Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: micturition and nocturia
Treatment: Myrbetriq
The insurer denied Myrbetriq.
The health plan's determination is upheld. 

This is a case review of a female being prescribed Myrbetriq (mirabegron) for the diagnosis of frequency of micturition and nocturia. 
The patient has been taking the prescribed medication for incontinence and urinary frequency. She was previously taking Ditropan (oxybutynin) which caused dry mouth and did not control her symptoms as she still required two to three trips to the bathroom per night. Disruption of sleep is noted to be a problem for her seizure threshold. Her prescribing physician notes that it is imperative that she have optimal sleep to prevent seizures.

A formulary exception is not indicated in this case.
The patient has only had a trial of one formulary medication, oxybutynin. She had severe anticholinergic side effects, and the medication was not effective for her. This is not an uncommon result of this medication class which has a mechanism of muscarinic receptor blockade. She was switched to the requested drug Myrbetriq (mirabegron) with good control of her symptoms; this medication works by a different mechanism, agonism of the beta-3 adrenergic receptor.
The plan formulary does not cover Myrbetriq (mirabegron), but it does cover Gemtesa (vibegron). Both of these medications are beta-3 adrenergic agonist medications and thus work through an identical mechanism of action. There are no head-to-head trials comparing the efficacy of these two medications. The available data suggests that Gemtesa might be slightly more effective: "Vibegron may have slightly larger reductions in mean voided volume and fewer nasopharyngeal and cardiovascular side effects, but the clinical significance of this is unclear." Therefore, a trial of Gemtesa would be appropriate before consideration of the non-formulary drug as it has the same mechanism of action.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Myeloma
Treatment: Inpatient admission for Carvykti infusion
The insurer denied Inpatient admission for Carvykti infusion.
The denial is upheld.

The patient in this case is an adult male with multiple myeloma. An appeal letter notes that this patient has oligosecretory versus non-secretory myeloma. He was diagnosed 3 years ago. An appeal letter indicates that he has had seven different lines of therapy since that time, plus radiation therapy, though it does not provide any details of his prior treatment. The letter notes that the patient has recently progressed after his seventh line treatment, and that he has multiple hyper metabolic bone lesions. Based on this, the letter notes that CAR-T (chimeric antigen receptor T-cell) treatment should be considered medically necessary. The health plan denied coverage of the requested inpatient admission for Carvykti infusion as not medically necessary. The denial is being appealed.

The requested Inpatient admission for Carvykti infusion is not medically necessary.

The only information provided is an appeal letter. This letter fails to detail this patient's prior treatment history other than noting that he has had seven different lines of treatment. Without knowing the details of his prior treatment and other details about his medical history and performance status, it cannot be concluded that the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dental issues
Treatment: Crown and Core Buildup on Tooth 31 
The insurer denied Crown and Core Buildup on Tooth 31 
The health plan's determination is upheld. 

The patient is a male who presented for the treatment of tooth #31. Provided for review are radiographic images, American Dental Association (ADA) claim forms, explanation of benefits, letters of appeal and denial, a letter from the treating provider, health plan language. Not provided are any clinical notes, nor any clinical images.
In question is the medical necessity of a Crown and Core Buildup on Tooth 31.

The requested Crown and Core Buildup on Tooth 31 is not medically necessary for this patient based on the provided documentation. None of the documents show evidence of the presence of decay nor loss of tooth structure nor any other damage to the tooth that would necessitate restoration. There is nothing in the provided documentation showing evidence of the medical necessity of the treatment provided.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder (missing tooth #14). 
Treatment: D6010 implant placement for Tooth #14; D6065 implant supported porcelain/ceramic crown for Tooth #14.  
The insurer denied D6010 implant placement for Tooth #14; D6065 implant supported porcelain/ceramic crown for Tooth #14. 
The determination is overturned. 

The patient is a female who presented for the treatment of tooth number (#) 14 with (6010) implant placement #14, and (6065) implant supported porcelain crown for #14. Provided for review are letters of appeal and denial, letters of medical necessity from multiple different providers, explanation of benefits, radiographic images before and after extraction of #14, clinical notes, clinical images of casts, lab values, and American Dental Association (ADA) claim forms. At issue is the medical necessity of (6010) implant placement #14, and (6065) implant supported porcelain crown for #14. 

As the patient is missing tooth #14, she has the diagnosis of partial edentulism as well as diminished posterior support. With the diagnosis of partial edentulism as well as diminished posterior support, the only therapy capable of addressing both diagnoses is that of implant therapy as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis. Fixed partial dentures do not offer additional support and actually depend on the residual dentition to replace the missing tooth simply putting additional load on the residual teeth without replacing the loss. Removable partial dentures are tissue supported prosthesis and do not offer any support to the dentition as they are designed to become passive upon load. After the implants have integrated they will require restorations in the form of abutments and crowns in order to complete the tooth replacement. This is standard in tooth replacement involving implants. Hence, the entire treatment of (6010) implant placement #14, and (6065) implant supported porcelain crown for #14 is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: post nasal drip (PND)

Treatment: Ryaltris (olopatadine-mometasone)

The insurer denied coverage for Ryaltris (olopatadine-mometasone)

The denial is upheld

 
According to the medical records, this is an adult female patient with post nasal drip (PND). The patient has tried and failed Flonase. The request is for Ryaltris (olopatadine-mometasone), which is under review.

The patient has not failed Azelastine-Fluticasone, Flunisolide, Fluticasone, and Mometasone, which can also be used for nasal symptoms, and a trial is reasonable.      

There were no records showing the patient has tried the plan's preferred options and there were no noted contraindications. The patient has not failed Azelastine-Fluticasone, Flunisolide, Fluticasone, and Mometasone, which can also be used for nasal symptoms. A trial is reasonable. Therefore, the request for Ryaltris cannot be approved, at this time. 

"The FDA has approved Ryaltris (Hikma), a fixed-dose combination nasal spray containing the H1-antihistamine olopatadine hydrochloride (Patanase, and generics) and the corticosteroid mometasone furoate (Nasonex 24 HR Allergy, and generics)." (Olopatadine/mometasone (Ryaltris) for allergic rhinitis 2023).

"RYALTRIS is a combination of olopatadine, a histamine-1 (H1) receptor inhibitor, and mometasone furoate, a corticosteroid, indicated for the treatment of symptoms of seasonal allergic rhinitis in adult and pediatric patients 12 years of age and older." (RYALTRIS (olopatadine hydrochloride and mometasone furoate monohydrate nasal spray) PRESCRIBING INFORMATION 2022). 

The formulary drugs are not expected to cause adverse effects. 

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

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 of a request for a Formulary Exception for Ryaltris (olopatadine-mometasone) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Knee Pain and Vomiting Blood
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male. He has a history of gout, atrial fibrillation, coronary artery disease, hyperlipidemia, and Grave's disease status post radioactive iodine ablation and now hypothyroidism. He presented to the emergency room with two episodes of vomiting blood, blood-streaked diarrhea, and right knee pain that was limiting his ability to walk. The patient's lactate was 3.1 and uric acid level was 12. Computed tomography (CT) of the abdomen was negative for intra-abdominal process or bleeding. He was treated with Tylenol, 
Motrin, and colchicine and admitted with an acute gout flare and inability to ambulate. During his hospitalization, non-steroidal anti-inflammatory drugs (NSAIDs) and Xarelto were held due to concern for possible gastrointestinal bleed. Hemoglobin (Hgb) and hematocrit (Hct) were monitored. On day #4 he had an episode of hematochezia. Gastroenterology evaluated the 
patient. As his hemoglobin and hematocrit remained stable, there was no intervention. The patient was treated with Tylenol, and colchicine was provided for gout.

The inpatient admission was not medically necessary.

The patient did not have hemodynamic instability, active or ongoing gastrointestinal bleeding, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding; or evaluation requiring the patient to not eat or drink for extended period (e.g., more than 24 hours). The patient did not have inability to maintain oral hydration (e.g., needs intravenous fluid support) that persisted after observation care; and did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure that could not have been performed on ambulatory basis. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with hypertension, diabetes, and previous tobacco use who presented to the emergency room with hypertension and hyperglycemia. His glucoses were in the 400s. He complained of a headache, dizziness, nausea and vomiting of 3 to 4 days duration. He also complained of dyspnea, shortness of breath after walking only about 10 steps. He was given intravenous fluid resuscitation for treatment of hyperglycemia, insulin and metformin. He received Zofran for nausea and vomiting.

He was admitted and evaluated by cardiology. He was started on treatment with furosemide, spironolactone, aspirin and carvedilol for cardiomyopathy and myocardial infarction (MI). Intravenous (IV) heparin was started for a left ventricular (LV) thrombus. The patient reported 3 episodes of black stools and had an associated drop in hemoglobin from 15 to 11.9, indicating acute gastrointestinal (GI) bleeding. The aspirin was stopped. Pantoprazole was started. Gastroenterology was consulted. It was noted that the patient's hemoglobin had dropped further, to 8.3. He also became hypotensive. An endoscopy was recommended but it was felt that the patient first needed cardiac clearance, including cardiac catheterization. He also needed cardiac magnetic resonance imaging (MRI) to evaluate possible rapidly progressive viral myocarditis. The patient was treated in the intensive care unit. He was discharged; transferred to a tertiary care hospital for cardiac catheterization, cardiac MRI and further evaluation and treatment of acute gastrointestinal bleeding. At issue is the medical necessity of an inpatient stay.

Inpatient admission is medically necessary/indicated for treatment of acute congestive heart failure (CHF), newly diagnosed cardiomyopathy and acute gastrointestinal bleeding.
The patient presented with multiple acute medical issues, including uncontrolled diabetes, type two non-ST elevation myocardial infarction, new onset CHF with severely decreased left ventricular systolic function and left ventricular thrombus. He further developed evidence for significant gastrointestinal bleeding with a drop in his hemoglobin from 15 to 8 and hypotension.
He required inpatient treatment as he could not safely be discharged until workup and treatment were completed, including cardiac MRI, catheterization and endoscopy. He was transferred to a tertiary hospital for these procedures.
Per Milliman Guidelines, inpatient admission is indicated for patients with gastrointestinal bleeding and hemodynamic instability or evidence for ongoing active bleeding, including continued drop in hemoglobin/ hematocrit. That is the situation for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is an adult pregnant female. She has a history of idiopathic intracranial hypertension. She presented to the emergency ward with the complaint of headache. At presentation, the patient's neurological examination and fetal assessment were normal. She was admitted to the acute inpatient level of care for further evaluation. 

The inpatient admission was not medically necessary. 

The patient had a pre-existing diagnosis of idiopathic intracranial hypertension. She had negative magnetic resonance imaging (MRI) and magnetic resonance venogram (MRV). She had a normal neurological examination. There was no evidence of acute intracranial pathology to warrant acute inpatient level of care. The diagnostic studies, monitoring, and treatment could have been safely and effectively provided at a lower level of care (1, 2).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Mounjaro 
The health plan denied: Mounjaro 
The determination is: Overturned 

The patient is a female diagnosed with type 2 diabetes mellitus (DM). She was prescribed Mounjaro. As per her visit note, she was diagnosed with latent autoimmune diabetes in adults. Initially, she was diagnosed as a type 2 diabetic and controlled the diabetes with diet and exercise; she subsequently had lyme disease and experienced worsening hyperglycemia and increased insulin requirement. Her DM is well controlled. She stopped Ozempic due to constipation and nausea. She is on Metformin, Basaglar, and Novolog. Her C-peptide was 3.3 and glutamic acid decarboxylase (GAD) was 0.04. Her glycated hemoglobin (HbA1c) is down to 7.3 percent (%) from a previous level of 7.7%.
At issue is the medical necessity of Mounjaro.

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

The requested health service/treatment of Mounjaro is medically necessary for this patient. Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon-like-peptide-1 receptor agonist (GLP-1) and gastric inhibitory polypeptide receptor (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in HbA1c as well as weight loss (1-3).
The patient is diagnosed with type 2 diabetes with an elevated HbA1c of over 6.5%. The patient has been unable to control her blood glucose levels with the current therapy, including metformin. The patient is expected to see a reduction in blood glucose levels with the requested medication. The request meets the standard of care and is, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Migraine
Treatment: Botox
The insurer denied Botox.
The determination is overturned.

This is a female patient with chronic migraine. Continued treatment with Botox is the subject of this review. The drug was denied because the plan indicated that the patient did not have chronic migraine. At issue is the medical necessity of the Botox.
The physician's documentation and patient account clearly demonstrate that the patient has chronic migraine. Botox is Food and Drug Administration (FDA) approved for treatment of chronic migraine. The patient has been receiving Botox with significant improvement in headache frequency and intensity. There is no medical reason to stop therapy at this time. The patient has previously tried and failed many classes of oral migraine preventative therapy. As such, the use of Botox is medically appropriate.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Hyperlipidemia and Hypetension
Treatment: Praluent 
The insurer denied Praluent. 
The determination is overturned.

This is a female patient with a history of hyperlipidemia and hypertension. According to the records provided, the patient has been intolerant to previous statin therapy including atorvastatin (10 milligrams (mg), 20 mg), simvastatin (20 mg, 40 mg), pravastatin (20 mg and 40 mg), and rosuvastatin (20 mg), all causing myalgias and moderate to severe transaminitis requiring liver biopsy. The patient's treating provider has recommended Praluent 75 milligrams per milliliter (mg/ml) for additional low-density lipoprotein (LDL) reduction control of hyperlipidemia. The patient's health plan has denied coverage for Praluent as not medically necessary as the patient has not met prior authorization criteria by failing treatment with formulary statin therapy. At issue is the medical necessity of Praluent.

Praluent 75 mg/ml is medically necessary for this patient for the treatment of hyperlipidemia given her strong history of statin intolerances therefore meeting the prior authorization health plan criteria. The patient has had documented significant intolerances to multiple statin medications causing transaminitis and myalgias prompting discontinuation then resolution of symptoms and lab abnormalities. For treatment of this patient's hyperlipidemia, the patient's treating provider has recommended the initiation of Praluent based on robust clinical trial data demonstrating the effectiveness of Praluent in lowering LDL cholesterol and cardiovascular risk reduction. According to the previously published medical literature, the treatment of alirocumab (Praluent) compared to placebo, when added to statin therapy, was shown to significantly lower LDL cholesterol levels in patients at high cardiovascular risk and LDL levels greater than (>) 70 mg/dl (milligrams per deciliter) (1). In addition, the administration of this medication to patients with a prior acute coronary syndrome in addition to maximally tolerated statin therapy with LDL >70 mg/dl resulted in significant reduction in LDL cholesterol levels and the composite primary endpoint of death from coronary heart disease, nonfatal myocardial infarction, fatal or nonfatal ischemic stroke, or unstable angina requiring hospitalization (2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malpositioned teeth
Treatment: Braces, monthly visits, and retainer
The health plan denied: Braces, monthly visits, and retainer
The determination is: Upheld.

The patient is a male with a Class II occlusion. He has 4-milimeter (mm) overjet and 6-mm overbite. The maxillary arch has excess space, and the mandibular arch has moderate crowding. He is treatment planned for 30-36 months of orthodontics to correct his malocclusion, but his insurance company rejected the claim on the basis that treatment is not medically necessary.
At issue is the medical necessity of braces, monthly visits, and a retainer.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of braces, monthly visits, and a retainer is not medically necessary for this patient. The patient has moderate crowding in the mandible. His bite is deep, but there is no indication of damage to the incisors or the palate in the photographs, and his cephalometric radiographs show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided that there is severe soft tissue damage (or any soft tissue damage) on this patient. There is no medical reason to correct his malocclusion with braces. The patient has a deep bite; however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.[1] This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 4-mm overjet, but this amount of overjet does not affect oral health related quality of life.[2] If his teeth were aligned, it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.