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

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) Services: 8 Hours/Day, 5 Days/Week, to Total of 40 Hours/Week
The insurer denied PCA services: 8 hours/day, 5 days/week, to total of 40 hours/week.
The health plan's determination is overturned.

The patient is a male with past medical history of osteoarthritis, dementia, coronary artery disease, hypertension, benign prostatic hyperplasia (BPH), gout, diabetes mellitus type 2, cardiac arrhythmia, squamous cell cancer of the skin, and urinary incontinence who had been assigned PCA (personal care aide) services.

PCA services: 8 hours/day, 5 days/week, to total of 40 hours/week are medically necessary for this patient.

There is documentation in the universal assessment of worsening functional and cognitive status with noted decline in activities of daily living (ADLs) status and deterioration in overall self-sufficiency. It was also noted the patient had increased assistance needs with multiple tasks when comparing the recent assessments. Specifically, the patient had an increased assistance needed with tasks of phone use, stairs, shopping, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. In addition, the patient's NFLOC (Nursing Facility Level of Care) score increased from 8 to 21 when comparing assessments. The tasking tool underestimated the patient's hours/week required to assist with ADLs and instrumental activities of daily living (IADLs). The patient will require assistance with ADLs outside of any informal help. The patient requires extensive assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time. The requested increase in PCA 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, PCA services 8 hours/day, 5 days/week, to total 40 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: Upheld

Diagnosis: dementia, diabetes mellitus, hypertension, hyperlipidemia, benign prostatic hypertrophy (BPH) and osteoarthritis.

Treatment: Personal care aide (PCA) services, Level 2, 12 hours per day, 7 days per week; total of 84 hours per week.

The insurer denied coverage for PCA services, Level 2, 12 hours per day, 7 days per week; total of 84 hours per week.

The denial is upheld.

Patient with chronic medical problems including dementia, diabetes mellitus, hypertension, BPH and osteoarthritis. He currently has PCA services 10 hours/day, 7 days/week, totaling 70 hours. The patient lives alone in a 1-bedroom apartment. He is requesting increase PCA services 12 hours/day, 7 days/week, totaling 84 hours, which is currently under review. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "minimally impaired." He is alert and fully oriented. He is totally dependent for bathing, and lower body dressing. Activities including personal hygiene, upper body dressing and toilet transfer/use require maximal assistance. He is occasionally bowel and bladder incontinent. The patient's functional status is much the same, if not slightly improved (e.g., locomotion, bed mobility, toilet use) when compared to the prior UAS report. The clinical records do not support a significant functional decline to warrant the requested increase PCA services 12 hours/day, 7 days/week, totaling 84 hours at this time.  

From a physical medicine and rehabilitation perspective, the requested increase PCA services, 12 hours/day, 7 days/week; total of 84 hours per week is not medically necessary.  

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

The insurer's denial of coverage for personal care aide (PCA) services, Level 2, 12 hours per day, 7 days per week; total of 84 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma.
Treatment: Xolair 150 milligrams (mg) subcutaneous (SC) solution reconstituted (SOLR)

The insurer denied coverage for Xolair 150 mg SC SOLR.  The denial is overturned.

This is a male who is labeled as a severe persistent asthmatic, who has been treated with Xolair every 3-4 weeks for the past 5 years. Prior to initiating Xolair, the child was described as having significant shortness of breath and asthma exacerbations. The record indicates that prior to beginning Xolair, the patient failed to respond to inhaled corticosteroid/long-acting bronchodilator and leukotriene inhibitor therapy. The patient has been prescribed Symbicort 80 mg (milligrams) 2 puffs twice a day and montelukast 5 mg per day.

The data from the insurer indicates that over a five-month period of time, the patient had not filled his prescriptions for inhaled steroids and montelukast. The insurer has denied approval for the continued administration of this medication.

The patient has a diagnosis of severe persistent asthma, and he has had a good response to ongoing treatment with Xolair. He has been treated with Xolair for the past 5 years. It is not uncommon for patients treated with Xolair for moderate and severe persistent asthma to be able to be weaned and even discontinue their need for inhaled steroids. The insurer cannot deny this ongoing treatment because the patient has been non-compliant with inhaled steroids. "In patients with moderate-to-severe asthma, treatment with omalizumab (compared with placebo) can decrease the incidence of exacerbations and result in a significant reduction in the dose of inhaled or oral glucocorticoids required to control symptoms". (1) The insurer is referring to the requirements of failure to respond to asthma therapies prior to approval for the initiation of this therapy, and they cannot require that the patient continue on these additional asthma therapies in order to continue to receive monthly Xolair therapy. The insurer should continue to cover the treatment with Xolair for this patient.

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

The insurer's denial of coverage for Xolair 150 mg subcutaneous (SC) solution reconstituted (SOLR) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney disease on dialysis, congestive heart failure, and cerebral vascular infarction with aphasia.

Treatment: Personal care assistant (PCA) services, continuous care split shift; 7 days x 24 hours per week .

The insurer denied coverage for PCA services, continuous care split shift; 7 days x 24 hours per week.

The denial is upheld.

This patient has chronic medical problems including kidney disease on dialysis, congestive heart failure, and cerebral vascular infarction with aphasia. She had a percutaneous endoscopic gastrotomy (PEG) tube placed after a recent hospitalization. She is requesting increase PCA services from 7 days x 24 hours (live-in) to continuous care split shift; 24 hours, 7 days/week; which is currently under review. 

The recent Uniform Assessment System (UAS) report was reviewed. Patient's cognition is described as moderately impaired. She is totally dependent for activities of daily living including bathing, personal hygiene, and dressing. She is frequently incontinent of bowel and bladder. She is also totally dependent for bed mobility and transfers. Patient underwent a PEG tube placement just prior to the recent UAS assessment. The letter from her treating physician, documenting patient's multiple chronic medical problems was also reviewed. Patient has significant functional impairments that support the medical necessity of PCA services 7 days x 24 hours (live-in). However, her condition and functional needs are not at a level or unpredictable as to require the requested continuous care split shift; 24 hours, 7 days/week. This physician would also agree this patient requires 24-hour monitoring. However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. The patient's health and safety can be appropriately provided and maintained by the currently authorized live-in 24 hours PCA services. 

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

The insurer's denial of coverage for personal care assistant (PCA) services, continuous care split shift; 7 days x 24 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg swelling.
Treatment: Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a female with a past medical history significant for coronary artery disease, hypertension, migraine headaches, provoked venous thromboembolism following knee surgery, and chronic right knee pain who presented with complaints of right leg swelling and knee pain of 5 days duration. She also complained of shortness of breath, which started 3 days before the presentation. The patient denied any trauma to the leg, fever, warmth, or erythema of the leg. The patient's symptoms such as leg pain and shortness of breath were aggravated by climbing stairs. At the same time, the patient denied chest pain, cough, hemoptysis, palpitations, lightheadedness, dizziness, or syncope. 

The inpatient hospital admission was not medically necessary for this patient.

According to nationally accepted standards of care, admission at the acute inpatient level of care is required in cases when pulmonary embolism is associated with hypoxemia, vital sign abnormality, history of chronic cardiopulmonary disease such as congestive heart failure (CHF), coronary artery disease, chronic obstructive pulmonary disease (COPD), or cor pulmonale, cardiac arrhythmias of immediate concern, right ventricular dysfunction or strain, positive cardiac biomarkers, need for administration of intravenous opioids, or in patients with a high risk of acute complications such as bleeding before anticoagulation, recent surgery, recent ischemic stroke, history of active bleeding while anticoagulated, also in cases when there is a contraindication to outpatient use of medications with rapid anticoagulation effect and some other circumstances not relevant to this clinical case.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal Colic
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay.
The determination is upheld.

The patient was admitted with right renal colic. Her vital signs were a temperature of 36.1 degrees Celsius, blood pressure 99/57, and pulse 72. The white blood cell count (WBC) count was 6200. The creatinine was 0.85 Prior computed tomography (CT) imaging demonstrated a 3 millimeter (mm) ureteral calculus for which surgery had been scheduled. Repeat computed tomography (CT) imaging demonstrated a 4 mm mid-ureteral calculus with mild hydronephrosis. She had a lactic acidosis and there was concern for a urinary tract infection. Intravenous (IV) pain medications, nausea medications, IV antibiotics and intravenous fluids (IVF) were administered.

IV pain medications, IV antibiotics and IVF were administered.
She had a ureteroscopy, laser lithotripsy and stent placement.
She was discharged home. She was afebrile and hemodynamically stable throughout the stay.
At issue is the medical necessity of an inpatient stay.

An acute inpatient level of care was not medically necessary. Care could have been provided at a lower level. She was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis. Following admission, there were no unstable vital signs reported. She did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. She did not have bilateral obstruction, acute renal failure, severe vomiting. Pain control, IV antibiotics and IVF followed by laser lithotripsy and stent placement in a non-toxic patient can be provided at a lower level of care. If there had been significant concern for obstruction with sepsis, then stent placement should have been performed on the same day or shortly after admission. Therefore, an inpatient stay was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension with Angina.
Treatment:   Edarbi 40mg (milligram) Tablet.
The insurer denied the Edarbi 40mg (milligram) Tablet.
The denial is upheld.

The patient is a male with history of hypertension. Request was received for use of Edarbi, an ARB (angiotensin receptor blockers). Notes state that he feels better on this drug and past medications include Bystolic.
Formulary alternatives are: candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan (generic Benicar), olmesartan-hydrochlorothiazide (generic Benicar HCT), telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

Other than Bystolic, no documentation of other medications tried and failed were included. Only comment was that only Edarbi can treat his diagnosis of hypertension.

No, the health plan should not cover the proposed treatment.
Edarbi (azilsartan medoxomil) is a ARB (angiotensin receptor blockers).  There are numerous alternative ARB's (angiotensin receptor blockers) on formulary, such as closely related irbesartan. There is no evidence of superior response or less side effects of Edarbi vs other ARB (angiotensin receptor blockers). In addition, ACE (angiotensin-converting enzyme) inhibitors have similar action profile. Other categories such as beta blockers, Calcium antagonists, and diuretics are also approved, effective, and safe medications on formulary that can be used in this clinical situation of hypertension and risk factors for CAD (coronary artery disease).

The Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults recommends if monotherapy is warranted, in the absence of comorbidities (eg, cerebrovascular disease, chronic kidney disease, diabetes, heart failure, ischemic heart disease, etc.), that thiazide-like diuretics or dihydropyridine calcium channel blockers may be preferred options due to improved cardiovascular endpoints (eg, prevention of heart failure and stroke). ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are also acceptable for monotherapy. Combination therapy may be required to achieve blood pressure goals and is initially preferred in patients at high risk (stage 2 hypertension or atherosclerotic cardiovascular disease [ASCVD] risk 10%) (ACC/AHA).

Avapro (irbesartan) and Edarbi (azilsartan medoxomil) are angiotensin II receptor blockers (angiotensin receptor blockers) used to treat high blood pressure (hypertension). Avapro is sometimes given together with other blood pressure medications. Avapro is also used to treat kidney problems caused by type 2 (non-insulin-dependent) diabetes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is upheld.

The patient has a history of sickle cell disease, chronic kidney disease (CKD) and hypertension. He presented to the emergency room (ER) with complaints of a two-day history of chest pain and was given morphine. A chest x-ray (CXR) revealed cardiomegaly and mild pulmonary venous congestion. Elevated troponin was likely due to CKD. The patient remained hemodynamically stable. He was continued on morphine and Benadryl as needed (PRN). The patient was admitted and discharged. He refused medication after the first or second morphine dosage (morphine was also given while in the ER) and he expressed that his pain went down to 2/10.

The inpatient admission is not considered medically necessary for this patient. There is no indication of chest syndrome, priapism or severe unresponsive pain, infection etc. The patient was reported to have gotten better the same day he was admitted and refused to take any further medication; then was discharged. The chest pain was midsternal and was not quantified. A chest x-ray was benign, showing cardiomegaly, which is chronic and mild pulmonary congestion. The patient denied fever/chills, palpitations, cough, earache, sore throat, back pain, syncope seizures, etc. He blamed his chest pain on a neighbor smoking and also that he needed refills on his medication. As such, the admission was not medically necessary.

"The diagnosis of ACS (acute coronary syndrome) depends on both radiographic evidence and clinical symptoms. To be diagnosed with ACS, a patient must meet the following criteria.

New pulmonary infiltrates on chest imaging (chest x-ray, CT [computed tomography]) involving at least one lung segment; this cannot be due to atelectasis and must have one of the following symptoms: Chest pain, Temperature more than 38.5 C (Celsius), Tachypnea, wheezing, rales, coughing, appearance of an increased work of breathing Hypoxemia, relative to baseline (more than 2% [percent] decrease in SpO2 [oxygen saturation] from steady state on room air, PaO2 [pressure of oxygen] less than 60 mmHg [millimeters of mercury])" (Friend A, Girzadas D. 2022).

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. There is no indication of chest syndrome, priapism or severe unresponsive pain, infection etc. The patient was reported to have gotten better the same day he was admitted and refused to take any further medication; then was discharged. The chest pain was midsternal and was not quantified. A chest x-ray was benign, showing cardiomegaly, which is chronic and mild pulmonary congestion.

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

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

Diagnosis:  Granuloma Annulare.
Treatment:  Xeljanz 5 milligrams (mg).

The health plan denied Xeljanz 5 milligrams (mg).  The health plan's determination is upheld.

The patient is a female with granuloma annulare. She has had granuloma annulare for 1.5 years. This condition is impacting her daily function. The patient has failed topical steroids and Prednisone. The medication under review is Xeljanz 5 milligrams (mg).

The health plan's determination of medical necessity is upheld.

The requested health treatment of Xeljanz 5mg is not medically necessary for this patient. According to the dermatology literature, conventional treatments for which a generic form is available, such as Hydroxychloroquine, are effective treatments for the management of granuloma annulare.[1] [2] Within the peer-reviewed literature, Bolognia et al. lists Hydroxychloroquine or Chloroquine under treatment of granuloma annulare, and gives it a stronger evidence rating based on "retrospective study or large case series".[1] Cyr et al. writes in "Diagnosis and Management of Granuloma Annulare" that "Antimalarial agents, including Hydroxychloroquine (Plaquenil) and Chloroquine (Aralen), have been used in the treatment of granuloma annulare. They have been presumed effective because of their immunosuppressive and anti-inflammatory properties".[2] Per the information provided by the physician, the request for Xeljanz is not medically necessary. It is noted that the patient has failed many therapies. However, there is no documentation provided that the patient has tried and/or failed Hydroxychloroquine. The patient also has no true contraindications listed to this conventional treatment modality that would make the use of Xeljanz medically more appropriate than the other options.

Therefore, the administration of Xeljanz is not strongly supported for this patient and not medically necessary based on the current evidence-based medical literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity.
Treatment: Saxenda.
The insurer denied the Saxenda.
The determination is upheld.

This is a patient with obesity with a body mass index of 32 kilograms per square meter with a co-morbidity. She has tried and failed Qsymia and metformin. The request for Saxenda is under review for medical necessity.

This request is for Saxenda for the treatment of obesity. The prior request was denied because the patient has not had a trial and failure to Xenical or Contrave. The patient has tried and failed Qsymia. The Endocrine Society guidelines do not recommend the use of Saxenda over all of the formulary alternatives which include Contrave. The patient does not have documented pre-diabetes or type 2 diabetes, which would be a medical reason to use Saxenda over the formulary alternatives. The patient does not have a documented contraindication to Xenical or Contrave. Therefore, the requested Saxenda is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Rosacea
Treatment: Opzelura 1.5% EX CREA (external cream)
The health plan denied the Opzelura 1.5% EX CREA. 
The health plan's determination is upheld.

The patient is a male with rosacea. He has tried and failed Metronidazole Gel, Azelaic Acid Gel, and Doxycycline. He has also failed Tacrolimus ointment. The medication under review is Opzelura.
At issue is the medical necessity for the requested medication, Opzelura.

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

The requested health service/treatment of Opzelura is not medically necessary for this patient. There is no documentation provided that the patient has tried and failed Eucrisa ointment. There is no documentation provided that the patient has tried and failed the standard of care treatment Sodium Sulfacetamide wash.
According to the dermatology literature, Sulfacetamide Sulfur topicals are effective treatments for the management of rosacea. [1-3]
Two et al writes in the Journal of the American Academy of Dermatology, "Rosacea: Part II. Topical and systemic therapies in the treatment of rosacea," that "Topical treatments approved by the US Food and Drug Administration for rosacea include topical Sodium Sulfacetamide..." [4]
Abokwidir writes, "Topical Sodium Sulfacetamide, 10% Sodium Sulfacetamide with 5% sulfur, is useful in treating patients with rosacea."[5]
The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents are appropriate agents for the treatment of the patient's rosacea. The formulary medications should be tried and failed prior to initiating Opzelura.