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

Diagnosis: Severe Rash
Treatment: Familial Mediterranean Fever genetic testing 
The health plan denied: Familial Mediterranean Fever genetic testing 
The denial is overturned.

The patient is a female for whom genetic testing for Familial Mediterranean Fever (FMF) was requested. This was denied by the health plan. Diagnosis codes submitted for the test in question included chronic urticarial rash and asthma. The patient appealed the denial. She reported a number of "autoimmune symptoms" over the past 15 years including severe chronic urticarial rash, asthma, chest pain, recurrent fevers, and polyarthropathy. She has seen numerous specialists including several immunologists, dermatologists, rheumatologists, and a pulmonologist without a satisfactory diagnosis made to date. Her laboratory testing had been notable for elevated immune markers and leukocytosis. She presented for a new rheumatology consultation to address her various symptoms. As part of the diagnostic evaluation, a test for FMF was ordered "in consideration of my ethnicity, familial history, and autoimmune symptoms". No one in her family had previously been diagnosed with FMF.

The health plan's determination is overturned.

In this case, the patient has an incompletely defined syndrome characterized by recurrent fevers, joint pain, urticarial rash, and elevated inflammatory markers in the absence of infection, malignancy, or specific autoimmune condition. Sulfasalazine had been partially helpful reportedly in alleviating some of the patient's symptoms although this medication is not utilized in the treatment of FMF. One could argue that one of the commercially available autoinflammatory genetic test panels via Next Generation Sequencing Autoinflammatory Disease (NGS-AID) which assess for hundreds of genes simultaneously would have been a more appropriate test for this patient with periodic/recurrent fevers, joint pain, urticaria, and repeated findings of inflammatory response. If a specific genetic mutation were identified on this panel, it would strongly suggest that the patient had an associated autoinflammatory syndrome even if the patient lacked other specific features of a given condition. Many patients have atypical or incomplete presentations of these auto-inflammatory conditions. Regardless, the provider opted to test specifically for MEFV (the gene associated with FMF). As discussed above, the patient's clinical scenario does not strongly suggest FMF, specifically, but this condition cannot be ruled out entirely either based upon the submitted documentation especially given her ethnicity. Genetic testing for FMF in this case was appropriate and consistent with current standards of care. As such, based upon current peer-reviewed medical literature the genetic test for FMF was medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara 90 mg (milligrams) every 4 weeks 
The insurer denied Stelara 90 mg every 4 weeks.
The determination is overturned.

This is a patient with Crohn's disease. She has failed Remicade and Humira. She started Stelara, with good disease control. She then had the onset of symptoms including abdominal pain, diarrhea, rectal bleeding, nausea, and vomiting four weeks after Stelara injections. She has had improvement on Stelara 90 milligrams (mg) every 4 weeks. At issue is the medical necessity of Stelara 90 mg every 4 weeks.

Current medical literature supports dose escalation of Stelara to 90 mg every 4 weeks as medically necessary for the treatment of Crohn's disease in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al). Another study showed a 73 percent (%) response in patients with anti-tumor necrosis factor (TNF)-resistant Crohn's disease, and 80% of responders maintained remission for 1 year (Kopylov, et al). The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor medications, which the enrollee has failed (Tuskey, et al). A study showed dosing at 90 mg every 4 weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every 4 weeks (Kopylov, et al). Multiple studies have shown that a majority of patients in whom Stelara dosing every 8 weeks failed to control symptoms responded to dosing every 4 weeks (Wils, et al; Battat, et al; Khorrami, et al).
In this case, the patient has had disease symptoms starting four weeks after Stelara injections while taking Stelara every 8 weeks. The American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should... have their medication dose adjusted in order to attempt to optimize therapy" (Battat, et al; Lichtenstein, et al). Decrease of dosing to every 8 weeks or discontinuation of Stelara (even if an alternative is attempted immediately) may result in loss of disease control, with complications such as stricture, fistula, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of this patient's Crohn's disease.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Testicular hypofunction, erectile dysfunction
Treatment: Stendra (avanafil)
The insurer denied Stendra (avanafil).
The determination is overturned.

This is a patient with a history of erectile dysfunction, who has tried and failed sildenafil and tadalafil and injection therapy, per the appeal documentation. At issue is whether the formulary drugs sildenafil (generic Viagra), tadalafil (generic Cialis) will be or have been ineffective, would not be as effective as the non-formulary drug, Stendra (avanafil) or would have adverse effects.

The appeal documentation states that both sildenafil and tadalafil have been tried and have been ineffective for the patient. One study (prospective, randomized, double-blind, two-arm, active-controlled, parallel, multicenter, non-inferiority phase III clinical trial was carried out at six tertiary care centers in India from January 2020 to October 2020) concluded that Avanafil is superior to sildenafil in improving the International Index of Erectile Function - Erectile Function domain score at the end of 12 weeks of treatment with the added advantage of faster onset of action (Kumar et al.). Even after many years of approval and successful use in the management of erectile dysfunction (ED), only limited data are available on comparative evaluation of the efficacy and safety of avanafil with other Phosphodiesterase 5 inhibitors. To date, only a single study has been published comparing the efficacy and safety of avanafil to sildenafil, that too in difficult to treat subset of patients; that is, patients undergoing rehabilitation therapy after robot-assisted unilateral nerve-sparing prostatectomy (Della). This reviewer is not aware of additional head-to-head studies that would support that either sildenafil or tadalafil are less effective or have more adverse effects than avanafil. However, since the patient has tried both formulary alternatives required by the health plan (sildenafil, tadalafil), the non-formulary medication (Stendra) is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Other/Tooth Decay
Treatment: Surgical Services (All)/Ambulatory Surgery
The health plan denied the requested ambulatory surgery as not medically necessary. 
The health plan's determination is overturned.

The patient is a female who presents to the office for dental therapy and has been referred for that dental treatment to be under general anesthesia in an ambulatory setting. Provided for review are letters of appeal and denial, clinical notes from the office of the provider, and radiographic images.
In question is the medical necessity of the ambulatory setting for the dental treatment.

I overturn, in whole, the health plan's determination of medical necessity.

Yes. Due to the extensive nature of the required dental treatment and the patient's age, there is not the typical ability to deliver care in an outpatient setting. A patient of this age cannot sit for procedures as extensive as these in an effective manner that would allow the practitioner to deliver the appropriate care. Further, children have smaller weights and cannot tolerate the required amount of local anesthesia and injections to carry out the work without elevated blood pressure and heart rate which use up local anesthesia at a faster rate, further limiting the practitioner's ability to carry out the treatment. Hence, due to the extensive nature of the required dental treatment and the age and stature of the patient, the treatment must be carried out in a hospital setting where an anesthesiologist can deliver the anesthesia that will result in the patient's vitals being controlled and the patient being able to tolerate the required treatment. This is very common within pediatric dentistry carried out on children at this age. Hence, the treatment of the dental needs under ambulatory anesthesia is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female who presented to the emergency department with left-sided chest and back pain. The patient has a history of diabetes and hypertension and began experiencing chest pain the previous night, with spontaneous resolution. She had no fevers or chills and no nausea or vomiting. The patient reportedly had a normal cardiac catheterization years ago, per a report in the emergency department.

The patient was admitted to medicine. Cardiology assessed the patient and noted that the patient had sharp chest pain with inspiration radiating to the back, non-exertional. Vital signs were stable. The cardiologist also noted that the patient had a negative computed tomography (CT) angiogram of the chest for pulmonary embolism. As a result, they recommended an outpatient stress echocardiogram and follow-up with cardiology. The patient was deemed stable for release home.

The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is upheld.

Inpatient hospital admission is not medically indicated for this presentation. This is low-risk chest pain, with a HEART (history, electrocardiogram [EKG] abnormalities, age, risk factors, and troponin) score of less than 3. The patient was admitted for acute coronary syndrome ruling out. Cardiac enzymes are negative, EKG shows no abnormalities, and there are no major electrolyte derangements. Pulmonary embolism was ruled out; there is no evidence of dissection, new onset heart failure, or other life-threatening chest pathology. The typical workup for this presentation is a brief monitoring stay, with subsequent outpatient follow-up. The medical literature is clear on this protocol. The patient could have been safely and appropriately managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral palsy
Treatment: Consumer Directed Personal Assistance Services, 10 Hours per Day, 7 Days per Week (Monday through Sunday): Total of 70 Hours per Week
The insurer denied Consumer Directed Personal Assistance Services, 10 Hours per Day, 7 Days per Week (Monday through Sunday): Total of 70 Hours per Week. 
The health plan's determination is overturned. 

The patient is a male with past medical history of cerebral palsy, anxiety, depression, urinary incontinence, morbid obesity, hypertension, gastroesophageal reflux disease (GERD), and systemic sclerosis who had a fall with injuries requiring back surgery and hospitalization. The patient was transferred to rehabilitation and the patient was discharged to home. There was a request to increase CDPAS (Consumer Directed Personal Assistance Services).

Consumer Directed Personal Assistance Services, 10 Hours per Day, 7 Days per Week (Monday through Sunday): Total of 70 Hours per Week is medically necessary for this patient.
There is documentation of increased activities of daily living (ADL) and Instrumental activities of daily living (IADL) needs following fall with hospitalization and surgery. The patient requires extensive assistance with toilet use and limited assistance with transfer toilet which are 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. The video assessment under estimated the patient's hours of ADLs/IADL assistance via tasking tool. The patient's medical provider documented the medical necessity of increased CDPAS services. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, CDPAS services 10 hours/day, 7 days/week, to total 70 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 his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glaucoma
Treatment: Vyzulta
The insurer denied Vyzulta. 
The health plan's determination is overturned.

The patient is a male with Primary Open-Angle Glaucoma. The Ophthalmologist is seeking the use of Vyzulta as the patient has failed two prior eye medications (latanoprost and Travatan-Z). The patient was treated with a sample of Vyzulta and demonstrated an excellent response by bringing the intraocular pressure down from 20 to 10 mmHg (millimeters of mercury). The patient reported tolerating the Vyzulta a lot better. 

Vyzulta is medically necessary for this patient.

Vyzulta was tried and shown to be effective at lowering intraocular pressure and was well tolerated in this patient. Vyzulta would be considered medically necessary to control this patient's intraocular pressure. The patient was unable to tolerate or failed two previous medications, but Vyzulta was demonstrated to work.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Miscarriage. 
Treatment: Genetic Testing (Factor V Leiden - 81479). 

The insurer denied: Genetic Testing (Factor V Leiden - 81479). 
The denial is upheld. 

The patient is an adult female with a history of a first trimester miscarriage. She underwent testing for Factor V Leiden as part of the evaluation of her miscarriage. Coverage was denied by the health plan, because this test was deemed to be not medically necessary. This denial is being appealed. 

The requested Genetic Testing (Factor V Leiden - 81479) was not medically necessary. 
Use of this test in this setting is not supported by peer reviewed data. It is not supported as standard of care or by professional organizations. 

Based on the studies cited below, Factor V Leiden testing is not recommended unless the patient has a history of recurrent pregnancy losses and a family history concerning for a clotting disorder. In this case, there is no documented family history of clotting, and one pregnancy loss event. Therefore, given the above, testing for Factor V Leiden is not supported by peer-reviewed data, it is not standard of care and not recommended by professional organizations in this patient's case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: psoriatic arthritis (PsA).
Treatment: Rinvoq.
The insurer denied Rinvoq. 
The health plan's determination is upheld.

The patient is a man with psoriatic arthritis (PsA) and psoriasis. Prior treatment has included systemic and topical corticosteroids, NSAIDs (non-steroidal anti-inflammatory drugs), and Otezla. Per a letter from the patient's provider, the patient has a fear of needles and does not feel comfortable with this route of administration. The issue, in this case, is Rinvoq 15 milligrams (mg) daily is being denied by the health plan. The reason for the denial is not medically necessary as the patient has not tried the covered alternatives, such as anti-TNF (tumor necrosis factor) therapy for PsA (e.g. Cimzia, Enbrel, Humira, Infliximab), Simponi, Simponi aria x 3 months, had a reaction to these drugs or there is a contraindication to one of these drugs.

Rinvoq 15 mg is not medically necessary for this patient. The patient does not have a contraindication to one of the preferred therapies on the health plan's policy. Per a letter from the patient's provider, the patient has a fear of needles and does not feel comfortable with this route of administration; however, this is not a medical contraindication, and he can still try an intravenous (IV) medication (e.g. Simponi aria or Infliximab) or an in-office injection (e.g. Cimzia). The approved drugs are all indicated for the treatment of PsA and there is no medical reason the patient cannot try one of them.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bitten by Cat
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission
The denial is overturned.

The patient presented to the hospital with an infected finger 24 hours after a cat bite. Incision and drainage were performed and intravenous (IV) antibiotics were administered. Cat bites are a source of major upper extremity morbidity and require urgent and aggressive treatment. 

In a 2020 study on cat bites to the hand, the investigators reported as follows: "In six years, a total of 69 patients with cat and dog bite injuries were treated in our hospital emergency room (ER). 45 patients arrived at the ER within 24 h after the injury (group I). 24 patients were treated more than 24 hours after injury for the first time (group II). A retrospective study with evaluation of the clinical data including wound aspect, tissue damage, treatment, and antibiotics was performed. In group I, 27 were outpatients and 18 were in-house patients with an average hospitalization period of 3.3 days  1.12 days. 16 patients were treated conservatively. An operation was performed in 29 patients and in 3 patients a second look surgery was necessary. In group II, 5 patients were outpatients and 19 were inpatients with an average hospitalization period of 5.8 days  1.9 days. An operation was performed in 22 patients, and 2 were treated conservatively. In five patients, a second look surgery was necessary in group II." (1) This study clearly shows that cat bites cause significant morbidity and hospitalization was commonly required for most patients, underscoring the severity of these infections.

A study by Kheiran et al found the following: "Domestic cat bites are common and are often treated by simple wound care with good outcome. However, delayed presentation may lead to significant morbidity or even mortality. Twenty cases of cat bites to the hand and wrist were retrospectively reviewed between. Eleven patients (Group A) were presented within 48 hours of their injury. Nine patients (Group B) presented later than 48 hours. Of these, 78% (n = 7) underwent multiple operations secondary to septic arthritis, osteomyelitis, necrotizing fasciitis, and deep collection. Mean length of hospital stay was 3.4 days in Group A, and 9.2 days in Group B, (p < .01). Four patients underwent digital or ray amputations." (2) Again, the literature clearly shows that hospitalization is the norm for these patients due to the severity of the injury. The patient's physicians appropriately recognized the complexity of the cat bite infection and hospitalized the patient for aggressive surgical and antibiotic treatment.

The hospitalization was medically necessary and consistent with the published standard of care for this type of injury. 

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 full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acquired absence of left leg above knee.
Treatment: Replacement artificial leg.

The health plan denied the requested artificial leg replacement as not medically necessary.  The health plan's determination is overturned.

This is a male with a right transfemoral amputation due to osteosarcoma. He has been using an Otto Bock X3 microprocessor prosthesis and needs replacement due to wear on the device and socket damage.

At issue is the medical necessity for the requested artificial leg replacement.

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

I believe it is in the best interest of the patient to replace his current prosthesis with similar components. There is medical necessity for replacement of his current prosthesis with a new Otto Bock X3 microprocessor device. Due to the patient's large habitus and high activity level with frequent exposure to uneven terrain and wet environments, the X3 is the appropriate device. To ensure safety and continued recreational and vocational activity, it is necessary to provide him with a replacement of the same device he is currently using.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic low back pain.
Treatment:  Pain Management (facet joint injections) (64493x2, 64494x2).

The insurer denied Pain Management (facet joint injections) (64493x2, 64494x2).  The denial is overturned.

The patient is an adult female with a history of chronic low back pain that rarely radiates to the posterior right thigh and not below the knee once or twice a week with the pain mostly in the low back. The pain affects her functionality. She had L5/S1 (fifth lumbar spine vertebra/first sacral vertebra) inter laminar epidural steroid injections last year with very short relief of approximately two days. The patient has failed conservative measures including physical therapy, chiropractic manipulation, home exercise program, Tylenol, Hydrocodone, Oxycodone, and different NSAIDs (nonsteroidal anti-inflammatory drugs). Previously, the patient had lumbar facet blocks with excellent relief. The MRI (magnetic resonance imaging) of the patient's lumbar spine showed facet arthropathies multilevel, Modic changes at L5/S1 (fifth lumbar spine vertebra/first sacral vertebra) with left disc protrusion contacting left S1 (first sacral vertebra). The request by the treating physician is for diagnostic bilateral L3 (third lumbar spine vertebra), L4 (fourth lumbar spine vertebra) and L5 (fifth lumbar spine vertebra) facet medial branch nerve blocks with possibility for radiofrequency ablation later.

The requested Pain Management (facet joint injections) (64493x2, 64494x2) is medically necessary.

This is the generally accepted medical option and treatment for possible lumbar acetogenic pain. The patient has suffered from chronic low back pain with previous lumbar facet blocks helping her pain excellently while recent L5/S1 (fifth lumbar spine vertebra/first sacral vertebra) interlaminar epidural steroid injections did not provide tangible relief. In addition the MRI (magnetic resonance imaging) lumbar spine showed facet arthropathies multilevel, Modic changes at L5/S1 (fifth lumbar spine vertebra/first sacral vertebra) with left disc protrusion contacting left S1 (first sacral vertebra). The pain is for diagnostic block towards possible radiofrequency ablation.

The reasons for denial by the health plan include lack of evidence of pain being more than three months and lack of plan for radio-frequency ablation, which is not consistent with what is evidenced in the records.