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

Diagnosis: Inclusion Body Myositis
Treatment: Durable Medical Equipment (wheelchair and/with power recline, power seat lift, bag hooks, and elbow pads)
The insurer denied durable medical equipment (wheelchair and/with power recline, power seat lift, bag hooks, and elbow pads).
The denial is partially overturned.

The patient is an adult female with a medical history of inclusion body myopathy or myositis. Other medical history is notable for diabetes mellitus type II, anxiety, and hyperlipidemia. The patient currently uses a power wheelchair with power tilt and recline, power elevating leg rests, and power seat lift. A power mobility assessment indicated that the patient is non-ambulatory and cannot propel a manual wheelchair. The patient has scoliosis and lacks the upper extremity strength to perform pressure relief. The patient requires maximum assistance for transfers and performing daily activities. She is noted to have 2/5 strength in the upper and lower extremities. The requested group 3 power wheelchair was considered not medically necessary per guideline policy with the rationale that it exceeds the needs of the patient, and the patient does not require power recline, power seat lift, bag hooks, and elbow pads. This decision is being appealed.

The group 3 power wheelchair with power tilt and recline, power seat elevator and elbow pads are medically necessary. However, the bag hooks for the power wheelchair are not medically necessary.

The patient is non-ambulatory and cannot use a cane or walker for mobility. She cannot 
functionally propel a manual wheelchair due to upper extremity weakness. The patient cannot operate a power scooter due to impaired sitting balance and upper extremity strength. She requires a power wheelchair for mobility and accomplishing daily activities. She requires a group 3 power wheelchair given the complexity of her inclusion body myositis and that she requires multiple power components to meet her seating and mobility needs. The patient requires power tilt and recline given that she has 2/5 motor strength in the upper extremities and cannot perform pressure relief. Typically, a power seat elevator is not indicated in patients who are not independent with transfers to and from the power wheelchair with the assistance of a power seat lift. However, the documentation indicates that this significantly improves the patient's and the patient's caregivers' ability to transfer and allow access in the home for performing daily activities given that a Hoyer lift is not accessible or usable. Therefore, it can be considered medically appropriate for her condition. The elbow pads are medically necessary to support the patient's arms and allow appropriate pressure relief given her upper extremity weakness. The bag hooks for the power wheelchair are not medically necessary because they are not medical in nature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fractured Right Ankle

Treatment: Skilled nursing facility subacute rehabilitation level 2

The insurer denied coverage for Skilled nursing facility subacute rehabilitation level 2

The denial is upheld

This patient fractured their right ankle after a fall. The patient was transferred to an SNF [skilled nursing facility].  Under review is the continued SNF subacute rehabilitation level 2.

The patient was initially an appropriate candidate for the SNF subacute rehabilitation level of care (1, 2, 3).   The patient received physical and occupational therapy during their stay with significant functional recovery.  

According to the occupational therapy notesthe patient was at the supervision, stand-by assistance or set up level for bathing, hygiene/grooming, toilet transfer/use and dressing.  

According to the physical therapy notes, there was a gradual plateau of functional progress.  The patient was able to transfer and ambulate 150 feet with contact assistance and limited subsequent improvement. The patient could have been discharged to a lower level of care (e.g., long term care, home with therapy services or outpatient therapy).  In addition, there were no specific acute medical or complicated nursing issues to support continued stay at an SNF.

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

Continued SNF stay was not medically necessary.   

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for skilled nursing facility subacute rehabilitation level 2 is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraines
Treatment: Formulary exception for Qulipta
The insurer denied the formulary exception for Qulipta.
The denial is overturned.

The patient is an adult female with migraines. She is currently on Botox and Quilipta. She was previously on Ajovy, amitriptyline, cyproheptadine and Nutraceutical, and Nurtec. Her provider wishes to prescribe Qulipta. The request was previously denied coverage by the health plan, as she had not tried all formulary alternatives. The denial is being appealed.

The health plan should cover the formulary exception for Qulipta.

Qulipta is continuation of care in this case. The patient has had improvement of migraines, which indicates that Quilipta is effective. Switching her to a formulary alternative could result in adverse side effects and decreased efficacy. Furthermore, research indicates that insurance-driven medication adjustments lead to decreased patient health outcomes. Lastly, the American Headache Society anti-calcitonin gene-related peptide (CGRP) guidelines do not differentiate between the different anti-calcitonin gene-related peptides.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Major Depressive Disorder
Treatment: Rexulti
The insurer denied Rexulti.
The determination is upheld.

This is a patient who was prescribed Rexulti tablet at a starting dose of 0.5 milligram (mg) daily to be titrated to 1 mg daily for augmentation treatment of recurrent and moderately severe major depressive disorder. The patient has a longstanding history of recurrent depressive episodes with multiple medication trials without a robust response or remission of symptoms. Again, Rexulti is prescribed for augmentation of the patient's antidepressant medication, duloxetine.
Clinical records indicate that the patient has a comorbid anxiety disorder and attention deficit of disorder (ADHD)-combined type with associated treatments, The patient also has rule-out diagnoses of obsessive-compulsive disorder (OCD) versus post-traumatic stress disorder (PTSD). There is no substance use disorder in this case.
The health plan has denied authorization for coverage of Rexulti (brexpiprazole). The denial determination indicates that there is one formulary alternative.

In this case, the formulary drug will be or has not been ineffective, and would be as effective as the non-formulary drug, and both the non-formulary drug and formulary alternative would pose risk for adverse effects.
The health plan references the formulary and provides a drug list with rationale for step therapy and a prior authorization, non-formulary request form. In this case scenario, the request is not approvable per the criteria-step therapy with the formulary alternative, Abilify (aripiprazole).
The formulary contains aripiprazole (Abilify) that has proven to be effective in treating major depressive disorder in combination with an antidepressant medication and may reasonably be selected and used to effectively treat the patient's mood disorder.
This answer is consistent with the scientific literature and societal guidelines, referenced below, as well as the terms of the plan and plan policy pertaining to step therapy and prior authorization for a non-formulary medication.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis: Obstructive Hypertrophic Cardiomyopathy
Treatment: Camzyos 5MG (milligram) OR (oral) Caps
The insurer denied: Camzyos 5MG (milligram) OR (oral) Caps
The denial is overturned.

The patient is an adult male with hypertrophic cardiomyopathy. The left ventricular ejection fraction (LVEF) was normal. He had New York Heart Association (NYHA) class II symptoms. The peak left ventricular outflow tract gradient was 100-120. He was on a beta blocker. Camzyos (mavacamten) is under review.

The proposed treatment is medically necessary.

This patient had symptomatic hypertrophic cardiomyopathy. There was ongoing dyspnea on exertion on a beta blocker. As there was essentially treatment failure with a beta blocker, treatment failure with a calcium channel blocker (Verapamil, Diltiazem) would be expected. In addition, treatment with a sodium channel blocker (Disopyramide) has a relatively high risk of side effects and arrhythmia so it is prudent to avoid this medication. In this setting, Camzyos is a safe and effective treatment toward improved hypertrophic cardiomyopathy status. It is, therefore, considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Saxenda
The insurer denied: Saxenda
The denial is upheld.

The patient is an adult female with obesity. She has a body mass index of 36. The request for Saxenda is under review. The prior request was denied coverage by the health plan because, "Our policy for Saxenda (Pharmacy-03) states that in order to be approved for this medicine you must meet the following requirements: Your Body Mass Index (BMI, a measure of obesity) must be at least 30. Along with counseling and monitoring by your doctor's office, you must also be enrolled in 
a qualified complete weight management program (such as Weight Watchers or a qualifying office-based program) for at least the past 3 months, with proof of current and prior enrollment. You have met the following requirements: you have a BMI [body mass index] that is greater than 30. This request is not approved because: you have not been enrolled in a complete weight management program along with counseling and monitoring by your doctor's office for the past 3 months." The 
denial is being appealed. It is noted that the patient joined FitBit community, as she noticed her weight gain was causing her hypertension to increase.

The requested Saxenda is not medically necessary.

This request is for Saxenda for the treatment of obesity. The prior request was denied coverage by the health plan, as the patient has not been enrolled in a qualified completed weight management program for at least the past three months. The Endocrine Society guidelines on the management of obesity recommend weight loss medications be considered as an adjunct to lifestyle changes for patients who have been unsuccessful with diet and exercise alone. This patient does not have a documented medical reason that would preclude involvement in a weight management program. While she has belonged to FitBit community, this is not recognized as a complete weight management program. Saxenda has risks, including nausea and vomiting. Therefore, no, the requested Saxenda is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Home health care

Diagnosis: Atrial fibrillation
Treatment: Home INR Monitoring
The insurer denied home INR monitoring. The health plan's determination is upheld. 

This is a case review for a female being prescribed a home international normalized ratio (INR) monitor for anticoagulation medication/therapy. Coverage for this device was denied by the health plan, and this is the subject under review.
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient requires home monitoring for warfarin dosing. She has been on this medication for chronic atrial fibrillation and prevention of deep venous thrombosis. No further detail was provided in the letter.

The requested Home INR Monitor is not medically necessary for this patient.
Milliman Care Guidelines (MCG) care guidelines (26th edition) for prothrombin time (INR) home monitoring device were reviewed and applied to this case. All criteria are required to be met to allow approval of the device. The criteria that was not met was as follows: "Self-management, involving self-testing as well as dose adjustment based on algorithm provided by prescribing physician or specialty clinic OR self-testing, involving home testing of INR but reporting values to a centralized service that prescribes the recommended dose adjustment, if any."
The patient has been testing her INR and reporting to her physician office for management. This does not meet the clinical indications for home INR testing and is one of the alternatives for management listed in the care guideline. Therefore, the request is not approvable as it has not been demonstrated to be medically necessary based on nationally recognized criteria for approval.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bradycardia
Treatment: Pacemaker (leadless pacemaker)
The insurer denied: Pacemaker (leadless pacemaker)
The denial is upheld.

This elderly male was referred for a leadless pacemaker for management of syncope from symptomatic bradycardia. His past medical history includes chronic atrial fibrillation with a slow 
ventricular response, failed atrial fibrillation ablation some years prior, fatigue, poor chronotropic response to exercise, prior Coumadin therapy, cerebral bleed from a mechanical fall, and 
subsequently changed to Eliquis therapy. The patient's cardiologist has recommended the Watchman device, but states that he will not do the procedure unless the pacemaker is a leadless type. The requested coverage has been denied based on the patient's policy and the patient is appealing the decision.

The proposed treatment is not medically necessary.

Based on the current peer-reviewed medical literature, while leadless cardiac pacing holds promise as a long-term permanent cardiac pacing option for patients requiring single ventricle 
(right ventricular [RV] only) pacing and appears both safe and efficacious in the short-term for an individual like this patient, longer-term follow-up is needed to assess the safety and efficacy of these devices. The potential for and incidence of long-term deleterious effects of pacing only the right ventricle (RV) will also need to be assessed. In this particular case, there is not an absence of available alternative therapies, such as submitted clinical documentation of any clinical situation where the traditional transvenous pacemaker was not feasible for this patient, such as unfavorable anatomy, venous occlusion, 
recurrent lead infections, or heightened risk for major systemic infection with an indwelling chronic vascular lead to establish it is medically necessary. While the physician prefers to avoid a transvenous pacemaker system because it may pose risk for successful Watchman implant, a single lead right ventricle pacemaker is not a contraindication. Thus, medical necessity has not been established for this patient and, therefore, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Otezla 30 mg (milligram) tablet. 
The insurer denied Otezla 30 mg tablet. 
The health plan's determination is upheld. 

The patient is a female with rheumatoid arthritis and psoriasis. The patient has tried and failed topical desoximetasone. A letter from the patient's dermatologist reports that the patient is to be treated with Cimzia for her rheumatoid arthritis, and Otezla for her psoriasis. 

Otezla is not medically necessary for this patient. 
The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, and/or Phototherapy. Particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, these preferred agents are as appropriate for the treatment of this patient's clinical scenario as is the requested Otezla. Therefore, Otezla is not medically necessary. 
Modern dermatology literature supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Otezla (including Cimzia used as monotherapy), particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and this literature recommends use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Otezla is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Palpitations.
Treatment:  Inpatient stay.

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

The patient is a male, who presented to the emergency department (ED) with palpitations and chest fluttering. Prior to that, the patient felt cold like symptoms and went to Urgent Care and was prescribed Augmentin. The patient developed palpitations after he took the first dose. The patient also developed jaw pain and redness of the left leg. 

The Inpatient Hospital Admission was not medically necessary for this patient.

The patient presented with the episode of paroxysmal atrial fibrillation and low blood pressure. However, the patient was not in distress, and he was comfortable. The Cardiologist felt that his low blood pressure could have been erroneous due to inaccuracy measuring on large arm. The patient converted back to sinus rhythm shortly after he was admitted and remained in sinus rhythm all the time after that.
The patient had previous episode similar to this seven months ago. The patient had known cardiomyopathy and congestive heart failure (CHF), and there was no cardiac work up done during this admission. His intravenous (IV) Cardizem drip was stopped as soon as he converted back to sinus rhythm. The patient was discharged on his preadmission medications.

Based on the above, the patient's condition and management did not meet criteria for inpatient admission. A lower level of care would have been more appropriate.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Irritable Bowel Syndrome. 
Treatment: Trulance (plecanatide). 
The insurer denied coverage for Trulance (plecanatide). 
The denial is upheld. 

The patient has a history of irritable bowel syndrome (IBS) with irregular bowel habits. The patient was treated with Xifaxan but did not improve. A workup was negative for irritable bowel disease (IBD) and microscopic colitis. The patient subsequently developed constipation and was treated with Miralax. The patient tested positive for pancreatic insufficiency and is taking Creon. The patient's doctor has also recommended Trulance. 

UpToDate has an article titled "Management of chronic constipation in adults." The article discusses pharmacologic therapy. There are several Food and Drug Administration (FDA) approved medications including Linactolide, Plecanatide, Lubiprostone and Prucalopride. Plecanatide has been approved for treatment in patients with chronic idiopathic constipation and irritable bowel syndrome - constipation (IBS-C). The most common side effect was diarrhea. 

This patient has IBS with irregular bowels and more recently constipation. The patient appeared to have had some success with Miralax. A medication history is provided in the doctor's progress notes. The patient, at some point, tried some samples of Linzess and had taken Amitiza from another provider but there is no medical documentation in the current progress notes of the patient's response to these drugs. 

Trulance is a recommended treatment for chronic idiopathic constipation and 
IBS-C. The medical record does not document that she has these conditions. The patient was previously treated with Xifaxan which is a treatment for irritable bowel syndrome - diarrhea (IBS-D). 

The insurance company has offered alternatives for the constipation with Amitiza and Linzess. 

There is not sufficient documentation that the patient has had a reasonable trial and failure with these drugs. It has not been shown that the formulary drugs would cause an adverse reaction or are ineffective based on the submitted documentation. It is not known if the requested drug would be more effective than the formulary drugs. 

The carrier's denial of a request for a Formulary Exception for Trulance (plecanatide) is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Digestive System/ Gastrointestinal
Pharmacy/Prescription Drugs

Diagnosis: Constipation
Treatment: Motegrity 2 mg Tablet

The health plan denied: Motegrity 2 mg Tablet
The determination is: Overturned

The patient is a female with chronic constipation, irritable bowel syndrome, and multiple sclerosis complicated by neurogenic bowel dysfunction, slow transit, and pelvic floor dysfunction. She has had one bowel movement per week, abdominal discomfort, incomplete evacuation, early satiety, and unintentional weight loss. She has failed Dulcolax, Linzess, and Trulance. The coverage is requested for Motegrity 2 milligrams (mg) daily for the treatment of constipation. The formulary alternatives are Linzess and Trulance.
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.
The health plan's determination of medical necessity is overturned in whole.
The request for Motegrity is supported, as the formulary alternatives Trulance and Linzess have already been attempted by the patient in this case and were ineffective. Motegrity is indicated for and is Food and Drug Administration (FDA)-approved for the treatment of constipation [1]. Motegrity has a different mechanism of action than Trulance and Linzess [2]. Guidelines for the treatment of constipation recommend the use of Motegrity regardless of whether Trulance or Linzess have been effective [3]. Multiple high-quality studies have found Motegrity to be safe and effective for the treatment of chronic constipation, and Trulance and Linzess have never proven safer or more effective than Motegrity in a direct comparison [4-10]. As the formulary alternatives have been ineffective, the request for Motegrity is supported in this case.