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

Diagnosis: Plaque Psoriasis.
Treatment: Formulary exception for Taltz autoinjector 80mg/ml AUTO INJCT, Pre-service.
The insurer denied the Formulary exception for Taltz autoinjector 80mg/ml AUTO INJCT, Pre-service.
The denial is upheld.

The patient is a woman. She has had psoriasis since she was a teenager. The psoriasis affects her scalp, nails, and sensitive areas. There is a family history of psoriasis. She has no relevant co-morbidities. She has tried and failed Stelara and Skyrizi. Topical medications include Tazorac and clobetasol. She started Taltz through a co-pay program in mid-March and is seeing positive results. This is a request for Taltz injections.

No, the health plan should not cover the Formulary exception for Taltz.
The patient has tried and failed Stelara and Skyrizi.

Per the health plan's formulary preferences, the patient must try all formulary medications before a non-formulary, such as Taltz is approved. Formulary medications include Humira, Otezla, Tremfya, Enbrel, Cosentyx, and Cimzia. They are acceptable alternatives to Taltz. Cosentyx and Taltz have a similar mechanism of action. Cosentyx is a human interleukin-17A antagonist indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy; adults with active psoriatic arthritis (PsA); adults with active ankylosing spondylitis (AS); and adults with active non-radiographic axial spondyloarthritis (nr-axSpA) with objective signs of inflammation.

It is reasonable to expect that other biologic medications, such as Humira, Tremfya, Enbrel, Cosentyx, and Cimzia will be beneficial for the patient's diagnosis.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Mental Health/Attention Deficit Hyperactivity Disorder (ADHD).
Treatment: Pharmacy/Prescription Drugs.
The health plan denied the request for prescription drug, Daytrana as not medically necessary.
The health plan's determination is upheld.

The patient is a male being treated with stimulant medication for attention deficit hyperactivity disorder (ADHD) diagnosed based on Vanderbilt scoring.
A prescribing physician ordered Daytrana 10 milligrams (mg) patch, which was denied, because there was no evidence the patient had a contraindication to, intolerance to, or inadequate clinical response to the formulary alternatives: extended-release Amphetamine-Dextroamphetamine (mixed salts), Dexmethylphenidate extended release, Methylphenidate extended release, Mydayis (another Amphetamine-dextroamphetamine mixed salt), and Vyvanse (Lisdexamfetamine). The plan requires that at least three formulary alternatives be tried when there are three or more alternatives.
I am provided a single encounter note for review. The provider documented that "medications include Mydayis 25mg. It is administered with ice cream. Compliance is variable. It is effective until 330 pm." It continues: "In the past he took Adderall, Daytrana, and Ritalin, and Vyvanse. Side effects include appetite suppression. Since the last visit  there is no change in review of symptoms. His weight was 56.8 pounds at the last visit. A weight is not available today. Functioning at home is improved. He has the attention span of the average boy his age. Media use is reduced at his mother's home. He is being advanced in math. The patient is doing well in school. It is anticipated he will be in an integrated co-taught class next year. Peer interactions are described as good." The assessment was "ADHD combined presentation, learning disorder, coordination disorder, and excessive media use," which has been reduced. The plan included stopping Mydayis and switching to Daytrana.

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

There is no evidence that the formulary drug he is currently taking has been ineffective or has had intolerable or unmanageable side effects. To the contrary, the single progress note included for review discusses the performance improvements on the Mydayis. There is no documented explanation that would support a change to a non-formulary medication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Diabetic Equipment, Supplies, and Self-Management Education. 
The insurer denied continuous glucose monitoring system. 
The denial is overturned.

The patient is a This is a male originally diagnosed with diabetes mellitus type 2 (DM2) who is now post complete pancreatectomy and completely insulin-dependent. This request is for Dexcom G6 continuous glucose monitor (CGM). He has since had pancreatic surgery with a pancreatectomy making him dependent on insulin. He is currently undergoing chemotherapy and has a variable food intake and fluctuating blood glucose (BG) with several episodes of hypo and hyperglycemia. He is on Lantus 15 milliliters (ml); Admelog 9 units. The patient checked his BG which ranges from 87 to 174 (not clear). The office visit note reports that they were ordering a new Dexcom for the patient. His glycated hemoglobin (HbA1C) was 6.8% The subject under review is the medical necessity for the continuous glucose monitor.

The health plan's determination is overturned.

This patient is reported to have hypoglycemia and hyperglycemia around his chemotherapy treatments. The patient is functionally now a type I diabetic as his pancreas has been removed. The patient will have closer monitoring of his glucoses and alarms when he has impending hypoglycemia. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing lower left posterior teeth,
Treatment: D5214 Partial Lower Denture.

The insurer denied the D5214 Partial Lower Denture.  The denial is overturned.

The patient is a male requesting dental benefits for a removable partial lower denture.
Panoramic x-ray reveals that the patient is missing all lower left posterior teeth (teeth numbers 17-21).

The patient is missing all of his lower left posterior teeth, which means he is unable to chew on his left side. The process of chewing is carried out by the posterior teeth--premolars and molars.  The effective mashing of food is the first step in proper digestion. Chewing on one side only limits the effectiveness of the chewing process and stresses the teeth and the muscles on the side that is constantly in use.  Therefore, by providing a lower partial denture to replace these teeth the patient has an opportunity to chew more effectively, distribute the stresses of the chewing forces more evenly and provide a replacement that will prevent the other teeth in the arch from drifting distally and the opposing teeth from super-erupting (when the teeth opposite of the missing teeth grow into the arch where the teeth are missing--in an attempt to fill in the space).

The proper compliment of teeth within each arch are not only necessary for proper chewing function, but they play a very important role in preventing shifting of adjacent teeth and super-eruption of opposing teeth. Prolonged absence of replacing missing teeth when there are opposing natural teeth present can lead to severe super-eruption, this can cause those opposing teeth to contact and bite into the gum; these otherwise healthy teeth would have to be eventually extracted to prevent trauma to the gums. The long term effects of non-treatment puts the entire patient's dentition at risk for subsequent deterioration.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied implant crown on teeth 8 and 9. 
The denial is overturned.

The patient is a male who presented to the office of his dental provider for evaluation and treatment of teeth #8 and 9 with implant restorations. Included for review are previous letters of appeal and denial and case notes. In question is the medical necessity of the planned treatment of implant restorations on the two front teeth. This was denied by the plan as not medically necessary.

The health plan's determination is overturned.

The implant crown on teeth 8 and 9 are medically necessary. 
As a result of missing teeth #8 and 9, replacement of the missing teeth with a denture does not replace the support retention and stability offered by the implants which are a direct analog of the teeth. Currently, sites #8 and 9 already have implants in place which now require implant restorations to replace the missing teeth. The patient has a diagnosis of partial edentulism and diminished support.
With the diagnosis of partial edentulism as well as diminished support the only therapy capable of addressing both diagnosis 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 implant restorations in the anterior maxilla are required.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Breo Ellipta 200-25MCG/INH AEPB
The insurer denied the Breo Ellipta 200-25MCG/INH AEPB
The denial is overturned.

The patient is a female with moderate persistent asthma is being treated with Breo.

Yes, the proposed treatment with Breo is medically necessary.

The patient is diagnosed with moderate persistent asthma. The patient is treated successfully with Breo. The patient has good asthma control with Breo. The asthma worsens when Breo is taken off. The standard of clinical practice is that patients should continue with the treatment that works and prevents the exacerbation of disease, irrespective of formulary alternatives. Since the patient is stable on Breo, the continuation of Breo is medically necessary. Not continuing it is likely to lead to destabilization of asthma and worsening quality of life, as well as frequent doctor's visits.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Absolute asthenozoospermia
Treatment: Genetic testing (unlisted molecular pathology)
The insurer denied the Genetic testing (unlisted molecular pathology)
The denial is upheld. 

This male has requested coverage for genetic testing for primary ciliary dyskinesia.  During an evaluation for male infertility, he was found to have absolute asthenozoospermia.  He has pseudotumor cerebri. The sperm concentration have been between 4 to 8.5 million sperm per milliliter (mL).  He has had bronchitis once, but no prior sinusitis or pneumonia.

No, the proposed genetic testing was not medically necessary.
Although this patient had sperm without motility, he did not have the more common manifestations of primary ciliary dyskinesia.  These include pulmonary complications characterized by frequent infections, difficulty clearing mucus, and chronic wheezing.  Situs inversus was not documented as having been present.  This testing is not recommended by American Urologic Association (AUA) Guidelines on male infertility.
Appeal type: Medical necessity
Decision: Overturned

Digestive system
Diagnostic testing

Diagnosis: Iron deficiency anemia.
Treatment: Gastrointestinal Tract Imaging.
The insurer denied the Gastrointestinal Tract Imaging. 
The health plan's determination is overturned. 

The patient is a female with iron-deficiency anemia and Barrett's esophagus. She had low ferritin which improved with iron supplementation; the progress note showed that anemia had improved but iron deficiency persisted. 
Esophagogastroduodenoscopy showed irregular squamocolumnar junction, small hiatal hernia, antral erythema, and normal duodenum; colonoscopy showed internal hemorrhoids. Small bowel series on was unremarkable. She had a wireless capsule endoscopy for the indication of iron-deficiency anemia that showed patchy gastric erythema with healing erosions and a tiny red spot in the small bowel. This is the subject under review.

The Gastrointestinal Tract Imaging is medically necessary as the patient had iron deficiency and anemia without definite explanation on esophagogastroduodenoscopy and colonoscopy. Based on published peer-reviewed data from well-constructed clinical studies, American Gastroenterological Association guidelines and American Society for Gastrointestinal Endoscopy guidelines recommend capsule endoscopy for investigation of iron-deficiency anemia when esophagogastroduodenoscopy and colonoscopy do not provide an explanation. Iron-deficiency anemia in the absence of visible gastrointestinal bleeding may be due to gastrointestinal lesions. In this case, the patient had iron-deficiency anemia which improved during iron supplementation, and the patient has had esophagogastroduodenoscopy and colonoscopy, as recommended by guidelines. Neither test demonstrated any pathology which would definitely cause iron-deficiency anemia. Therefore, the Gastrointestinal Tract Imaging is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized anxiety disorder. 
Treatment: Extended outpatient treatment services (code 90837). 

The insurer denied coverage for extended outpatient treatment services (code 90837). 

The denial is upheld. 

This is a female patient who reportedly was in outpatient psychotherapy treatment with a Licensed Clinical Social Worker (LCSW). The provider stated, in letters, that the patient was being treated with eye movement desensitization reprocessing (EMDR) for post-traumatic stress disorder (PTSD) and that the patient had flashbacks of trauma, memories interfering with functioning including work ability, concentration problems, and sleep. She also reportedly had chronic medical problems. The diagnosis submitted on the bills in the records for review reported a diagnosis of generalized anxiety disorder. There were no medical records for review of the dates of denial for the extended session of 60 minutes for outpatient mental health treatment services. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder reports that EMDR is a form of psychotherapy that includes an exposure-based therapy with multiple brief, interrupted exposures to traumatic material, eye movement, and recall and verbalization of traumatic memories of an event or events. It therefore combines multiple theoretical perspectives and techniques, including cognitive behavior therapy. 

According to the APA Practice Guidelines for the Treatment of Patients with Post Traumatic Stress Disorder, trauma exposure cognitive behavioral therapy is a treatment of choice for PTSD and EMDR is considered a form of cognitive behavioral therapy and exposure therapy. Some point to the use of directed eye movements as a feature markedly distinguishing this form of therapy from other cognitive behavior approaches. Like many of the studies of other cognitive behavior and exposure therapies, most of the well-designed EMDR studies have been small, but several meta-analyses have demonstrated efficacy similar to that of other forms of cognitive and behavior therapy. 

The only medical records provided for review reported a diagnosis of generalized anxiety disorder. There were no specific documented medical records stating that the patient had a diagnosis of PTSD or documented treatment of EMDR for extended sessions of 60 minutes duration with a Current Procedural Terminology (CPT) code of 90837 in clinical medical records for review. Without medical records for review stating specifically that the patient required and received EMDR for the treatment of PTSD during the denial dates, there was not sufficient medical records provided to support the medical necessity for extended sessions of 60 minutes for outpatient mental health treatment services for the dates of service under review. 

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

The insurer's denial of coverage for extended outpatient treatment services (code 90837), is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Digestive system
Diagnostic testing

Diagnosis: gastric ulcers
Treatment: Upper Gastrointestinal Endoscopy 
The insurer denied the Upper Gastrointestinal Endoscopy. The health plan's determination is overturned. 

The patient is a male with history of gastric ulcers. He had reflux symptoms for 17-18 years. Esophagogastroduodenoscopy showed an esophageal ulcer and Los Angeles Grade A esophagitis; biopsies showed reflux esophagitis and mild chronic gastritis. He had improvement in symptoms on pantoprazole 40 milligrams (mg) daily. A repeat esophagogastroduodenoscopy was recommended to assess healing of esophagitis. At issue is coverage for an Upper Gastrointestinal Endoscopy.

Upper Gastrointestinal Endoscopy is medically necessary for this patient. According to the American Society for Gastrointestinal Endoscopy guidelines for the management of gastroesophageal reflux disease, "We suggest that repeat esophagogastroduodenoscopy (EGD) be performed in patients with severe erosive esophagitis after at least an 8-week course of proton pump inhibitor (PPI) therapy to exclude underlying BE (Barrett's esophagus) or dysplasia". Treatment with proton pump inhibitor is not always effective, and persistent ulcer healing can indicate other underlying pathology; additionally, Barrett's esophagus can be obscured by inflammation, and found on endoscopy after inflammation resolves. In this case, in which the patient had a frank esophageal ulcer, which is beyond erosive esophagitis, a repeat esophagogastroduodenoscopy is warranted in accordance with guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis (ALS), coronary artery disease, diabetes mellitus and dementia.
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services TO 12 Hours per Day, 7 Days per Week, a Total of 84 Hours per Week.
The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) Services TO 12 Hours per Day, 7 Days per Week, a Total of 84 Hours per Week.
The denial is overturned.

The patient is a female with a history of amyotrophic lateral sclerosis (ALS), coronary artery disease, diabetes mellitus and dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 84 hours per week personal assistance services to offer increased activities of daily living support.

Yes, the proposed treatment of 84 hours per week personal assistance services is deemed medically necessary.
This is a female with a history of amyotrophic lateral sclerosis (ALS), coronary artery disease, diabetes mellitus and dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Recent documentation noted in clinical encounters with her Neurologist an amyotrophic lateral sclerosis (ALS) specialist, indicates that her dysphagia, dyspnea, extremity muscle weakness and memory loss are progressively becoming worse. Hence, this documentation reveals that the currently approved plan of 35 hours per week personal assistance services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 84 hours per week personal assistance services is deemed medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD). 
Treatment: Transoral fundoplication (CPT code 43210). 

The insurer denied coverage for transoral fundoplication (CPT code 43210). 

The denial is overturned. 

This is a male patient who has been previously diagnosed with gastroesophageal reflux disease (GERD).  The patient has been recommended to undergo transoral incisionless fundoplication (TIF) due to the chronic gastroesophageal reflux.  The patient has experienced symptoms that include regurgitation as well as belching and heartburn despite medication management with omeprazole and Dexilant.  The physician does indicate the current standard of anti-reflux surgery is the Nissen fundoplication however the physician indicates the procedure has numerous shortcomings. The recommendation was made for the requested procedure due to much less of an invasive procedure being performed.  The submitted documentation includes a prior esophagogastroduodenoscopy revealing gastritis without bleeding.  The documentation also detailed this patient has undergone ambulatory potential of hydrogen (pH) monitoring.  The patient did have a DeMeester score of 20.5.  The physician indicated the patient should undergo the requested surgery due to the risk of the patient developing Barrett's esophagus as a consequence of longstanding GERD. 

The procedure is Food and Drug (FDA) approved.  There are guidelines supporting the use of TIF for patients with manometric pH results.  This procedure is especially beneficial for this patient with regurgitation. Regurgitation is not alleviated by medical therapy and an endoscopic procedure like TIF will offer more benefit than medical treatments. These less invasive endoscopic procedures are standard of care in lieu of surgical fundoplication.

The insurer's denial of coverage for transoral fundoplication (CPT code 43210) is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD). 
Treatment: Transoral fundoplication (CPT code 43210). 

The insurer denied coverage for transoral fundoplication (CPT code 43210). 

The denial is overturned. 

This is a male patient who has a history of gastroesophageal reflux disease (GERD). The patient had experienced chronic symptoms including regurgitation, belching, and heartburn, despite medication management with proton pump inhibitors including omeprazole and Dexilant.  The provider noted that the prolonged exposure of the lower esophageal tissue to stomach acids may place at risk for developing Barrett's esophagus as a consequence of longstanding GERD.  Barrett's esophagus was the only known precursor in the development of adenocarcinoma.  The patient had a DeMeester score of 20.5 and had undergone potential of hydrogen (pH) testing. The request was for a transoral fundoplication. 

Transoral incisionless fundoplication (TIF) has been compared with proton pump inhibitor (PPI) therapy in several randomized trials. In the latest trial, Tempo, 63 patients with GERD refractory to PPI received TIF versus maximum standard dose PPI therapy. At six months, both regurgitation and extra-esophageal symptoms were eliminated in more TIF than PPI patients (62 versus 5 percent); 90 percent of TIF patients were off PPIs. After six months, all patients in the PPI (control) group elected to cross over to TIF. At three years, 90 and 88 percent of patients reported elimination of troublesome regurgitation and all atypical symptoms, respectively. At five years, troublesome regurgitation was eliminated in 80 percent of patients; 34 percent were on daily PPI therapy, and the average total GERD health-related quality of life score improved from 22.2 (baseline) to 6.8. 

Transoral fundoplication is likely to be beneficial for this patient since he has remained with symptoms on long-term PPI therapy. 

The insurer's denial of coverage for transoral fundoplication (CPT code 43210) is overturned.