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

Diagnosis: Osteoarthritis
Treatment: Bilateral knee Euflexxa injections code J7323LT x 3, J7323RT x 3
The insurer denied bilateral knee Euflexxa injections code J7323LT x 3, J7323RT x 3.
The denial is upheld.

This is the case of an adult female with a history of osteoarthritis, high cholesterol, and hypertension. She presented to her doctor's office for pain to bilateral knees from osteoarthritis. She received Zilretta injections in her knees. Her doctor reports she has not had long-term relief with short acting cortisone injections. She has pain in both knees that worsens with extension. Her doctor is requesting Euflexxa injections. 

The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis if all other courses failed prior to surgery. The recommendations for use of viscosupplementation have changed. 

The 2013 OA (osteoarthritis) knee treatment CPG (Clinical Practice Guideline) contains one significant recommendation change from the 2008 CPG, and this is about the issue of viscosupplementation. The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG.

The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria. The CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). 

The Orthopedic group reports "strongly do not recommend use." There has been no change to this Guideline.  Additional references and expert opinion do not support benefit. A meta-analysis was completed of multiple references. This is a high level evidence based criteria which does not support use. 

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

The insurer's denial of coverage for the bilateral knee Euflexxa injections code J7323LT x 3, J7323RT x 3 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID-19 (2019 Novel Coronavirus) pneumonia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

The patient is an adult male who presented to the emergency department (ED) with complaint of worsening shortness of breath (SOB). He came to the ED with Temperature 98.7 Fahrenheit (F), Heart Rate 101, Respiratory Rate 20, blood pressure (BP) 126/76 and oxygen saturation of 86% (percent) on room air. He had rales on lung exam.  White blood cells (WBC) were 10.2, hemoglobin (Hb) 11.1, blood urea nitrogen (BUN)/ Creatinine 17/1.6. Chest X-ray (CXR) revealed patchy infiltrates consistent with COVID-19 (2019 Novel Coronavirus) pneumonia. Ferritin, c-reactive protein (CRP) and procalcitonin (PCT) were elevated. The patient was admitted to the hospital with a diagnosis of COVID-19 pneumonia.

The patient's temperature spiked to 102.5 F and he was placed on intravenous (IV) steroids, and Remdesivir. The patient was also given IV fluids and supplemental oxygen (O2).

This patient had COVID-19 pneumonia with hypoxic respiratory failure. Admission was appropriate due to hypoxia and need for Remdesivir and Steroids. He was at a high risk for death due to his co- morbidities of diabetes and hypertension, and he had elevated bio markers.

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 inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient presented with abdominal pain. The patient was afebrile, and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. An abdominal Computed Tomography scan showed a mildly dilated appendix but no fluid collection. The pain rapidly resolved, and the patient was able to tolerate a diet. The gastroenterologist advised that the patient did not have acute appendicitis, but that gastritis was possible. 

Clinical indications for admission for Undiagnosed Abdominal Pain (Milliman Care Guidelines M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

This patient had abdominal pain. Although the appendix was mildly dilated, the clinical picture was not consistent with acute appendicitis. Intravenous hydration, antiemetics, and Proton Pump Inhibitor therapy could have been given in the Emergency Room with observation status. The patient's symptoms rapidly improved and the patient did not require any surgical interventions. The patient did not meet Milliman Care Guidelines criteria for admission for Undiagnosed Abdominal Pain. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, prostate cancer, heart disease
Treatment: Personal care aide 144 hours per week, consumer direct, 1 client
The insurer denied coverage for personal care aide 144 hours per week, consumer direct, 1 client.
The denial is upheld.

This is a geriatric patient with diagnoses that include hypertension, prostate cancer, and heart disease. The patient is also legally blind due to bilateral chronic glaucoma. The patient lives with daughter and her family. The patient is approved for Personal Care Aide (PCA) 84 hours per week, and the patient is requesting PCA 144 hours per week, consumer direct, 1 client.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as minimally impaired. The patient requires maximal assistance for bathing and lower body dressing. Extensive assistance is needed for personal hygiene, upper body dressing, locomotion, ambulation (uses a cane) and toilet transfer and use. The patient is occasionally incontinent of bladder and continent of bowel. The patient is otherwise independent with bed mobility and limited assistance for eating. There have been no falls, change in activities of daily living (ADL) status or self-sufficiency over the prior 90 days. The patient's medical condition, functional ability and mobility are not at the level as to require the requested PCA 144 hours per week. This physician would agree the patient (who lives with daughter and her family) may require additional monitoring. However, safety monitoring under Personal Care Services (PCS) does not include monitoring an individual when no other Level I or Level II personal care service tasks are being provided. Based on the records reviewed, the patient's health and safety are appropriately provided and maintained by the approved PCA 84 hours per week, consumer direct, 1 client.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based. From a physical medicine and rehabilitation perspective, PCA 144 hours per week, consumer direct, 1 client is not medically necessary. 

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

The medical necessity for personal care aide 144 hours per week, consumer direct, 1 client is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: diabetes/hypertension
Treatment: Long term placement. 
The insurer denied long-term placement. 
The health plan's determination is upheld. 

This is a male patient with diabetes, hypertension (HTN), hypothyroid, substance abuse, myoclonus, and seizures who was admitted to subacute level rehab. He progressed with therapies but has requested long term placement. 

Long Term Placement is not medically necessary for this patient. The patient is supervision level for activities of daily living (ADL), transfers, and ambulation and can receive outpatient therapies in the home environment. His functional level does not justify the need for Long Term Placement. At this point, the patient can be cared for at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent Syn 300 
The health plan denied the requested prescription medication, Dupixent Syn 300 as not medically necessary.
The denial is upheld.

The patient is a female with moderate to severe atopic dermatitis (30% body surface area involvement) since childhood, and which now covers her arms and back. The patient has tried and failed topical Mometasone, Ketoconazole, Fluocinolone, and Triamcinolone.

The medical necessity of Dupixent is under review. The health plan's determination of medical necessity is recommended to be upheld.

The requested Dupixent is being prescribed out of convenience and/or preference, which is not the same as true medical necessity. First-line therapies for this condition remain topical, and the patient has used neither more potent topical steroids nor first-line nonsteroidal topical therapies (calcineurin inhibitors Tacrolimus or Pimecrolimus) for her condition. Traditional/oral therapies (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil) and/or Phototherapy have also not been utilized, and therefore all other viable treatments, systemic and topical, have not yet been used to confirm that Dupixent is truly medically necessary.

The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors or more potent topical steroids, and/or standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil) that would obviate the need for further topical therapies (despite these oral medications not being required step therapy for Dupixent). Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, as per the patient's health plan policy language, [1] and consistent with current medical literature, [2-5] the requested Dupixent is not medically necessary and does not meet the health plan coverage requirements.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) level 2 services: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift) - total of 168 hours/week
The insurer denied PCA level 2 services: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift) - total of 168 hours/week.
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, hyperlipidemia, diabetes mellitus (DM) type 2, coronary artery disease, dementia, iron deficiency anemia, chronic kidney disease, urinary incontinence, osteoarthritis, and bowel incontinence who was assigned PCA (personal care aide) services.

PCA level 2 services: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift) - total of 168 hours/week are medically necessary for this patient.

There is documentation from the patient's medical provider of medical necessity of increased PCA services. The provider also documented the need for turning and repositioning every 2 hours. The patient has diagnosis of sacral ulcer and bedbound status. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. Due to the patient having 24-hour care needs, the plan should not have utilized a tasking tool to estimate PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's care needs in the overnight hours would not allow a PCA 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, PCA level 2 services: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split shift) - total of 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Psoriasis vulgaris.
Treatment:  Siliq.

The insurer denied coverage for Siliq.  The denial is overturned.
 
The patient is aa adult with a diagnosis of severe recalcitrant psoriasis vulgaris.  The patient has failed therapy with multiple systemic agents, including methotrexate, prednisone, and Tremfya.  The patient has also failed topical steroid and non-steroid therapies, including tacrolimus and Wynzora.  The requested medication is Siliq. 
 
Based on the submitted documentation, Siliq is medically necessary for the treatment of the patient's psoriasis vulgaris.  The patient has failed numerous therapies, including methotrexate and Tremfya.  The patient requires systemic biologic therapy for appropriate disease management.  Siliq is Food and Drug Administration (FDA) approved for moderate-severe psoriasis and is a reasonable alternative for the patient.  The joint American Academy of Dermatology - National Psoriasis Foundation (AAD-NPF) psoriasis guidelines list Brodalumab (Siliq) with a strength of recommendation of "A" as monotherapy for adults with psoriasis.  The use of Siliq is approved under the medical supervision of the treating dermatologist.   

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 Siliq is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Narcolepsy with Cataplexy
Treatment: Wakix 4.45 MG (milligrams) TAB (tablet)
The insurer denied Wakix 4.45 MG TAB.
The determination is overturned.

This is a female patient with daytime sleepiness. The patient was diagnosed with narcolepsy. The Multiple Sleep Latency Test (MSLT) showed reduced mean sleep onset latency down to 3.7 minutes and no sleep onset rapid eye movement (REM). The provider is requesting the coverage of Wakix. The patient tried and failed Provigil with residual sleepiness with an Epworth score of 16. The patient continues to have cataplexy despite Prozac.

The requested health service/treatment of Wakix 4.45 mg (milligrams) tablet is medically necessary for this patient.

The patient suffers from narcolepsy with cataplexy. The patient continues to have severe residual daytime sleepiness with an Epworth score of 16 despite Provigil. The patient continues to have cataplexy despite Prozac. Although they are prescribed for cataplexy, none of the preferred medications (Venlafaxine, Duloxetine, Imipramine, Clomipramine, Protriptyline, Desipramine, Atomoxetine) are expected to improve the patient's daytime sleepiness. The Wakix is a first-of-its-kind medication that increases histamine levels in the brain. Wakix is the first and only once-daily tablet that is Food and Drug Administration (FDA) approved to treat excessive daytime sleepiness (EDS) and cataplexy in adults with narcolepsy.

Therefore, the Wakix is medically necessary for this patient over the preferred medications (Venlafaxine, Duloxetine, Imipramine, Clomipramine, Protriptyline, Desipramine, Atomoxetine).
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Dry eye syndrome
Treatment: Bepreve (bepotastine)
The insurer denied coverage for Bepreve (bepotastine).
The denial is upheld.

This is an adult with a history of dry eye syndrome. Approximately one year ago, visual acuities were 20/30 in the right eye (OD) and 20/25 in the left eye (OS). Exam showed decreased tear break up time in both eyes (OU). Diagnosis of chronic allergic conjunctivitis OU was noted. 

One year later, visual acuities were 20/20 OU. Diagnoses of dry eye syndrome and allergic conjunctivitis were noted.

Two weeks later, visual acuities were 20/25 OD and 20/20 OS. Exam showed decreased tear break-up time and 1+ (plus) inferior superficial punctate keratitis (SPK) OU. 

Six weeks later, visual acuities were 20/25 OU. Exam showed decreased tear break-up time and 1+ inferior SPK OU. Diagnoses of dry eye syndrome and acute allergic conjunctivitis. Patient noted to have poor efficacy with Xiidra and Cequa. Patient to use Bepreve OU. 

In a letter, the request for Bepreve was denied because patient has not tried and failed the required number of formulary alternatives or has intolerance or contraindication to formulary alternatives. Formulary alternatives noted were azelastine, bepotastine, cromolyn sodium, olopatadine.

In a letter, the optometrist noted that the patient has bilateral dry eye disease and Bepreve is indicated for the treatment of the signs and symptoms of this condition. The optometrist noted that Bepreve is the only therapy that has successfully alleviated her symptoms. She had previously tried and failed azelastine, bepotastine, Pataday, artificial tears, Restasis and Zaditor, and that she has had an allergic reaction to the medications.

The formulary drugs are not likely to cause the patient an adverse reaction. The attending provider noted that the patient has tried and had allergic reactions to some formulary alternatives, including azelastine and olopatadine. The patient has not been noted to have tried the formulary alternative cromolyn sodium. 

Some of the formulary drugs have been ineffective. In particular, the attending provider noted that patient has tried and had allergies to azelastine and olopatadine. Also, the provider noted that the patient failed bepotastine which is the generic name for Bepreve. Thus, it is unclear why Bepreve would be of value. Also, patient has not tried cromolyn sodium.

There is no evidence to suggest that the requested drug (Bepreve) would be more effective than the formulary drug. There is no literature to support that Bepreve is more effective than cromolyn sodium.

The formulary drugs were not all tried, and the patient did have an adverse reaction or contraindication to some.

The formulary drug is not expected to be ineffective.

The non-formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial for formulary exception for Bepreve (bepotastine) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus.
Treatment: Humalog.
The insurer denied the requested Humalog.
The health plan's determination is upheld.

The patient is a female with uncontrolled type 1 diabetes. The request is for Humalog. The patient has tried and failed Ademlog due to worsening hypoglycemia. The patient has supplies to start on Omnipod.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient. The requested Humalog was not medically necessary and was appropriately denied.

The request is for Humalog for the treatment of type 1 diabetes is not medically necessary. The patient has tried and failed Ademlog due to hypoglycemia. The formulary alternative is insulin Lispro. Humalog is also a form of the insulin Lispro. Humalog and generic insulin Lispro are expected to have identical safety and efficacy for the treatment of type 1 diabetes. The American Diabetes Association clinical guidelines do not recommend the use of Humalog over insulin Lispro. Therefore, the requested Humalog is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cardiomyopathy.
Treatment: Camzyos
The insurer denied Camzyos. 
The health plan's determination is overturned. 

The patient is a man with symptomatic hypertrophic cardiomyopathy. He has a history of recurrent near syncope, orthostatic lightheadedness and exertional dyspnea. 

Based on the documentation provided, treatment with Camzyos is medically necessary.
This patient has hypertrophic cardiomyopathy (HCM) and New York Heart Association (NYHA) Functional Class III symptoms despite treatment with high dose metoprolol and ventricular pacing. In the pivotal trial involving patients with HCM and a resting outflow tract gradient of 50 or greater, NYHA Class II-III symptoms, mavacamten (Camzyos) substantially improved exercise tolerance, functional class and quality of life and significantly decreased resting gradients. The drug is Food and Drug Administration (FDA) approved to improve functional capacity and symptoms in patients, such as this man, with symptomatic New York Heart Association class II-III obstructive hypertrophic cardiomyopathy (HCM).
Other than surgery, this highly symptomatic man's treatment options are limited. Calcium channel blockers were listed as a possible alternative to mavacamten in the denial letter. However, per the 2020 American Heart Association (AHA) / American College of Cardiology (ACC) guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy, "The use of calcium channel blockers in combination with beta-blockers, as therapy directed at HCM, is unsupported by evidence." Moreover, their use (even without beta-blockers) is sometimes limited by their vasodilatory properties and resultant hypotension which would be of particular concern in this man who already complains of orthostatic lightheadedness. The denial letter also mentions disopyramide as a therapeutic option. While this has shown to have a favorable effect on outflow tract gradients, it is often poorly tolerated due to its anticholinergic effects, particularly in men. In addition, it is associated with a significant risk for QT prolongation and proarrhythmia. In contrast, in clinical trials mavacamten has been well-tolerated with a side effect profile similar to that of placebo.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion, anterior crossbite.
Treatment: Braces.
The insurer denied: Braces.
The denial is overturned.

The request is for orthodontics in this adolescent female patient. The patient has a Class I malocclusion, mild upper spacing and mild lower crowding. She has an anterior crossbite. The prior denial was due to a handicapping index score of seven.

The proposed treatment is medically necessary.

Teeth #'s 7 and 27 (both permanent anterior teeth) are in crossbite. Tooth #27, the lower right canine, is outside of tooth #7, the upper left lateral incisor. This is reverse to what is normal. 
There is gingival attachment loss present. This is an automatic qualifier according to the handicapping index scale.