient was getting approximately 2 episodes per week that lasted for 3 to 4 minutes and reported having multiple episodes a day.  The physician stated that this is the only approved Food and Drug Administration (FDA) medication for periodic limb paralysis and the patient's health and wellbeing depends on access to the recommended treatment.  This review pertains to the denial of coverage for Keveyis 50 MG (milligram) OR (oral) Tabs. 

The Food and Drug Administration states that Keveyis is indicated for the treatment of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants.  The recommended dosage is 50 mg daily with the maximum recommended dosage 200 mg daily.  The information provided for the review stated that the patient was previously denied coverage for Keveyis 50 MG OR Tabs because the patient had not tried and failed the maximum dose of the preferred product consisting of acetazolamide.  The physician responded stating that the patient had been treated with acetazolamide to 50 mg tablets at 2 tablets daily for 2 weeks, which was ineffective for the member.  The patient's listed diagnoses consisted of periodic paralysis and hemiplegia along with other fatigue and muscle weakness.  The neurological examination noted intention tremor in both hands with deep tendon reflexes 3+ and equal bilaterally.  Given the provided information, it was determined that the requested medication is appropriate and within the standard of care.  As such, the request for Keveyis 50 MG OR Tabs is medically necessary. 

Based on the above, the insurer's denial must be reversed. 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 Keveyis 50 MG OR Tabs is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Endocrine/Metabolic/Nutritional
Pharmacy/Prescription Drugs

Diagnosis: Obesity
Treatment: Wegovy

The health plan denied: Wegovy
The determination is: Upheld

The patient is a male being prescribed Wegovy for the diagnosis of obesity. His medical history is significant for obesity, sleep apnea, asthma, fatty liver, and impaired fasting glucose. His current body mass index (BMI) is 47. Office visit notes were provided for review. The patient has lost 33 pounds over the past year. The patient has multiple weight related comorbidities as listed above. Therefore, the physician is requesting Wegovy for medical assistance with weight loss.

The health plan denied coverage for the requested medication. The plan notes that there has been a national supply shortage of Wegovy that is expected to last until at least September 2023. This shortage is impacting lower doses of Wegovy. Only the highest dose, 2.4 milligrams (mg), has shown effectiveness with weight loss. The plan is suspending coverage for Wegovy until all dosage formulations are available. Once the drug is available again, they will be considering new requests for review.

The health plan's criteria for coverage for weight loss medications was provided. The health plan considers the requested drug, Wegovy, to be medically necessary if certain criteria are met. These criteria are in line with the current Food and Drug Administration (FDA) approved indications for treatment with Wegovy, and include having a BMI of 30 or greater.

At issue is the medical necessity of Wegovy.

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

The requested health service of Wegovy is medically necessary for this patient; however, the health plan's proposal to delay treatment is appropriate given the national shortage.
The patient qualifies for treatment with Wegovy based on its FDA approved indications and the health plan's own criteria. However, the plan is correct that there has been a national shortage of Wegovy that has led to disruptions in treatment. The approved course of treatment is to start the medication at doses of 0.25 mg per week and increase stepwise through 0.5 mg, 1 mg, 1.7 mg and 2.4 mg with increases every 4 weeks as tolerated. Due to the shortage, many patients are having disrupted treatment courses and needing to start at the beginning. This is not an approach that has been studied or approved. Therefore, waiting until the shortage is resolved to approve treatment is appropriate for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Developmental delay
Treatment: Occupational therapy
The insurer denied occupational therapy.
The health plan's determination is overturned.

The patient is a young female with developmental delays, sensory processing disorder, sensory seeking disorder, and other behavioral and emotional disorders. Documentation provided from her mother and treatment team detail her sensory and behavioral issues, which improved with skilled occupational therapy.

The requested occupational therapy visits are medically necessary for this patient. The documentation from the patient's mother and physician, as well as the relevant occupational therapy evaluation, document significant delays and impairments in sensory and behavioral skills severely impacting her functionality at home and in the community. Furthermore, the literature clearly supports occupational therapy to assist with children with sensory processing and functional deficits as well as behavioral dysregulation due to sensory challenges. Therefore, the occupational therapy in question was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent. 
The insurer denied Dupixent. 
The denial is overturned. 

The patient is an adult male with atopic dermatitis, treated with Dupixent and Opzelura with excellent control. Prior to Dupixent therapy, his BSA (body surface area) was 20%, and he was treated with topical steroids, topical calcineurin inhibitors and Eucrisa. His provider is requesting continuation of Dupixent. 
The health plan denied coverage of the request, as Dupixent is used in combination with Opzelura. The denial is being appealed. 

The requested Dupixent is medically necessary. 

This patient has responded favorably to Dupixent for over 2 years. Opzelura can be used with Dupixent. There are known contraindications to this combination, but Opzelura is used only for spot treatment. The patient has limited body surface area remaining due to Dupixent. Therefore, the request is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: weakness/dizziness
Treatment: Home health care
The insurer denied Personal Care Assistance Services: Total of 45 Hours per Week. The health plan's determination is upheld. 

This is a case review for a female with medical history notable for cerebellar ganglioglioma, chronic fatigue, dizziness, anxiety, depression, and gastritis. The patient and her care team requested Personal Care Assistance Services: Total of 45 Hours per Week. This denial is the subject under review.
The patient's physician provided a letter of support for this appeal. The patient suffers from long term sequelae of a cerebellar ganglioglioma resection including weakness and chronic dizziness. She has limited ability to climb, lift, and bend. She has chronic pain due to sciatica and scoliosis that occasionally flares. The letter states that she has two ventral hernias that need repaired but that the surgery has been postponed "due to the denial of augmented request of hours as she will need increased hours in the post-operative period." She has informal assistance from her spouse but he works 5am - 7:30pm daily. The physician requests additional hours to help with household cleaning, food preparation, shopping, and transportation to doctor's appointments.

The requested health service of Personal Care Assistance Services: Total of 45 Hours per Week has not been demonstrated to be medically necessary for this patient.
The patient has some functional limitations as outlined in the UAS. These revolve primarily around her instrumental activities of daily living. Her physician also requested the hours to assist primarily with Instrumental activities of daily living (IADL). The patient's current allotment of hours should be sufficient to assist with these tasks. She does not have any documented personal care needs that are not being met at her current level of hours. The patient has an upcoming surgery but increases in home health hours are not typically granted in anticipation of a future short term need. At the time of her surgery, her care may be more appropriately given in another setting. The patient is able to ambulate and toilet without a care aide. Therefore, she does not need continuous care throughout the day and additional hours beyond those recommended by the task tool. The increase in personal care assistance services has not been demonstrated to be medically necessary based on the documentation provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple sclerosis and epilepsy
Treatment: Increase in Personal Care Assistance (PCA) services to 128.5 hours/week
The insurer denied an increase in PCA services to 128.5 hours/week.
The denial is upheld.

The patient is an adult female with multiple sclerosis and epilepsy. The request is for an increase in personal care assistant (PCA) services from 100 hours/week to 128.5 hours/week. This was previously denied coverage by the health plan because the previously provided 100 hours weekly were sufficient to meet the needs of the patient. The denial is being appealed.

The increase in PCA services to 128.5 hours/week is not medically necessary.

In this instance, this patient was previously utilizing PCA services of 100 hours weekly. Although the patient does have difficulties completing activities of daily living (ADLs), the previously noted documentation demonstrated that 100 hours weekly are sufficient for her current ADLs: Walking, locomotion, bed mobility, personal hygiene, upper body/lower body dressing, eating, toiletry, transfers, bathing. As such, the increase from 100 hours weekly to 128.5 hours/week is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Epilepsy
Treatment: Lamictal XR (lamotrigine ER)
The insurer denied Lamictal XR (lamotrigine ER). The health plan's determination is Upheld. 

The patient is a female with epilepsy. Treatment with brand Lamictal is the subject of this review. The drug was denied because the member has not tried and failed three formulary alternatives. The provider appealed the determination. A letter of medical necessity indicates that the patient has "tried generics" in the past; however, there is no information included about what generic drugs were tried and failed in the past.

A formulary exception is not indicated in this case.
The provided formulary alternatives are carbamazepine, carbamazepine extended release, divalproex sodium, divalproex sodium extended release, gabapentin, lamotrigine, lamotrigine extended release, levetiracetam, levetiracetam extended release, oxcarbazepine, phenobarbital, phenytoin, phenytoin extended release, primidone, tiagabine, topiramate, valproic acid, zonisamide, Aptiom, Fycompa, Oxtellar XR (extended release), Trokendi XR, Limpet, and Xcopri.
There is not documentation in the letter of medical necessity or progress note that the patient has tried and failed any of these specific medications. The provider only knows that the patient has tried and failed "generics". In the progress note, there is mentioned that the patient considered clobazam and previously used clonazepam.
The patient is diagnosed with localization related epilepsy. Many of the drugs on the formulary list are safe and effective for treatment of localization related epilepsy and are Food and Drug Administration (FDA) approved for this or similar indications.