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

Diagnosis: Severe autism
Treatment: CDPAS 92 hours/week 
The insurer denied the CDPAS 92 hours/week.
The denial is overturned, in part. 

Yes, in part; CDPAS 56 hours weekly is medically necessary; however, CDPAS 92 hours/week is not medically necessary for this patient.

The patient is a male child with medical history significant for autism. He is essentially non-verbal with occasional vocalizations. He reportedly has self-injurious behaviors and is difficult to redirect or soothe. He requires constant supervision to prevent injury to self and damage to surroundings. He takes a high-calorie gluten-free diet by mouth. He is independent with transfers and mobility, but dependent for all activities of daily living. He can urinate independently but is incontinent of stool. He lives with his parents and three older siblings, two of whom attend school outside of the home and one of whom is home-schooled. His father works full-time outside of the home. The patient is no longer in school because his parents have declined to vaccinate, and vaccination is required for school attendance. 

The patient's parents currently receive six hours weekly of respite as well as 52 hours consumer directed personal assistance services (CDPAS). They are requesting an additional 40 hours weekly to cover the time that he would be in school. His calculated need has been determined to be 32 hours weekly. 

According to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents with Chronic Disease, "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens."  Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." 

This male child has autism and requires constant supervision to maintain health and safety. He is not fully dependent in some activities such as eating and voiding but fully dependent upon caregivers for other activities such as bathing and stooling and dressing, some of which can be quite challenging. He is no longer in school because of the state vaccine regulations, increasing the number of hours that his family is responsible for his care. While there is no medical need to increase his CDPAS hours to the requested 92 hours weekly, the family has been basically just getting by providing for the needs of their son with the current 52 hours weekly. Based on his current needs, behavioral issues, and safety concerns, the most appropriate assistance would be 56 hours weekly (as an average of eight hours daily), to be apportioned by the family based on the participation of one or both parents. 

Therefore, an additional four hours is medically necessary for a total of 56 hours per week.
Appeal type: Medical necessity
Decision: Upheld

The patient with moderate to severe atopic dermatitis (40% body surface area involvement) with a comorbidity of asthma. The patient has erythematous and lichenified plaques of the arms, legs, face, back, chest, and neck. The patient is currently taking Dupixent, 300 milligrams (mg) every two weeks, and continues to have poor quality of life with difficulty sleeping, and despite hydroxyzine. The patient is also using topical triamcinolone and tacrolimus. Weekly Dupixent injections are being requested and is the subject under review for medical necessity. 

The health plans determination of medical necessity is upheld in whole. 

No, Dupixent 300 weekly is not medically necessary for this patient. Weekly Dupixent is not confirmed to be reliably more effective, and better tolerated, than the Food and Drug Administration (FDA)approved dosing of Dupixent used every two weeks. Side effects of Dupixent (such as conjunctivitis and face/neck atopic exacerbation) do exist, and treatment with oral/systemic therapies to supplement Dupixent have not occurred. 
"Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries."[3] 

Accordingly, weekly Dupixent injections are not medically necessary to treat this patient's severe atopic dermatitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision
Treatment: Home Health Care

The patient is a male with past medical history significant for legal blindness from retinitis pigmentosa and also cardiac arrhythmia. The patient requests an increase in personal care service hours. Currently the patient is receiving 21 hours per week. The patient is requesting an increase to 56 hours a week, 8 hours a day 7 days a week.
This was denied based upon medical necessity. The patient is appealing that decision.

The health plan's determination is upheld. 

The patient requests additional hours due to the patient being legally blind secondary to retinitis pigmentosa. There is also noted the patient suffers cardiac arrhythmia causing dizziness. The patient has had multiple falls in the past and needs assistance at home. No ER visits were noted. Of note, a Uniform Assessment System (UAS) state of New York evaluation was not available for review. The patient requests assistance with cooking food, eating, daily chores, going to the bathroom, and showering, along with personal hygiene needs. 

Additional services are not noted to be medically necessary. Typically, services would be considered medically necessary for activities of daily living (ADLs) and instrumental activities of daily living (IADLs). There was no notation in the provided documentation that the patient requires more help with ADLs or IADLs. The request was for help due to the patient's dizziness and falling. Unfortunately, an aide cannot be available at all times to help prevent falling. The services being requested which include cooking, meal preparation along with showering and other personal hygiene needs can be performed in the allotted time.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Glaucoma 
Treatment: Cosopt PF 

The health plan should not cover the Formulary exception for Cosopt PF. 

The patient is a female with primary open angle glaucoma for whom coverage of Cosopt PF (dorzolamide-timolol) is requested. Coverage was previously denied as it was not determined that the patient had tried and failed all three of the formulary alternatives which include dorzolamide-timolol, latanoprost, and Travatan Z. Upon appeal, it is identified that the patient has tried and failed latanoprost, timolol maleate, Cosopt (dorzolamide-timolol), Rhopressa and Rocklatan. 

The patient's glaucoma has been difficult to control medically for the past few years. At an exam this year, the patient was using timolol maleate and Rocklatan when vision was documented as 20/25 OU (both eyes) and intraocular pressures were 22 mm Hg OD (right eye) and 20 mm Hg OS (left eye). The provider recommended holding timolol maleate, continuing Rocklatan and starting Cosopt PF. 

In this case, a formulary exception for Cosopt PF is requested for a patient with primary open angle glaucoma. Coverage was previously denied, as it was not determined that the patient had tried and failed all three of the formulary alternatives which include dorzolamide-timolol, latanoprost, and Travatan Z. Upon appeal, it is identified that the patient has tried and failed latanoprost, timolol maleate, Cosopt (dorzolamide-timolol), Rhopressa and Rocklatan. Therefore, the patient has tried two of three formulary alternatives. It is not identified that the patient has tried and failed Travatan Z, which is generally considered more effective at lowering intraocular pressures than latanoprost. The records do show that the patient has previously tried Cosopt (dorzolamide-timolol) without reports of allergy or side effects. No rationale is provided as to why the patient would need a preservative free formulation when Cosopt is restarted, and a review of the peer reviewed medical literature does not find Cosopt PF more effective than Cosopt. Therefore, the medical necessity of a formulary exception for Cosopt PF is not established.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder  
Treatment: Pharmacy/Prescription Drugs  

The patient has end-stage renal disease status due to lupus nephritis.  A cadaveric renal transplant was performed.  The immunosuppressive regimen has included corticosteroids, mycophenolate mofetil, and Envarsus XR.  The use of Envarsus XR is under review.  

The health plan's determination is upheld.  Tacrolimus has been shown to be more efficacious at preventing renal transplant rejection than cyclosporine formulations.  That being said, the patient has not failed or been intolerant to and has no contraindication to the formulary agent tacrolimus capsule.  There are no published studies demonstrating an increase in adverse events with tacrolimus capsules compared with Envarsus XR.  The formulary drug has not been ineffective and would be as effective as the non-formulary drug Envarsus XR.  The formulary drug would not have more adverse effects than Envarsus XR.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes
Treatment: Invokana
The health plan should not cover the Formulary exception for Invokana 300mg or tabs.

The patient is a male diagnosed with T2DM (type 2 Diabetes Mellitus). This request is for Invokana. As reported; He is on metformin HCL 1000 mg; Invokana with good control on his BG (blood glucose). 

The patient's A1C (glycated hemoglobin) was 9.3%. Later, it was 8.8%. Then it was 9.2%. 

The request is for Formulary exception for Invokana. The health plan's Formulary includes Farxiga and Jardiance. 

Farxiga (Dapagliflozin) Jardiance (Empagliflozin) and Invokana (Canagliflozin) are SGLT-2 (sodium-glucose cotransporter-2) inhibitors used to treat type II diabetes  [1, 2]. SGLT-2 inhibitors are good options for treating diabetes based on the latest American Association of Clinical Endocrinologists recommendations [3-6]. 

They are at the same level as GLP1 (glucagon-like peptide-1) agonists and DPP4 (Dipeptidyl Peptidase-4) inhibitors on the latest AACE recommendations [6]. 

Invokana is FDA-approved [2] for treatment of type 2 diabetes (see below). 


----------------------------INDICATIONS AND USAGE----------------------------
INVOKANA is a sodium-glucose co-transporter 2 (SGLT2) inhibitor indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (1)
Limitation of Use:
1) Not for treatment of type 1 diabetes mellitus or diabetic ketoacidosis(1)
-----------------------DOSAGE AND ADMINISTRATION-----------------------
2) The recommended starting dose is 100 mg once daily, taken before the first meal of the day (2.1) 
3) Dose can be increased to 300 mg once daily in patients tolerating INVOKANA 100 mg once daily who have an eGFR of 60 mL/min/1.73 m2 or greater and require additional glycemic control (2.1)
4) INVOKANA is limited to 100 mg once daily in patients who have an eGFR of 45 to less than 60 mL/min/1.73 m2 (2.2)
5) Assess renal function before initiating INVOKANA. Do not initiate INVOKANA if eGFR is below 45 mL/min/1.73 m2(2.2)
6) Discontinue INVOKANA if eGFR falls below 45 mL/min/1.73 m2(2.2) 

There are no studies showing superiority of the requested medication over the formulary alternatives. The patient has an A1c not at goal. There is no documented justification provided as to why the patient cannot try the formulary alternatives. The patient can try the formulary alternatives. The health plan should not cover the Formulary exception for Invokana 300mg or tabs.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal 
Inpatient hospital 

Diagnosis: Abdominal pain 
Treatment: Inpatient hospital 

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

This case involves a man with a history of chronic obstructive pulmonary disease (COPD) hypertension and alcohol dependence, who presented to the emergency department with abdominal and back pain. The pain has been intermittently present for about a month, sharp 7 out of 10 on the pain scale most prominent in the right upper quadrant radiating to the left side of the abdomen. There is some nausea and vomiting associated with the symptoms and aggravated by drinking. He continues to drink alcohol, continues to lose weight. There is a prior history of alcohol withdrawal. He appeared anxious, complained of headaches and tremors in the upper extremities with pins and needle sensation. The patient is admitted to the hospital with a principal problem of alcohol withdrawal and hypokalemia. 

The inpatient hospital admission is medically necessary for this patient. This patient is going through moderate to severe alcohol withdrawal symptoms. He was deemed incompetent to make medical decisions by psychiatry. His alcohol withdrawal scale is elevated between 11 and 13, and the patient required multiple doses of benzodiazepines, as well as Haldol, to keep him calm. This is an indication for an inpatient hospitalization. A lower level of care would not be appropriate.
Appeal type: Medical necessity
Decision: Upheld

Dx: Cardiac/Circulatory Problems 
Tx: Inpatient Hospital 

Denied: Inpatient stay 
Denial: UPHELD in whole 

The patient is a morbidly obese male with a history of hypertension, heart failure with reduced ejection fraction, chronic kidney disease, and atrial fibrillation. He presented to the emergency department complaining of shortness of breath, orthopnea, and edema. He reported having run out of his medications three weeks prior. His blood pressure was 107/70 millimeters of mercury (mmHg) with a heart rate of 107 beats/minute. His respiratory rate was 20/minute with a room air oxygen saturation of 100%. On physical exam he had bibasilar rales and edema of the legs, buttocks and abdominal wall. Chronic venous stasis changes were noted on his lower extremities. His creatinine level was at his baseline. His troponin level was normal. His brain natriuretic peptide (BNP) level was mildly elevated. An electrocardiogram showed atrial fibrillation with a ventricular rate in the 110s. There were no acute changes. Chest x-ray showed mild volume overload. He was treated with intravenous furosemide and oral amiodarone and admitted to the hospital for management of decompensated heart failure due to medication noncompliance. The patient complained of mild dyspnea. His chest was clear. Per the cardiologist's note, he had no edema. Furosemide was continued. The next day the patent denied complaints. His chest was clear. He had no edema. Furosemide was continued. He was discharged the following day. Medical necessity for an inpatient stay is at issue. 

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

An inpatient stay was not medically necessary. This patient presented with dyspnea, orthopnea and edema and was in mildly decompensated heart failure due to medication noncompliance. He was hemodynamically stable. He was not hypoxic, there was no evidence of ischemia and his renal function was at his baseline. His serum sodium level was normal as was his troponin level. He responded well to a dose of intravenous furosemide and was much improved by the day after admission. Two days after admission he had no complaints, clear lungs and no edema. In heart failure patients, such as this patient, without high risk features, studies have shown that lower level care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this instance, a lower level of care status would have been sufficient; an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Dx: Digestive System/Gastrointestinal 
Tx: Inpatient Hospital 

Denied: Inpatient stay 
Denial: UPHELD in whole 

The patient is a female with history of severe constipation and hemorrhoids, who came into the emergency department because of rectal pain rated 10/10 and the inability to have a bowel movement. She was noted to have a white blood cell count of 11.2 with a left shift. The patient underwent an examination under anesthesia, hemorrhoidectomy, superficial lateral sphincterotomy, and fecal disimpaction. On post operative day 1 the patient was doing well and was discharged home. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld, in whole. 
 
The patient had a clear need for a surgical procedure, but did not have a need for inpatient level of care from the hospital. There is no physician documentation of the need for an inpatient level of monitoring, complex diagnostics, or treatments other than the surgery. There is no evidence of patient specific problems that would require an inpatient level of care to meet medical needs or to assure patient safety. There is no evidence of a complicating event that occurred before, during, or after the patient's care that would require inpatient level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Plaque psoriasis.
Treatment: Taltz autoinjector (three pack) 80mg/ml auto inject.
The insurer denied the Formulary Exception for Taltz autoinjector (three pack) 80mg/ml auto injct.
The denial is upheld. 

This is a man with psoriasis affecting 40% body surface area (BSA) for whom Taltz is requested. He is currently on Cosentyx and Clobetasol and failing the treatment. He has failed Humira in the past.

No, the health plan should not cover the proposed formulary exception for Taltz because the plan requires documented contraindications, intolerance or treatment and failure with formulary medications prior to approving a formulary exception. The patient is a candidate for systemic therapy (topical therapies are inappropriate as monotherapy for severe psoriasis). The available formulary alternatives that may be appropriate include Otezla, Stelara and Tremfya. The current treatment guidelines that are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis recommend typical first line treatments such as topical corticosteroids and calcipotriene followed by typical second line treatments such as ultraviolet phototherapy, oral systemic treatments (methotrexate, cyclosporine) and biologics. The patient has no documented contraindications to the use of the preferred medications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fibromyalgia
Treatment: Lyrica
The insurer denied the Lyrica.
The denial is overturned. 

Yes, the proposed Lyrica (brand) is medically necessary.

The patient is a female with fibromyalgia (FMS).  She failed treatment with duloxetine and gabapentin.  Per attached documentation, she tried three different generic formulations of Lyrica (pregabalin), and none were effective.  Per attending physician (AP) telehealth note, she re-started brand Lyrica and felt better. Attached pharmacy records demonstrate that brand Lyrica was filled and generic pregabalin was filled. Appeal is for Lyrica (brand) 50MG OR CAPS for the treatment of FMS.

Lyrica is FDA-approved for the treatment of fibromyalgia (FMS).  This patient with FMS failed treatment with duloxetine and gabapentin.  She failed treatment with three different generic formulations of Lyrica (pregabalin), but responded to brand Lyrica in the past, and pharmacy records document prior dispensing of brand Lyrica.  Although generic and brand medications have the same active ingredient per FDA guidelines, per a recent UpToDate review, "one study found that while most generic antiseizure drugs (i.e., Lyrica) provide total drug delivery similar to the reference product, differences in peak concentrations were more common, and switches between generic products caused greater changes in plasma drug concentrations than generic substitution of the reference product".  Thus, it is indeed conceivable that this patient responds better to brand Lyrica than generic pregabalin for the treatment of her FMS.  Therefore, the proposed Lyrica (brand) 50MG OR CAPS for the treatment of FMS in this specific patient is medically necessary, as she failed treatment with three different generic formulations of pregabalin (Plan-preferred).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Inpatient Hospital 
The insurer denied: Inpatient Stay 
The denial is: Upheld in whole 

The patient is a female who presented with severe abdominal pain that had started the previous day. She did have associated nausea, but no diarrhea, dysuria, fever, or chills. The patient's lab work revealed a white blood cell (WBC) of 12.23. A computed tomography (CT) scan of the abdomen and pelvis demonstrated an 11 millimeter (mm) appendix consistent with acute appendicitis. The patient was taken to the operating room and underwent a laparoscopic appendectomy. During the operation it was noted that there were phlegmonous changes in the right lower quadrant with inflamed small bowel and an inflamed appendix. A Jackson-Pratt (JP) drain was placed after appendectomy was completed. The patient was hospitalized after the procedure. Progress notes demonstrated that on post-op check on the day of the procedure the patient had been able to void and was tolerating regular diet. The patient was on Intravenous Cefoxitin postoperatively. The next day the patient was doing well, tolerating a regular diet, and was voiding spontaneously. No labs or additional testing were performed. The following day the patient was noted to have improved abdominal pain and continued to tolerate her diet. No additional labs or testing were performed.  The next day the patient was discharged home on Augmentin. Pathology demonstrated suppurative appendicitis. 

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

The inpatient stay was not medically necessary. The patient had acute suppurative appendicitis without perforation but did not have evidence of other complications. The patient did very well after surgery and was able to tolerate a diet that same day. While the patient remained in the hospital additional laboratory testing was not performed. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care. The patient did not utilize complex testing or therapy other than surgery that would have required an inpatient level of care. Treatment could have been carried out at a lower level of care status.