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

Diagnosis: Psoriatic Arthritis
Treatment: Taltz
The insurer denied the Taltz.
The denial is upheld. 

The patient is a female with guttate psoriasis and psoriatic arthritis.  She failed treatment with Otezla, Humira, methotrexate (oral and injectable), NSAIDs (nonsteroidal anti-inflammatory drugs) and local steroid injections.  At her telehealth visit, the patient was being treated with Humira 40 mg every other week and Rasuvo (injectable methotrexate) 12.5 mg weekly, but still had refractory hip pain and disabling fatigue.  The AP (attending physican) wishes to switch Humira to the IL (interleukin)-17 inhibitor Taltz.  The patient has not tried or failed other Plan-preferred alternatives (i.e., Cosentyx, Enbrel, infliximab formulations, Orencia, Stelara or Xeljanz).  Appeal is for Taltz for the treatment of psoriatic arthritis.

No, this patient with psoriasis and psoriatic arthritis failed treatment with Otezla, Humira, methotrexate (oral and injectable), NSAIDs (nonsteroidal anti-inflammatory drugs) and local steroid injections.  Due to persistent hip pain and fatigue, the AP wishes to switch the TNF (tumor necrosis factor) inhibitor Humira to the IL-17 inhibitor Taltz.  Taltz is FDA (Food and Drug Administration)-approved for the treatment of both psoriasis and psoriatic arthritis.  However, this patient has not tried or failed other plan-preferred alternatives, as listed above.  Per a recent UpToDate review, "in patients with peripheral arthritis who experience an inadequate response to an initial TNF (tumor necrosis factor) inhibitor, we use a second TNF (tumor necrosis factor) inhibitor rather than trying a different class of biologic agent".  Thus, alternative plan-preferred TNF inhibitors (i.e., Enbrel, infliximab) could be appropriate for this patient.  If an alternate mechanism of action is preferred, the plan-preferred agents Cosentyx, Orencia, Stelara or Xeljanz could be appropriate treatment options for this patient.  Specifically, if the AP prefers a trial of an IL-17 inhibitor, Cosentyx would be a reasonable plan-preferred treatment alternative to Taltz.  There are no data to suggest that Taltz would be superior to any of these plan-preferred alternatives for the treatment of psoriatic arthritis in this patient.  Therefore, the health plan should not cover the requested treatment with Taltz for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Restless Leg Syndrome.
Treatment: Formulary exception for Ropinirole Extended Release.
The insurer denied the Formulary exception for Ropinirole Extended Release.
The denial is upheld. 

The patient is a male with restless leg syndrome (RLS). He has tried and failed ropinirole IR (immediate release). His provider is requesting continuation of ropinirole ER (extended release) noting improvement in his condition with treatment.

No, the health plan should not cover the Formulary exception for Ropinirole Extended Release.

There is no documented reason as to why the patient cannot be treated with the preferred agent, pramipexole, for his condition. Pramipexole is considered first-line, standard-of-care treatment for RLS (restless leg syndrome). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Ropinirole ER (extended release) relative to the preferred pramipexole. Therefore, the health plan should not cover the Formulary exception for Ropinirole Extended Release.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Renal Disease
Treatment: Formulary exception for Lanthanum Carbonate
The insurer denied the Formulary exception for Lanthanum Carbonate.
The denial is overturned. 

The patient is a female with end-stage renal disease on dialysis. Lanthanum carbonate was prescribed for hypophosphatemia. She had hypercalcemia with Phoslo, Phoslyra and calcium acetate with serum calcium levels of 10.5 or greater after retrials. She failed to respond to Auryxia, with phosphate levels between 8.0-9.0 despite maximal dosing. The patient had gastrointestinal intolerance to Velphoro.

Yes, the health plan should cover the Formulary exception for Lanthanum Carbonate.

The patient has failed three formulary alternative phosphate binders (calcium acetate, Phoslyra, and Velphoro). The patient failed three calcium-based binders due to hypercalcemia, failed to respond to Auryxia, and had gastrointestinal intolerance to Velphoro. Lanthanum carbonate is FDA (Food and Drug Administration)-approved for end-stage renal disease and hypophosphatemia (1, 2), which is the condition for which it was prescribed in this case. As it is not a calcium-based binder, it does not raise the serum calcium level. In summary, lanthanum carbonate is medically appropriate and the health plan should cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque psoriasis; Dyschromicum perstans

Treatment: Otezla 30mg

The insurer denied coverage for Otezla 30mg.

The denial is upheld. 

This female patient with a history of plaque psoriasis and dyschromicum perstans.  Psoriasis is located on her hands and her feet.  Her condition is improving with betamethasone but symptoms still persist.  The physician is requesting Otezla to treat psoriasis.  

The insurer has denied coverage for Otezla.

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 support the administration of Otezla for this patient's condition as an accepted standard of practice in the U.S.  Based on the evidence-based literature, the Otezla (apremilast) tablets are not medically necessary.  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 phototherapy is most appropriate for patients with >10 % affected body surface area who have not responded to topical treatments...NB-UVB ..effective treatment options for psoriasis...Long-term data on NB-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 PASI75 at 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.  

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

The carrier's denial of coverage for Otezla 30 MG OR Tabs to Treat Psoriasis is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rising Chromogranin A titer
Treatment: PET Scan With CT For Attenuation, Pre-service
The insurer denied the PET Scan With CT For Attenuation, Pre-service.
The denial is overturned. 

The patient is a female. She was diagnosed with carcinoid tumor.

The patient underwent hemicolectomy. Pathology revealed well differentiated neuroendocrine tumor, measuring 2cm (centimeters) in maximal dimension. There were four involved lymph nodes. She was monitored with serial Chromogranin A measurement, and records indicate that the Chromogranin A titer rose over the course of a year.

The patient's urine 5-HIAA (5-hydroxyindoleacetic acid) was normal as of recently. CT (computed tomography) scans were done earlier this year. CT (computed tomography) chest revealed a right adrenal adenoma. There were no lung nodules. CT (computed tomography) abdomen and pelvis revealed a 2.1cm (centimeter) low density liver lesion, and MRI (magnetic resonance image) was recommended to see if this was a hemangioma.

MRI (magnetic resonance image) was done, and this study revealed the same 2.1cm (centimeter) low density lesion along the hepatic dome. This lesion was felt to be possibly artifactual. Multiple other lesions were seen and characterized as hemangiomas. There was also an adrenal adenoma identified, along with hemangioma involving the L3 (third lumbar spine vertebra) vertebral body. Given continued rising Chromogranin A titer, Gallium Dotatate PET/CT (position emission tomography/computed tomography) was ordered.

Yes. the requested PET/CT (position emission tomography/computed tomography) is medically necessary.

This patient has a rising Chromogranin A and underwent imaging that revealed mostly benign findings, but did reveal a 2.1cm (centimeter) hepatic dome lesion that could not be definitively characterized. Dotatate PET/CT (positron emission tomography/computed tomography) is a standard and effective test in the evaluation of well differentiated neuroendocrine tumors. It is used in the evaluation of suspected recurrence and in patients confirmed to have recurrence to help assess extent of disease and also to assess for potential sensitivity to somatostatin receptor based treatment. 

This patient had a hepatic dome lesion seen on CT (computed tomography) and MRI (magnetic resonance image) that was not definitely characterized. Dotatate PET/CT (positron emission tomography/computed tomography) was medically necessary in this case to determine whether this lesion is a metastatic lesion. Identification of single site metastatic disease would allow for potentially curative resection.

The health plan acted based on their assessment of the initial evidence supporting use of Dotatate imaging.  However, when considering all the facts and records received, the PET/CT (positron emission tomography/computed tomography) is medically necessary in this case, as described above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crowded and impacted teeth.
Treatment: Braces and periodic orthodontic treatment visits.
The insurer denied the Braces and periodic orthodontic treatment visits. 
The denial is upheld. 

The patient is a female. The request is for adjustment and insertion of braces.

The clinical dental summary states that the patient presents with Class I molar, mild upper and lower arch crowding, over-retained primary Canine, impacted upper right Canine.

No, the Braces and periodic orthodontic treatment visits are not medically necessary.

The patient's overall positioning of her teeth do not present any challenges to her ability to have a normal chewing pattern and/or speech function.

While the delayed eruption of the upper right canine is of concern, it is possible that this can be rectified without the use of braces at this time. Normal eruption of the canines can occur up to and around the age of 13.

The records and the information supplied do not show the type of severe malocclusion that would warrant orthodontic therapy for this patient at this time.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female. She has right atrophic kidney with history of UTI (urinary
tract infection) for which she was treated and discharged from the hospital, and
then she returned to the ED (emergency department) on the day of discharge. She
presented with upper and mid-abdominal pain, 8/10 in severity, associated with
nausea and no vomiting. She denied any history of hematemesis, melena, or bright
red per rectum.

In the ED (emergency department), the patient was hemodynamically stable and
afebrile. Her CBC (complete blood count) and Chem-panel were normal. She was
given IV (intravenous) fluids, Zofran, IV (intravenous) Morphine, and Reglan, and
PPI (proton pump inhibitor). The Ultrasound of the abdomen revealed a small gall
bladder polyp, possibly a stone, but no cholecystitis or pancreatitis, and atrophic
right kidney. The CT (computed tomography) scan of the abdomen revealed gastric
wall thickening suspicious for gastritis, and stools in the colon.

The patient was started on clear liquid diet, and continued on IV (intravenous)
fluids, IV (intravenous) morphine and Reglan. She was also started on bowel
regimen consisting of Senna and Miralax for constipation. The GI
(gastroenterologist) was consulted. The patient underwent EGD
(esophagogastroduodenoscopy) which revealed small, non-bleeding ulcers and
gastritis/duodenitis. After the procedure, she was started on regular diet, and
started on Protonix 40mg (milligrams) PO (by mouth) BID (twice daily). She was
also diagnosed with UTI (urinary tract infection) and cystitis. She was started on
Vantin for UTI (urinary tract infection). She was discharged home in a fair and
stable condition and advised to follow up with GI (gastroenterology) and PCP
(primary care provider).

No, the Inpatient admission was not medically necessary.

The patient was admitted with abdominal pain and nausea and no vomiting. In the
ED (emergency department) and during hospitalization for two days, she was
hemodynamically stable and afebrile. Her CBC (complete blood count) and Chem
panel were normal. Her pain and nausea were controlled symptomatically, and she
was able to tolerate clear liquid diet. Her CT (computed tomography) scan and US
(ultrasound) abdomen did not show any acute findings except a gall bladder
polyp/stone and gastric wall thickening. The EGD (esophagogastroduodenoscopy)
showed few superficial, non-bleeding ulcers and gastritis. After the procedure, she
was able to tolerate regular diet. Her abdominal pain improved remarkably and her
constipation resolved. Her UTI (urinary tract infection) and cystitis were treated with
oral antibiotics. and her abdominal pain improved significantly on the day of
discharge. Given this clinical scenario, she could have been appropriately managed at the lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Erectile dysfunction. 
Treatment: Inpatient stay. 

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

This male with a malfunction inflatable penile prosthesis was treated with a placement of a semi-rigid implant. The surgery was uncomplicated. He was discharged home the following day. Under review is the medical necessity of the inpatient admission. 

An inpatient admission is not medically necessary for an overnight stay associated with an uncomplicated penile prosthesis revision. A malfunction of an inflatable penile prosthesis has an impairment of the physical function of erectile function. Although intravenous (IV) antibiotics and pain control were administered, these could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.

Treatment: Orthodontic Braces.

The insurer is denied coverage for orthodontic Braces.

The denial is upheld. 

This patient is a female patient who was evaluated for orthodontic treatment. On the Handicapping Labio-Lingual Deviation (HLD) Index report documented, the following automatic qualifier was chosen: Deep impinging overbite with severe soft tissue damage. Orthodontics & Dentofacial Orthopedics Practitioner is requesting authorization of Orthodontic Braces for this patient.

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labio-Lingual Deviation (HLD) Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage.  In this case, the clinical circumstance does not meet the insurer and the plan criteria to justify orthodontic care. This reviewer concurs with the Handicapping Labio-Lingual Deviation (HLD) index of the insurer attaining 15 points (i.e., 3 points overjet, 4 points overbite, 5 points anterior crowding and 3 points labiolingual spread).

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 Orthodontic Braces upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures

Treatment: Inpatient stay

The insurer is denied coverage for inpatient stay.

The denial is overturned. 

This female patient with a past medical history of seizures who presented to the Emergency Department (ED) via Emergency Medical Services (EMS) for intermittent seizure episodes with clenched jaw.  In the ED, the patient was postictal and confused.  The patient was given intravenous (IV) Keppra and IV Ativan.  The patient was admitted to the Medical Surgical unit for the diagnosis of seizures.  The patient's computed tomography (CT) of the head without contrast, revealed: no evidence of acute intracranial hemorrhage, displaced clavicular fracture, major territorial infarct or mass effect.  The patient was noted to be under the care of an Epileptologist and was taking Keppra 1500 milligrams (mg) twice daily and Lamictal 200 mg twice daily. Neurology was consulted and recommended to continue Keppra 1500 milligram (mg) twice daily and increase Lamictal to 225 mg twice daily.  

The EMS stated that the patient had a seizure episode in route to the hospital with her eyes rolled back lasting about 30 seconds to 1 minute.  The patient had not given any verbal responses since then but did give a thumb up.  The patient's vital signs remained stable.  The patient cannot provide any coherent history or review of systems.  The physical examination revealed that the patient was not in acute distress. The patient had clenched teeth.  The patient's eyes were closed.  The patient was given IV Keppra and Ativan.  The patient was admitted to the Medical unit for the diagnosis of seizure.  The patient's computed tomography (CT) scan of the head without contrast was normal.  The patient was postictal and confused in the ED.  The patient was under the care of an epileptologist.  The patient was currently utilizing Keppra 1500 mg twice a day and Lamictal 200 mg twice a day.  The patient's Lamictal was increased to 225 mg twice a day and she was discharged home after being cleared by neurology.

Based on the review of the medical record and literature, inpatient stay was medically necessary for this patient. The patient was noted to have multiple seizures, and had
post-ictal confusion after the seizures. Due to this patient's having multiple seizures in a short period of time, this would be considered "status epilepticus", for which an admission is considered medically necessary.

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

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

Diagnosis: Mediastinal mass; pneumothorax
Treatment: Inpatient stay
The insurer is denied coverage for continued inpatient stay.
The denial is upheld. 

The patient is a male with a past medical history of gastroesophageal reflux disease (GERD), hypertension, morbid obesity, coronary artery disease, type 2 diabetes mellitus, hypothyroidism, stomach adenocarcinoma, and peripheral neuropathy.  The patient was a former smoker.  The patient presented for admission due to a mediastinal mass.  The patient was admitted for surgery.  The patient underwent upper endoscopy, right thoracoscopy, right thoracotomy, and excision of the mediastinal cyst.  After the procedure, the patient had episodes of hypoxic respiratory failure.  The patient's chest X-ray showed a right pneumothorax.  The patient was treated with a chest tube, pain management, intravenous antibiotics, furosemide, and respiratory treatments.  The patient received supplemental oxygen.  The patient was subsequently weaned.  The patient had been transitioned out of Intensive Care Unit (ICU) and felt comfortable using his own insulin pump.  The patient underwent physical therapy (PT) and occupational therapy (OT) as an inpatient.  The patient was discharged in stable condition with home care.

Based on the review of the medical record, continuous inpatient stay was not medically necessary for this patient. The patient had a mediastinal mass and was admitted for resection.  The patient had a difficult and prolonged course after surgery due to respiratory failure and right pneumothorax and subsequent chest tube placement and some pleural effusions. However, following his long intensive care unit (ICU) stay, the patient was extubated, was oxygenating well and participating in pulmonary toiletry well, and had good pain control with only minimal oral analgesics. The patient was ready for discharge and the one extra day of inpatient stay was not required. The patient's room air saturation was 92% and thus, the patient did not need supplemental oxygenation.  All studies in literature have between 90-92% room air saturation as the dividing line on who needs supplemental oxygen, and this patient exceeded that threshold.  Furthermore, this patient's pain from his incisions and other factors was controlled on oral analgesics at low dose alone, and thus, the patient did not need inpatient stay for intravenous (IV) analgesics.  Thus, the patient should have been discharged to home care with outpatient physical/occupational therapy and home nursing for pulmonary toiletry and help with ambulation.

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 continued inpatient hospital admission is upheld.  The medical necessity is not substantiated.