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

Diagnosis: fibroids

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is overturned. 

This female patient has a history of uterine fibroids and obesity.

This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in hospital for 48 hours. On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. On postoperative day 2, if the patient is passing flatus, and tolerating regular diet she is discharged home. This patient was managed according to the guidelines and the standard of care.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Other/Skin Mass
Treatment: Surgical Services
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This case describes a female patient who noted a large right thigh mass. She presented for elective removal of the thigh mass and sciatic nerve exploration. The surgery was successful with no documented complications. The patient remained in the hospital, then was discharged home with home care. The patient's health plan denied the inpatient stay with a determination that the hospital stay was not medically necessary. At issue in this case is the medical necessity of the inpatient hospital admission.

I uphold, in whole, the health plan's determination of medical necessity in this case.

The requested health service/treatment of an inpatient hospital stay was not medically necessary for this patient. This determination is based upon the provided records. The care rendered in this case was consistent with the recommendations of the current, peer-reviewed literature on lipomas of the thigh as documented by Pompo and colleagues and by McTighe and associates. The medical necessity of the inpatient stay, however, is not established based on the documentation in this patient's medical records. The progress notes document that the patient was able to ambulate 150 feet on this date. Vital signs and lab values were within normal limits and no complications were documented from the operation that would necessitate inpatient hospitalization. Therefore, the health plan's denial of the inpatient hospital admission should be upheld in this case.

The rationale for this determination is based upon the provided medical records and the recommendations of the current, peer-reviewed literature. The provided medical records include a post-operative therapy progress note in which the patient ambulated 150 feet with no loss of balance. The inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine / Metabolic / Nutritional. 
Treatment: Pharmacy Prescription Drugs. 
The insurer denied waver of ancillary charges for Synthroid. 
The denial is overturned.

The patient is a male with hypothyroidism treated with Synthroid. The patient has tried and failed generic levothyroxine per signed appeal documentation. Per the patient letter, generic levothyroxine caused him to feel dizzy, lightheaded, and nauseated. Thyroid stimulating hormone (TSH) was 6.41. The medical necessity for the waiver of ancillary charges for Synthroid is under review.

The health plan's determination is overturned in whole. 

The waiver of ancillary charges for Synthroid is medically necessary for this patient.
This patient has tried and failed generic levothyroxine. The American Thyroid Association clinical guidelines recommend that patients stable on a brand of thyroid supplementation continue on the same brand of thyroid supplementation due to a high risk of hypothyroidism/hyperthyroidism with switching to another brand because the strength between brands are not equivalent even at the same prescribed dose.
This patient has hypothyroidism and is stable on Synthroid. Without Synthroid, this patient is at risk of the complications of untreated hypothyroidism, which can cause myxedema coma, which can be life-threatening. Therefore, the requested waiver for ancillary charges for Synthroid is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dermatomyositis
Treatment Repatha auto-injectors
The insurer denied coverage for Repatha auto-injectors
The denial is overturned

The patient has a history of hypercholesterolemia and hypertriglyceridemia  and dermatomyositis. Repatha/Praluent injection was prescribed due to the patient's history of dermatomyositis.  Initial cholesterol panel revealed a low-density lipoprotein (LDL) level of 273 that dropped to 196.  Total cholesterol was noted to be 306 / high density lipoprotein (HDL) 62 / triglycerides (TG) 242.  Cardiology office notes document hyperlipidemia due to familial hypercholesterolemia.

The formulary requirement for statin drugs is likely to cause this patient an adverse reaction.  She suffers from dermatomyositis. Current literature supports avoidance of statin medications in patients with dermatomyositis as this may result in an inflammatory reaction requiring high dose steroid treatment (Reference 1,2).

This patient suffers from severe hypercholesterolemia and remains with an LDL cholesterol level of greater than 190mg/dl (milligrams per deciliter), despite dietary modification. Current American Heart Association and American College of Cardiology guidelines clearly note that in patients with severely elevated low density lipoprotein cholesterol (LDL-C) (>190) treatment with statin medications for primary prevention of atherosclerotic cardiovascular disease (ASCVD) is indicated. These same guidelines recommend that randomized trial proven non-statin therapy should be considered when statin medications are not tolerated. (Reference 3,4).  

Given these findings, Evolocumab (Repatha) therapy is medically necessary and is the current standard of care according to recent guideline statements.   It is not reasonable to administer statin therapy to a patient that continues to complain of limb and girdle muscle weakness and already suffers from a baseline myopathy. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been successfully utilized to treat hypercholesterolemia in immune mediated myopathic diseases (Reference 5). 

In conclusion, the proposed treatment is medically necessary and would be safer than the formulary medications. 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 Repatha Sureclick auto-injectors is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic neck pain and headaches
Treatment: Pain management (right destruction by neurolytic agent)
The insurer denied Pain management (right destruction by neurolytic agent)
The denial is upheld. 

The patient is a male with chronic neck pain and headaches. He has failed conservative treatment.  The patient underwent an intra-articular facet injection, as well as a confirmatory medial branch block. There is a letter, written by the patient, that he had minimal relief with the first injection, and near complete relief with the second injection. The patient then underwent radiofrequency ablation (RFA).

No, the proposed treatment was not medically necessary.
The patient is a male with chronic neck pain with a diagnosis of cervical spondylosis. He has magnetic resonance image (MRI) evidence consistent with this diagnosis. He has failed conservative treatment in the form of physical therapy (PT), massage, medications, trigger point injections, and subsequently radiofrequency ablation (RFA).  The patient underwent an intra-articular facet injection, as well as a confirmatory medial branch block.   However, the literature to support intra-articular (IA) injections as diagnostic has been shown to be poor.  Therefore the patient only underwent one diagnostic block - the medial branch block.  According to the Spine Intervention Society and American Society of Interventional Pain Physicians (ASIPP) guidelines, a dual block technique is recommended.  Although no specific documentation of the response to the patient's injections is provided in the medical record, the ASIPP ( American Society of Interventional Pain Physicians) recommends two medial branch blocks, and only one was completed.   Given the lack of two medial branch blocks, in accordance with the ASIPP ( American Society of Interventional Pain Physicians) procedural guidelines, and standard of care, the requested radiofrequency ablation (RFA) was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis. 
Treatment: Full hospital admission. 

The insurer denied coverage for full hospital admission. 

The denial is overturned. 

This is a female with a history of hypertension, congestive heart failure (CHF), migraines, osteoarthritis, gout, and atrial fibrillation. She presented to the hospital for a scheduled right total hip arthroplasty (THA). The procedure was performed. Estimated blood loss (EBL) was 300 milliliters (ml). After the procedure the patient was difficult to arouse. She responded to a sternal rub. The patient was admitted to the surgical step down unit for post-operative care. Routine bloodwork was collected. Pain medications were given as ordered. Sequential compression devices (SCD) were applied. Physical therapy and occupational therapy (PT and OT) services recommended having the patient getting out of bed (OOB) and ambulating. Cardiology services recommended trending cardiac enzymes, monitoring the patient on telemetry for 24 hours, and obtaining a chest x-ray (CXR). The workup was negative and the patient was discharged after a period of hemodynamic stability. 

The medical record demonstrates an acute event to require ongoing management. The report of non-responsiveness was significant. The event occurred and required additional testing/monitoring. The patient required consultations and Troponin enzymes. She required telemetry. Additional laboratory tests were also requested including chest x-ray and urinalysis. Her hematocrit had dropped dramatically to 23.  The next day it continued to drop to 22. 

Based upon the acute event and decreasing hematocrit, additional hospitalization would be required. No specific etiology was found but nevertheless, discharge to lower level of care would not be appropriate. 

The health care plan did not act reasonably. The admission and services provided were medically necessary. 

The insurer's denial of coverage for the full hospital admission is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic esophageal adenocarcinoma. 
Treatment: Stereotactic body radiation therapy (SBRT). 

The insurer is denied coverage for stereotactic body radiation therapy (SBRT). 

The denial is overturned. 

This male patient has a history of stage 2 B adenocarcinoma of the distal esophagus. 

The Stereotactic Ablative Radiotherapy for Comprehensive Treatment of Oligometastatic Tumors (SABR-COMET) trial (Palma et al.) enrolled patients with a controlled primary malignancy and 1-5 metastatic lesions, with all metastases amenable to SABR.  The patient would have been eligible for the SABR-COMET trial. The SABR-COMET trial demonstrated a survival benefit for oligometastatic patients randomized to local SABR compared to patients receiving standard care alone. A recent analysis (Mehrens et al.) suggests that local treatment with SABR adds quality adjusted life years for patients with certain oligometastatic cancers and represents an intermediate- and long-term cost-effective treatment strategy. For these reasons, SBRT/SABR is medically necessary in this case. 

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

The carrier's denial of coverage for the stereotactic body radiation therapy (SBRT)is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified Hyperlipidemia 

Treatment: Pre-Service Request for Vascepa 1 GM Capsules

The insurer denied coverage for Pre-Service Request for Vascepa 1 GM Capsules.

The denial is overturned.

The patient is a female with moderate hypertriglyceridemia in the (150-499 mg/dl) range and atherosclerotic heart disease and diabetes mellitus.  She has previously been treated with Simvastatin, Pitavastatin and atorvastatin, as well as Zetia.  Therapy was discontinued due to myalgia, nausea and inefficacy.  A request for approval of Vascepa is submitted, the patient has been tolerating this medication for over one year's time.

The American Heart Association (AHA) guidelines recommend intensive statin therapy for the treatment of moderate to severe hypertriglyceridemia as well as omega 3 fatty acid treatment (1).  There have been conflicting trial results demonstrating the efficacy of omega 3 fatty acids in reducing atherosclerotic cardiovascular disease (ASCVD) risk in those with hypertriglyceridemia.  However, these findings were largely due to differing patient enrollment and differing doses of omega 3 fatty acids.  The REDUCE-IT trial was a prospective double blind placebo controlled trial that enrolled patients with high cardiovascular risk.  Over half of the patients had diabetes and all had statin resistant hypertriglyceridemia.  Among patients with elevated triglyceride levels despite the use of statin, the risk of ischemic events and cardiovascular death was significantly lower in the patients treated with Vascepa (2).  The AHA science advisory noted that the use of Vascepa is an effective and safe option for reducing triglycerides (3).  

This patient, with a history of ASCVD, moderate hypertriglyceridemia and intolerance/inefficacy to statin therapy meets guideline criteria for therapy with Vascepa.

Vascepa 1gm is medically necessary in this case.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the Pre-Service Request for Vascepa 1 GM Capsules to Treat Unspecified Hyperlipidemia is reversed.  Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right tibial plateau fracture.
Treatment: Joint Surgery (29877 - removal or shaving of knee joint cartilage using endoscopy).

The insurer denied the Joint Surgery (29877 - removal or shaving of knee joint cartilage using endoscopy).  The denial is overturned.

This patient is a female who sustained a right tibial plateau fracture. Her physician performed arthroscopy and then an open reduction internal fixation. Her post surgical course was complicated by pain and stiffness. Her physician performed additional arthroscopic surgery/chondroplasty, and removal of hardware. 

Yes, the proposed treatment is medically necessary.

The records demonstrate this patient had ongoing symptoms. She reported catching and other mechanical complaints which are consistent with an intraarticular condition. Based upon her previous operative fixation, it would be likely she had associated chondral damage versus meniscal pathology. A magnetic resonance image (MRI) would not likely provide additional information because of the metal implant. There would be artifact. Additional imaging studies would also likely not provide benefit. Based upon clinical history, failure to improve with conservative treatment, arthroscopic evaluation of the knee with hardware removal would be the best course. The physician found chondral flaps and documented them on photographs. Definitive management would include chondroplasty.

An intraarticular examination of the joint would be appropriate because of ongoing problems after operative management.  Definitive management for this patient would include chondroplasty.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Right Transfemoral Amputation
Treatment: Treatment: Lower Limb Prosthesis With A Microprocessor Knee
The insurer denied the Treatment: Lower Limb Prosthesis With A Microprocessor Knee 
The denial is overturned.

The patient is a male with history of initial muscle spasms. The led to Right Knee
and Ankle contractures, and he later developed Complex Regional Pain Syndrome
(CRPS). He subsequently had a Right Transfemoral Amputation (Above-Knee
Amputation [AKA]). Prior to the AKA (above knee amputation), he was very active,
involved in recreational sports and working as a waiter. His job required working in
an environment where he needs to navigate, stand, walk, carry, maintain balance
and ensure safety with required stability and prevention of stumbling/buckling and
fall. He is dependent on stable prosthetics with a stable knee component.

The request is for an Above-Knee Prosthetic with a Microprocessor Knee.
Yes, the health plan should cover the Lower Limb Prosthesis With A Microprocessor Knee.
The proposed AKA (above knee amputation) Prosthetic for all of the requested
codes is medically appropriate for the patient. He is a very active man, involved in
recreational sports and working as a waiter. His job requires working in an
environment where he needs to navigate, stand, walk, carry, maintain balance and
ensure safety with required stability and prevention of stumbling/buckling and fall.
He is dependent on a stable prosthetics with a stable knee component. The foot
and microprocessor knee and components of the prosthetics will be essential to
enable him remain active, stable on his feet and be able to navigate terrain that is
particular to the nature of his work and level of activity.

The alternatives would be another prosthetic without the microprocessor knee, and
a different foot. Based on the current standard of care and the patient circumstance
as stated above, the AKA (above knee amputation) prosthetic with the foot and
microprocessor knee components will be more appropriate for a young person of
his age who is very active, and it will also enable him to return to working as a
waiter with ability to ambulate and navigate within such an environment, as stated
above.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Taltz autoinjector (3 pack) 80 mg/ml. 

The insurer is denied coverage for Taltz autoinjector (3 pack) 80 mg/ml. 

The denial is upheld. 

This male patient has a history of psoriasis. 

The patient has inverse psoriasis who has failed topical therapy with triamcinilone and a brief trial of Otezla.  Laboratory tests provided as well as documentation provided do not demonstrate any contraindication to traditional therapies used to treat psoriasis. There are no comparative, controlled studies showing that Taltz has a superior efficacy to numerous alternatives such as Methotrexate, Humira, Enbrel, Stelara, Skyrizi, Tremfya, and Cosentyx.  

There is no medical and 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 the American Academy of Dermatology (AAD) and the National Psoriasis Foundation (NPF)  AAD-NPF guidelines for the treatment of psoriasis, Stelara and Cosentyx have a strength of recommendation of "A" for monotherapy in adult patients with psoriasis vulgaris. 

According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient. 

The preferred agents 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. Taltz would not be more effective in treating the patient's psoriasis than the formulary drugs. 

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

The carrier's denial of coverage for Taltz autoinjector (3 pack) 80 mg/ml is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Crohn's disease. 
Treatment: Pentasa 500 milligrams (mg) CR capsule. 

The insurer is denied coverage for Pentasa 500 milligrams (mg) CR capsule. 
The denial is upheld. 

This female patient has a history of Crohn's disease. 

UpToDate article titled "Overview of the Medical Management of mild Crohns Disease in Adults" notes, recommended treatments for ileal disease include Budesonide, and 5-ASA (aminosalicylic acid) preparations. There is no recommendation that the patient needs to be given Pentasa instead of other mesalamine preparations. 

The American College of Gastroenterology has published a guideline "Management of Crohns Disease in Adults." The recommendation is that for Crohns Disease 5-ASA preparation have not been consistently shown to be effective. Sulfasalazine is a recommended treatment. There is no recommendation to give Pentasa. 

The insurance company has offered several mesalamine preparations. The scientific literature does not support pentasa being superior to other mesalamine preparations. The formulary drugs are not likely to cause an adverse reaction. The record does not show that the formulary drugs have been tried and failed. 

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

The carrier's denial of coverage for the Pentasa 500 milligrams (mg) CR capsule is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Clostridium difficile.
Treatment: Bezlotoxumab (Zinplava).
The insurer denied the Bezlotoxumab (Zinplava).
The denial is overturned.

The patient is a male with recurrent clostridium difficle (C-diff). He was hospitalized and has filled two outpatient prescriptions for oral vancomycin since discharge. The attending physician (AP) is requesting treatment with bezlotoxumab (Zinplava).

Yes, the proposed treatment is clinically appropriate and accepted standard of medical care, and is medically necessary.
Johnson et al stated that for patients with a recurrent clostridium difficle infection (CDI) episode within the last six months, we suggest using bezlotoxumab as a co-intervention along with standard-of-care (SOC) antibiotics rather than standard of care (SPC) antibiotics alone (conditional recommendation, very low certainty of evidence). They stated that patients with a primary clostridium difficle infection (CDI) episode and other risk factors for clostridium difficle infection (CDI) recurrence (such as age 65 years, immunocompromised host [per history or use of immunosuppressive therapy], and severe clostridium difficle infection [CDI] on presentation) may particularly benefit from receiving bezlotoxumab. 

Kelly et al recommend bezlotoxumab in those aged 65 years or older with at least one of the following additional risk factors: experiencing their second episode of clostridium difficle infection (CDI) within the past six months, immunocompromised, or severe clostridium difficle infection (CDI). 

Therefore, as the patient was hospitalized twice in the past six months with clostridium difficle, and has had two outpatient prescriptions filled for vancomycin, the proposed treatment is clinically appropriate and accepted standard of medical care, and is medically necessary.