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

Diagnosis: Head and neck pain
Treatment: 64490 x 1 (Diagnostic #1 Left cervical 3rd occipital nerve block - targeting C2 and C3)
The insurer denied the 64490 x 1 (Diagnostic #1 Left cervical 3rd occipital nerve block - targeting C2 and C3).
The denial is upheld. 

The patient is a female with head and neck pain.

No, the 64490 x 1 (Diagnostic #1 Left cervical 3rd occipital nerve block - targeting C2 and C3) is not medically necessary.

The patient is a female with neck and head pain that started after a fall. She sustained C1 (first cervical spine vertebra) fracture, and has tenderness over the occipital area on the reported exam. It is not documented that the patient has failed conservative treatment. She has not done PT (physical therapy). The reason for no PT is due to the time it took for the C1 fracture to heal. However, if the fracture is not healed, and thus the patient is not cleared to undergo PT, it should be presumed the neck is unstable to be placed in the prone position. This is further complicated by the fact there is notation that the patient has exercises that "she may have learned in PT."  It is not clear when this was, and for what condition.

Standard of care for a patient such as this would include a less invasive option of an occipital nerve block, which is not what is being requested in this case, and it has not been documented to have been failed. Occipital nerve block (ONB) is a minimally invasive procedure that can help with migraines and occipital neuralgia. An occipital nerve block is a block at the site of the occipital nerve. A third occipital nerve block, as requested in this case, is commonly known as a medial branch block at the junction of C2-3 (second cervical spine vertebra-third cervical spine vertebra), and C3 (third cervical spine vertebra).

Therefore, given the lack of failure of conservative treatment, the requested left third occipital nerve block targeting C2 (second cervical spine vertebra) and C3 (third cervical spine vertebra) (medial branch blocks) is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Cholesterol
Treatment: Repatha Sureclick 140mg/ml SC SOAJ, Pre-service
The insurer denied the Repatha Sureclick 140mg/ml SC SOAJ, Pre-service
The denial is upheld. 

The patient is a female with a history of coronary artery disease (CAD) status post (s/p) prior myocardial infarction, coronary artery bypass grafting (CABG) and stent placement.  She also has a history of severe dyslipidemia, and as per records, she had adverse reactions to multiple statins. She has been managed with Repatha. Coverage for Repatha was denied as the patient did not have a trial of the Plan's preferred alternative - Praluent.

No, the proposed treatment is not medically necessary.
The medical necessity of the proposed treatment is not established.

Both Repatha and Praluent are indicated as adjuncts to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low density lipoprotein cholesterol (LDL-C).  

This patient has a known diagnosis of coronary artery disease, as well as significant hyperlipidemia, and is intolerant of statins by history. Given the history and the findings as documented in the attached medical records, the patient meets criteria for the use of the proprotein convertase subtilisin/kexin type nine (PCSK-9) inhibitor. Based on the results of the clinical trials, both of these subcutaneous proprotein convertase subtilisin/kexin type nine (PCSK-9) inhibitors provide significant low density lipoprotein cholesterol (LDL-C) reductions. There is no documented adverse reaction to Praluent, or therapeutic failure. Therefore there is no indication that specifically Repatha, and not Praluent, is medically necessary in this specific case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type II Diabetes Mellitus. 
Treatment: Ozempic (Pre-service). 

The insurer denied the Ozempic. 
The denial is upheld. 

This patient is a female who is overweight with pre-diabetes and Hashimoto's thyroiditis. She was intolerant to metformin. A request for Ozempic for weight loss is under review. The prior request for Ozempic was denied as the patient does not have a diagnosis of type II diabetes. 

No, the proposed treatment with Ozempic is not medically necessary. 
This request for Ozempic is for the treatment of pre-diabetes and weight loss. The Ozempic prescribing information does not support the use of Ozempic in this clinical situation. The American Diabetes Association clinical guidelines also do not support the use of Ozempic for treatment of pre-diabetes. Ozempic has risks, including nausea and vomiting. Therefore, the proposed Ozempic is not medically necessary. 

The requested Ozempic is not medically necessary and does not meet the plan criteria and it was appropriately denied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell pain crisis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

According to the medical records, this is an adult female with a history of sickle cell trait and beta thalassemia minor. One week prior to admission she tested positive for COVID (Coronavirus) and 3 days prior to admission she noted back and leg pain. The patient presented to the hospital with an uncomplicated pain crisis. Her chest x-ray (CXR) was negative. Her vital signs and most labs were normal; the D-dimer test was elevated so a computed tomography (CT) scan angiography was performed which was negative for pulmonary emboli. The patient was given Dilaudid, and she was admitted to the hospital for sickle cell pain crisis. It was later determined that she did not have sickle cell pain crisis. The patient remained in the hospital for 9 days and was then discharged. 

Uncomplicated sickle pain crisis does not warrant acute level hospitalization. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. Based on the medical records, the inpatient hospital admission was not considered medically necessary for this patient.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Persistent tachycardia. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This is the case of a female patient who has been treated for systemic hypertension with lisinopril by Pediatric Nephrology. The patient presented to the Emergency Department (ED) with a history of 4-5 hours of headache and dizziness and one episode of nausea and vomiting. The patient was treated with intravenous (IV) fluids and was admitted to the hospital due to persistent tachycardia. 

Review of the ED provider note states "all symptoms have resolved", and there was a "normal physical exam" except for sinus tachycardia for the patient. The patient's vital signs revealed a heart rate of 116 and blood pressure (BP) of 128/67; blood pressure that is very acceptable for this patient with history of hypertension. 
The ED workup included an electrocardiogram (EKG), bedside echocardiogram, and appropriate lab bloodwork [i.e., brain natriuretic peptide (BNP), comprehensive metabolic panel (CMP), venous blood gas (VBG)]. None of the results supported hospital admission. 
Admission to the hospital was based only on the patient's pulse rate that was over 100 beats per minute (bpm). The ED note states that upon observation, the patient should be discharged for rate below 100bpm and admit for a rate over 100 bpm, which according to the medical record were "maintained below 100bpm while admitted". A longer observation period in the ED would have alleviated any concern about the patient's tachycardia. 
Most importantly the patient's discharge was recorded as an admission of 19.5 hours (less than 24 hours). The above hours represented only a period of observation and could have been performed in an observational setting. 
Therefore, based on the review of the medical record above and the literature, the patient's admission to an inpatient hospital bed was not medically necessary. 
The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Close Fracture, Pelvis

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is an adult female patient with a history of tobacco use. She presented to the emergency Room (ER) with complaints of 7 out of 10 right leg pain after falling off of a ladder. A computed tomography (CT) scan of the pelvis revealed right superior and inferior pubic ramus fractures. The patient was admitted to Trauma service for care. Trauma recommended keeping the patient weight bearing as tolerated (WBAT), administering pain medication, and trending labs. Orthopedics noted that the patient was stable. They recommended ambulating to prevent deep vein thrombosis (DVT). Physical therapy (PT) evaluated the patient. She was able to walk 20 feet with a rolling walker. The patient was discharged after a period of medical stability. 

The patient sustained an isolated closed fracture to her pelvis. There were no open wounds. There were no other sites of trauma. The management of this condition is to rest and weight bear with a walker when tolerable. Her vital signs were stable (no fever). She was able to tolerate oral medication. She did not require treatment for an underlying medical condition. Imaging and subspecialty consultations were completed on a timely basis. 

There were no factors to substantiate admission and length of stay as provided. The services could have been completed at a lower level of care. The medical record demonstrates a non-complicated condition to warrant the admission and length of stay as provided.

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

The insurer's denial of coverage for the inpatient admission upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis

Treatment Otezla 30 milligram (mg) tablet

The insurer denied coverage for Otezla 30 milligram (mg) tablet

The denial is upheld

The patient has a history of scalp psoriasis affecting 2% [percent] total body surface area (TBSA).  The patient has failed topical therapy with Protopic ointment and DermaSmoothe oil.  The requested medication is Otezla tablet.  

Based on the submitted documentation, Otezla is not medically necessary for the patient's condition.  There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly supports the administration of Otezla for this patient's condition as an accepted standard of practice over available alternatives. 

There are no comparative, controlled studies showing that Otezla has a superior efficacy and safety profile to the formulary alternatives such as phototherapy and methotrexate. 

According to the "National Physician Specialty Society recommendations" for psoriasis- the American Academy of Dermatology Psoriasis Guidelines- and dermatology literature, phototherapy and methotrexate are effective treatments for the management of psoriasis (1-3).   Within the peer-reviewed literature, Racz et al writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (4).  Mehta et al writes Ultraviolet (UV) B (rays) phototherapy is most appropriate for patients who have not responded to topical treatments...effective treatment options for psoriasis...Long-term data on NB (narrowband)-UVB indicate that it has a good safety profile (5).
 
Additionally, West et al 2016 conducted a review of ELEVEN comparative, controlled studies that passed a Cochrane risk of bias analysis.  They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques.  Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve ...primary endpoint,  Thus, methotrexate is an effective first-line treatment for the management of psoriasis (6).

Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not necessary. There is no documentation provided that the patient has tried and/or failed phototherapy or methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Otezla medically more appropriate than the other options.  

Therefore, the administration of Otezla (7) is not strongly supported for this patient, and Otezla is not medically necessary for this patient based on the current evidence-based medical literature. 

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

The insurer's denial of coverage for Otezla 30 milligram (mg) tablet is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis. 
Treatment: Humira. 

The insurer denied the Humira. 
The denial is overturned. 

The patient is a male with severe psoriasis for whom Humira injections are
requested. He has failed triamcinolone, tacrolimus, clobetasol, Otezla, and several other topical medications. 

Yes, the treatment with Humira is medically necessary. 

The patient has severe psoriasis for which systemic therapy is indicated. He is not a candidate for phototherapy, because of the location of psoriasis in the scalp, which cannot be reached by phototherapy. In the era of biologic therapies for psoriasis, use of methotrexate, cyclosporine or acitretin is not the most appropriate first-line treatment, because their long term safety and efficacy are inferior to biologic therapies. 

Biologics show superior results to conventional systemic therapies (70%
improvement versus 40% improvement) for the treatment of patients with moderate to severe psoriasis, as measured by decrease in simple-measure for assessing psoriasis activity (S-MAPA) (physician global assessment [PGA] multiplied by body surface area) at week 24. These results were observed despite the fact that patients on biologics had a greater baseline severity and had a greater number of previous treatments. 

Based on the above data, Humira is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent 300 mg per week.
The insurer denied the Dupixent 300 mg per week.
The determination is overturned.
 
The patient has atopic dermatitis. He has tried and failed clobetasol and mometasone. He has also failed three courses of prednisone. He has also used crisaborole ointment, tacrolimus ointment, and triamcinolone ointment. He has improved with Dupixent at standard dosing, but the provider would like to increase to weekly dosing for improved response. The medication under review is Dupixent 300 milligrams (mg) per week.

Based on the current peer-reviewed literature, Dupixent weekly is medically necessary. The patient has tried and failed biweekly Dupixent. There are no other systemic therapies approved for use in atopic dermatitis. Thibodeaux et al published "A review of dupilumab in the treatment of atopic diseases." in which they demonstrated that weekly dosing of Dupixent had significant efficacy (1). Beck et al also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to 3 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis" (2).

Deleuran et al writes "This first-step analysis of a long-term, open-label study of dupilumab 300 mg weekly in patients who previously participated in randomized, double-blinded, placebo-controlled clinical trials of dupilumab is, to our knowledge, the longest published study with a systemic drug in adults with atopic dermatitis (AD) to date and the first report of dupilumab safety and efficacy beyond 52 weeks of treatment...he safety and efficacy profile from this study supports the role of dupilumab as continuous long-term treatment for patients with moderate to severe AD" (3).

Therefore, based on the patient's clinical findings and refractory disease, weekly Dupixent is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ovarian suppression.

Treatment: total abdominal hysterectomy and bilateral salpingo-oophorectomy.

The insurer denied coverage for a total abdominal hysterectomy and bilateral salpingo-oophorectomy.

The denial is upheld. 

This female patient has a history of invasive ductal carcinoma of the right breast.

This patient had breast cancer so ovarian suppression was medically necessary. Ovarian function can be suppressed with gonadotropin releasing hormone (GnRH) agonists or by permanent methods, such as oophorectomy. In other words, the oophorectomy was medically necessary for this patient. However, it is unclear why a hysterectomy was performed. 
	
The reason given is that the patient needed to be shifted from Tamoxifen to Arimidex. The reason given is not supported clinically. Contrary to Tamoxifen, that could cause endometrial hyperplasia, Arimidex does not cause any uterine pathology. Actually, Arimidex (anastrozole) has been used to manage endometrial hyperplasia and fibroid uterus. 

Note that there was no evidence that this patient had any genetic testing that showed that she is at an increased risk of developing ovarian cancer.  In summary the hysterectomy performed was not medically necessary for this patient. The patient could have undergone a prophylactic laparoscopic salpingo-oophorectomy which is an ambulatory procedure.

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 total abdominal hysterectomy and bilateral salpingo-oophorectomy is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dislodged PEG (feeding) Tube
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She underwent an acute hospitalization. The diagnosis for the hospital stay was a dislodged PEG (percutaneous endoscopic gastrostomy) feeding tube. The patient has a history of asthma, a concussion, migraines, pseudo-seizure, adrenal insufficiency, Clostridium (C) difficile colitis, GERD (gastroesophageal reflux disease), IBS (irritable bowel syndrome), Crohn's disease on Remicade, gastroparesis and constipation.

Nausea was reported, but no emesis. The patient was observed and a PEG tube was not replaced, as the risks were felt to be too high. 

No, the inpatient admission was not medically necessary. The treatment was medically appropriate, but not medically necessary at the level at which it was provided.

The patient had a dislodged PEG feeding tube. The tube was not replaced. The care was supportive in nature in its entirety. The care could have been rendered at a lower level of care.

The care as provided could have been rendered in its entirety at a lower level of care. The patient had a dislodged PEG tube, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (deep impinging overbite, with severe tissue damage) 

Treatment: D8080 braces and D8670 monthly visit 

The insurer denied coverage for D8080 braces and D8670 monthly visit. 

The denial is overturned. 

This is a male patient who presented to the Orthodontist's office for an evaluation. X-rays were taken and an evaluation was done. According to a medical record by the patient's Orthodontic resident, "the patient presents with excessive overjet of four millimeters (mm), and deep overbite of seven millimeters that is impinging on his palate and causing soft tissue damage. This clinical presentation is affecting the patient's ability to eat, due to the trauma of his teeth hitting his palate. It is also affecting his ability to speak and having a significant social impact on the patient. Orthodontic treatment is recommended." Handicapping Labio-Lingual Deviation (HLD) score sheet is provided, claiming an automatic qualifier of deep impinging overbite with severe tissue damage. Cephalometric X-ray is provided. 

Medical records include a letter by the Orthodontic resident reviewing that the patient presents with excessive overjet of four millimeters, and deep overbite of seven millimeters that is impinging on his palate and causing soft tissue damage. This clinical presentation is affecting the patient's ability to eat, due to the trauma of his teeth hitting his palate. It is also affecting his ability to speak and having a significant social impact on the patient. 

The condition that automatically qualifies the patient for Orthodontic treatment is the deep impinging overbite, with severe tissue damage. Cephalometric X-ray is provided, verifying the deep impinging overbite on the anterior teeth. 

The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. They denied the orthodontic treatment that was medically necessary.  
                                         
The insurer's denial of coverage for D8080 braces and D8670 monthly visit is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Plaque Psoriasis. 
Treatment: TALTZ autoinjector 80 mg/mL AUTOINJCT, Pre-service. 

The insurer denied the TALTZ autoinjector 80 mg/mL AUTOINJCT, Pre-service. 
The denial is upheld. 

The patient is a male with severe psoriasis affecting sensitive areas, such as the hands, feet, neck, and scalp, and psoriatic arthritis. He has tried and failed Humira and then Otezla. The prior authorization form also states he has failed Taltz. 

No, the health plan should not cover the proposed treatment with Taltz. 

The patient has severe psoriasis and is a candidate for systemic therapy or phototherapy. The plan offers multiple biologic therapies including Cosentyx which is an interleukin 17 inhibitor in the same drug category as Taltz and with the same Food and Drug Administration (FDA)-approved indications. 

Cosentyx (secukinumab) for injection and Taltz (ixekizumab) injection are human monoclonal antibodies to interleukin-17A used to treat moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. Treatment guidelines recommend both drugs, and Stelara (an interleukin 12/23 inhibitor) as options for people who need a biological treatment for psoriasis or psoriatic arthritis. 

There is no documented reason that the patient cannot try the formulary medications available, such as Cosentyx or Stelara.