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

Diagnosis: CAD, COPD, Depression, Glaucoma, DM
Treatment: Increase in Consumers Directed Personal Assistance Program (CDPAP) to 8 hours per day - 7 days per week - for a total of 56 hours per week
The insurer denied the Increase in Consumers Directed Personal Assistance Program (CDPAP) to 8 hours per day - 7 days per week - for a total of 56 hours per week.
The denial is upheld. 

The patient is a female with a history of Coronary Artery Disease (CAD), COPD (chronic obstructive pulmonary disease), Depression, Glaucoma and Diabetes Mellitus (DM). Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). An appeal review was requested for potential approval of 56 hours/week Personal Assistance Services to offer increased ADL support.

No, the Increase in Consumers Directed Personal Assistance Program (CDPAP) to 8 hours per day - 7 days per week - for a total of 56 hours per week is not deemed medically necessary. 

This is a female with a history of Coronary Artery Disease, COPD, Depression, Glaucoma and Diabetes Mellitus. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). However, an in-home assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved plan of 22.5 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. There is no additional documentation that demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment 56 hours/week Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thoracic spine chondrosarcoma metastases
Treatment: Proton Beam Radiation Therapy
The insurer denied Proton Beam Radiation Therapy. The health plan's determination is upheld.

The patient has a history of chondrosarcoma involving his femur. He had a local resection with no adjuvant treatment. He then developed rib metastases with resection only. He now has thoracic spine chondrosarcoma metastases post resection with residual soft tissue disease and a high risk of recurrence. To decrease this risk, radiation therapy is recommended to the thoracic spine with intensity modulated radiation therapy (IMRT) to 41.4 gray (Gy) followed by a boost with proton beam radiation to 23.4 Gy. The proton beam radiation component is under review for medical necessity.

The requested treatment of proton beam radiation therapy is not considered medically necessary for this patient. The recommended proton beam radiation therapy as a boost for this patient and his metastatic chondrosarcoma post resection is not considered medically appropriate or necessary as this disease is metastatic and the minimal studies published in peer reviewed journals looking at proton radiation in the thoracic spine are for non-metastatic patients. There are no data supporting the use of proton radiation, in this clinical setting, where there are improved outcomes of control or survival.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart problems
Treatment: Inpatient stay
Decision:  Upheld 

Summary:
The patient is a female with a past medical history significant for bipolar disorder, physiologic chronic heart murmur. She was transferred from psychiatry for tremor, non-compliance with medical therapy and sinus tachycardia. 

The patient was tachycardic, with evidence of sinus tachycardia on ECG (electrocardiogram). BP (blood pressure) was stable. ECG revealed no ischemic changes. Cardiac enzymes were normal. BNP (brain natriuretic peptide) was not elevated. The patient was admitted to telemetry and treated with IV hydration. Thyroid profile was negative for thyrotoxicosis. Chest X-ray was negative. 2D echo was obtained, revealing normal LV (left ventricle) function, no significant pressure gradient. Patient was evaluated by psychiatry while in the hospital, medical therapy for her psychiatric condition was adjusted and she was placed on 1:1 observation. Her sinus rate improved with hydration and the patient was cleared for transfer back to psychiatry unit.

The patient presented with sinus tachycardia due to dehydration, poor PO (oral) intake in the setting of bipolar disorder. The patient had no evidence of hypotension.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or atrial fibrillation. There was no acute neurological or cardiac event. ECGs revealed sinus mechanism. Echo revealed normal LV function. Her heart rate improved with hydration. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care with subsequent transfer to psychiatry.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease 
Treatment: Zetia (Ezetimibe) 10 mg 

The insurer denied Zetia (Ezetimibe) 10 mg. The determination is overturned. 

This is a patient with coronary artery disease. She had a non-ST segment elevation myocardial infarction. She has had recurrent episodes of acute cholestatic hepatitis with several statins. On ezetimibe, her low density lipoprotein (LDL) cholesterol level was 67 milligrams per deciliter (mg/dl). At issue is the medical necessity of Zetia (Ezetimibe) 10 milligram (mg) tablet. 

Ezetimibe is medically necessary in this instance. This patient has a contraindication to statin therapy. The patient has atherosclerotic cardiovascular disease (ASCVD). Her National Lipid Association recommended goal LDL cholesterol level (LDL-C) is less than 70 mg/dl. On ezetimibe, which decreases LDL-C by approximately 15-20%, her most recent level was 67 mg/dl. Thus, it is likely that, without the ezetimibe, her level would be substantially above goal. Per the American College of Cardiology (ACC) Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk, ezetimibe is an acceptable alternative to statin use in patients with ASCVD who have true statin intolerance or a contraindication to statin therapy. This patient has had recurrent cholestatic hepatitis with statins; this constitutes a contraindication to statins.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia areata (AA)

Treatment: Jakafi

The insurer denied Jakafi.

The denial was overturned.   

The patient has alopecia areata (AA) to scalp, brows and lashes and is requesting the use Jakafi (a JAK inhibitor). She has tried and failed kenalog injections, clobetasol scalp solution, Medrol dose packs, Nizoral shampoo, Olux foam, otezla, and Spectazole topical. 

The patient has tried and failed kenalog injections, clobetasol scalp solution, Medrol dose packs, Nizoral shampoo, Olux foam, otezla, and Spectazole topical. She has been taking Jakafi with improvement. The use of JAK inhibitors has been studied and demonstrated itself to be an acceptable treatment for alopecia areata. This has been supported by a few studies. JAK inhibitors for alopecia areata has become an accepted treatment for the condition with studies to support use. 

Jabbari, et al. noted, "Our open-label studies of ruxolitinib and tofacitinib have shown dramatic clinical responses in moderate to severe AA, providing strong rationale for larger clinical trials using JAK inhibitors in AA." 

Bokhari, et al. stated, "Our findings suggest that topical JAK inhibitors could be developed as a potential new treatment for AA and alternative to clobetasol dipropionate 0.05% ointment." 

Almutari, et al. intcated that "Both tofacitinib and ruxolitinib induced remarkable hair regrowth, with a mean change in SALT score of 93.8  3.25 in the ruxolitinib group and 95.2  2.69 in the tofacitinib group." 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  The prescription Jakafi is considered medically necessary.

Based on the above, the medical necessity for the prescription Jakafi (ruxolitinib) to treat the patient's diagnosis of alopecia areata is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Syncytial Virus, Influenza, Dehydration. 

Treatment: Acute inpatient admission. 

The insurer denied coverage for acute inpatient admission. 

The denial is overturned. 

This patient is a male child who had several days of fever, coughing and post-tussive vomiting. The child had been seen in the Emergency Room (ER) 5 days prior to admission for this illness and was diagnosed with an upper respiratory infection. When the child's fever persisted, and there was poor oral intake and a decrease in urine output, the mother decided to return to the ER for additional treatment. 

In the ER, he was noted to be febrile and appeared to be tired. A physical exam described the child as being fatigued with sunken eyes and having a prolonged capillary refill time of 3 seconds. He was treated with an intravenous (IV) fluid bolus of normal saline. A respiratory viral panel was positive for respiratory syncytial virus (RSV) and influenza. A chest x-ray showed blunting of the left costal angle which was suspicious for a pleural effusion. The child remained febrile and fatigued despite several IV fluid boluses of normal saline. The decision was made to admit him to the hospital to treat dehydration with IV fluids, and influenza with Tamiflu. A blood culture subsequently reported as positive for acinetobacter. 

Documentation in the medical record shows that the child had persistent fever and dehydration related to a 7-day illness with RSV and influenza. His symptoms did not improve with appropriate treatment in the ER. There continued to be evidence of dehydration and ongoing poor oral fluid intake. The decision to admit this child to the hospital for ongoing IV fluid was consistent with the standard of care for treatment of dehydration. After receiving an IV fluid bolus of normal saline, the child could not have been safely discharged home because he remained unable to tolerate oral fluids. 

The insurer has denied this admission, stating that there was no documentation in the medical record to establish the medical necessity of an acute inpatient hospital stay. 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 stay is overturned. The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgical Services. 
The insurer denied vascular embolization. 
The health plan determination is upheld in whole. 

The patient  reported on initial consultation with the vascular surgeon of severe bilateral "groin, buttock, and lower pelvic pain, mild swelling, aching, tenderness and heaviness extending distally," that limited the ability to ambulate and perform  activities of daily living (ADLs). The patient has failed a 3-month trial of conservative therapy including compression stockings, nonsteroidal anti-inflammatory drugs (NSAIDs), weight loss, exercise and leg elevation. The physical examination documents bilateral bulging varicosities of the upper and lower legs. Bilateral leg and pelvic venous duplex demonstrated bilateral lower extremity axial truncal superficial venous reflux in the great saphenous veins and small saphenous veins bilaterally along with pelvic varices. The treating provider concluded that the patient suffers from symptomatic chronic venous hypertension and warrants treatment. The provider stresses in his note that the patient is not suffering from pelvic congestion syndrome.
Treatment begins on the day of initial consultation and the patient then undergoes bilateral multiple pelvic vein embolization procedures using the sclerosant 1.5% Na Tetradecyl of pelvic varices. 

The vascular embolization procedures performed is not likely to be more beneficial that standard treatment for symptomatic venous hypertension.
The patient described in the brief initial consultation note complaining of Clinical-Etiological-Anatomical-Pathophysiological (CEAP) class 3 symptomatic lower extremity venous hypertension that has failed conservative management. Venous duplex demonstrates bilateral axial truncal superficial venous reflux in both the great and small saphenous veins. Standard of care treatment based on the referenced guidelines below is treatment of axial truncal superficial venous reflux first (greater saphenous vein [GSV], small saphenous vein [SSV]). This was not performed.
There is published literature advocating the use of the CHIVA technique which aims to eliminate the venous-venous shunts by disconnecting the escape points, preserving the saphenous vein. The CHIVA literature describes a surgical ligation of the venous-venous shunts (so called leak points). The procedures performed by the patient's provider to treat the pelvic leak points in this patient do not use the standard surgical ligation, but rather use endovascular embolization with sclerosant which is by no means standard of care for the CHIVA technique. 
Regardless, none of the well established guidelines for treatment of bilateral lower extremity symptomatic venous hypertension recommend treatment of the pelvic leak points first as was performed for this patient.
Therefore, this is not likely to be more beneficial to this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgical Services. 
The insurer denied vascular embolization. 
The health plan determination is overturned in whole. 

The patient  presents with groin, buttock and lower pelvic pain, aching, tenderness and heaviness. The patient has bilateral symptoms as well as irritation, burning and fatigue. The patient works as a nurse and  symptoms interfere with activities of daily living. The patient has attempted other conservative measures including compression stockings, leg elevation and exercise. A duplex scan demonstrates multiple refluxing venous malformations in the pelvis. The provider is recommending pelvic vein embolization for treatment of her condition.

Pelvic vein embolization is likely to be more beneficial than any other treatment or treatments for the patient's disabling condition (symptomatic venous malformation of incompetent pelvic veins).
This patient is a good candidate for venogram and treatment of refluxing pelvic malformations and refluxing pelvic veins as listed below. This treatment is supported by the peer reviewed literature and is consistent with the current standard of care in the vascular surgery community. The patient presents with symptomatic pelvic pain, aching, heaviness and burning. Her presenting symptoms are likely caused by the refluxing pelvic veins identified on ultrasound.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Surgical Services. 
The insurer denied vascular embolization. 
The health determination is overturned.

The patient was evaluated by a vascular surgeon . The patient presented with groin, buttock, lower pelvic pain and mild swelling. On exam,  was noted to have bilateral bulging atypical (high anterior, medial, and posterior) varicosities above knee (AK) and below knee (BK) and bilateral multiple spider veins.

Venous Duplex ultrasound revealed multiple bilateral varices/venous ectasias/venous malformations and severe chronic venous hypertension and demonstrated the extent of venous congestions from the pelvis extending distally bilaterally. There was no evidence of deep vein thrombosis (DVT). The above is consistent with severe pelvic derived venous disease. The patient was diagnosed with severe pelvic derived venous disease/chronic venous hypertension and congestion with inflammation.

The treating provider recommended treatment of pelvic varices/venous ectasias/venous malformations (leak points) with vascular occlusion or embolization. The patient underwent treatments.

The treatment is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The patient has symptomatic lower extremity varicose veins, pelvic vein incompetence and symptomatic pelvic varicose veins. The patient has lower extremity venous insufficiency arising from her pelvic veins and pelvic varicose veins.

Treatment of pelvic venous insufficiency and pelvic varicose veins with sclerotherapy and/or embolization is the treatment of choice in women with pelvic venous insufficiency and pelvic varicose veins.

This treatment has been shown to be efficacious in women with symptomatic lower extremity varicose veins and pelvic venous insufficiency and pelvic varicose veins, and has become the standard of care in the treatment of this condition.

Vascular embolization and sclerotherapy of pelvic varicose veins are proven treatments of pelvic derived lower extremity venous disease. Patients with pelvic derived lower extremity venous disease benefit from this treatment. This patient has benefited from the treatment.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes with hyperglycemia. 
Treatment: Formulary exception for Janumet. 

The insurer denied the Formulary exception for Janumet. The denial is upheld. 

No, the health plan should not cover the Formulary exception for Janumet (sitagliptin-metformin). 

The patient is a male diagnosed with T2DM (type II diabetes mellitus). This request is for Janumet (sitagliptin-metformin). 

As reported, the patient's A1C (glycated hemoglobin) and glucose both decreased on Janumet and increased on Jardiance and glyburide. He has already had a left amputation and has worsening Charcot ankle on the right. He has CAD (coronary artery disease), HLD (hyperlipidemia), and HTN (hypertension). He tried Januvia; Lantus; and metformin 1000 mg. He has diabetic neuropathy. 

The DPP IV (Dipeptidyl Peptidase-4) Inhibitors have similar efficacy. There are no trials showing superiority of one DPP IV inhibitor over another including linagliptin (Tradjenta), saxagliptin (Onglyza), vildagliptin (Galvus), alogliptin (Nesina) or sitagliptin (Januvia) [1-4]. The American Association of Clinical Endocrinologists consensus statement regarding treatment of patients with type two diabetes is as follows [5, 6]: It recommends the use of metformin followed by the use of a DPP4 inhibitor or a GLP1 (glucagon-like peptide-one) agonist. 

The formulary alternatives that are proposed by the health plan are Jentadueto and Jentadueto XR. There are no studies showing superiority of the requested medication over the formulary alternatives. The formulary alternatives are in the same class as the requested medication and are interchangeable. The patient can try the formulary alternatives, which are expected to be as effective as the requested medication. Therefore, the health plan should not cover the formulary exception for Janumet (sitagliptin-metformin), as it is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hyperlipidemia, hypertension and hypothyroidism. 
Treatment:  Repatha.

The insurer denied the Repatha.  The denial is upheld. 

No, the proposed treatment with Repatha is not medically necessary.

The patient is a female with history of hyperlipidemia, hypertension and hypothyroidism. The patient has a family history of premature coronary artery disease (CAD).  The patient was previously intolerant to Lipitor and Zetia due to myalgia.  The most recent pre-treatment low density lipoprotein (LDL)-C level was 111 mg/dL.  The patient was given Repatha samples and LDL-C decreased to 63 mg/dL.  Her prior cardiac work-up included a nuclear stress test which revealed no evidence of ischemia, and an echocardiogram which revealed normal left ventricular (LV) function.  There is no history of heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD).

Repatha is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low density lipoprotein cholesterol (LDL-C).  Currently, it does not have an FDA indication for treatment of mixed hyperlipidemia in patients without clinical atherosclerotic cardiovascular disease (CVD).  This patient had no history of myocardial infarction, acute coronary syndrome, stable or unstable angina, cerebral vascular accident (CVA) or transient ischemic attack (TIA), peripheral or coronary revascularization, or evidence of CAD by catheterization or coronary computed tomography (CT) and thus does not meet the criteria for clinical atherosclerotic cardiovascular disease. As per attached records, the patient had adverse reaction to atorvastatin and Zetia.  There is no history of therapeutic failure of rosuvastatin or pitavastatin.  There is not sufficient medical or scientific evidence to determine the benefit in patients such as this one, as the medication has not been studied in this population.  The effect of Repatha on cardiovascular morbidity and mortality in such patients has not been determined.  Therefore, the medical necessity of using Repatha in this clinical scenario is not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ezcema
Treatment: Dupixent (dupilumab) 300mg/2ml sc sosy 
The insurer denied the Dupixent (dupilumab) 300mg/2ml sc sosy.
The denial is overturned. 

Yes, the treatment with Dupixent is medically necessary.

The patient is a woman. She has more than 80% BSA (body surface area) affected by eczema. She has tried and failed gabapentin, fexofenadine, hydroxyzine, triamcinolone, tacrolimus, crisaborole, halobetasol, betamethasone and hydrocortisone, with no improvement. She has widespread disease, which is interfering with her quality of life.

The patient has severe atopic dermatitis affecting multiple areas of the body. She is a candidate for systemic therapy, as the BSA is too large for reasonable control with topical medications. Topical calcineurin inhibitors (tacrolimus), topical crisaborole (Eucrisa) and topical steroids have failed and are not appropriate therapy for severe, widespread atopic dermatitis, affecting sensitive areas, which should be treated with systemic therapy. 

Given its unprecedented efficacy, dupilumab is emerging as a first-line therapeutic for moderate-to-severe AD (atopic dermititis). The patient has failed topical steroids, calcineurin inhibitors, and systemic steroids. Additionally, topical calcineurin inhibitors are not indicated for severe disease.

Phototherapy is not appropriate for sensitive areas and impossible to obtain during the COVID-19 pandemic. Cyclosporine, azathioprine, methotrexate, mycophenolate mofetil are not FDA approved for use in atopic dermatitis (Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is. The patient is not a candidate for conventional systemic therapy (methotrexate, azathioprine, mycophenolate), due to her gender and childbearing age. Systemic steroids and cyclosporine are not a reasonable long-term treatment for moderate to severe atopic dermatitis, due to their severe side effect profile.

Therefore, given the above, Dupixent is medically necessary.