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

Diagnosis: Digestive System / Gastrointestinal / Abdominal / Stomach Pain. 
Treatment: Inpatient Hospital. 

The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld. 

This patient is a female without a significant past medical history who presented to the emergency room (ER) with one month of abdominal pain. The pain was associated with nausea and vomiting. Vital signs were all within normal limits. A white blood cell count (WBC) was normal. An abdominal ultrasound revealed cholelithiasis. A computed tomography (CT) scan revealed gallbladder wall thickening with a small amount of pericholecystic fluid. A hepatobiliary iminodiacetic acid (HIDA) scan revealed findings consistent with acute cholecystitis. The patient was made nothing by mouth (NPO) and was started on intravenous (IV) antibiotics and IV pain medications. The patient was given an oral trial and found to have an improvement of pain and plans were discussed for an interval cholecystectomy and she was discharged home with oral antibiotics. 
At issue is the medical necessity of the inpatient stay. 

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

No. The patient was evaluated for abdominal pain of 1 month duration. Vital signs and labs were normal. A thorough work-up revealed possible acute vs. chronic cholecystitis. The patient was given a dose of IV antibiotics and was offered a trial for oral, which was tolerated. The patient was discharged home with oral antibiotics and plans were made for an interval cholecystectomy. A decision to proceed with surgery was not made. The patient was discharged within a 23-hour observation period. Acute inpatient admission is not supported by the medical records.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This female reportedly was admitted to inpatient substance detoxification treatment for detoxification. She reportedly had alcohol withdrawal symptoms including tremors, irritable mood, anxiety, and sleeping problems, and had a reported CIWA (clinical institute withdrawal assessment) of 8. She reportedly was drinking 1-2 pints of liquor per day, smoking $20 of crack/cocaine daily, and $20 per day of cannabis. She reportedly had an alcohol, cannabis and cocaine history. She reportedly was using her public assistance money to obtain alcohol and substances. She had multiple inpatient detoxification treatments with at least 8 past reported treatments. She reportedly left AMA (against medical advice) from an inpatient alcohol/substance treatment. She had comorbid bipolar disorder. She reportedly was put on a 3-day Librium protocol and seizure precautions. She reportedly left and stated that she would return for inpatient rehab. in the future. 

According to the LOCADTR (Level of Care for Alcohol and Drug Treatment) she did require 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use large amounts of alcohol, crack/cocaine, cannabis, and she required detoxification medication including being placed on a Librium protocol. She reportedly continued to use daily and put herself at risk of severe, complicated, and life-threatening withdrawal, and could not stop alcohol and substance use despite multiple inpatient detoxification treatments. The risk of delirium tremens can occur 3-4 days after alcohol use so she was considered at risk for this. She also was at risk medical issues due to large amounts of crack/cocaine and alcohol use daily. She also had comorbid bipolar disorder which put her more at risk. She did require 24-hour medical hospital detoxification treatment and it was considered unsafe for her to have detoxification at a less restrictive level of care as she was considered a high medical risk. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient hospital treatment for detoxification. It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient then. 

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Stay. 

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

The patient is a woman who presented with abdominal pain. She had been previously seen in the emergency department (ED) for this condition also. At the time of this presentation, the patient was without fever and vital signs were normal. She was tender in the right upper abdomen. The white blood cell (WBC) count was normal at 10.9. The complete metabolic panel was without findings of biliary obstruction. Diagnostic evaluation identified gallstones and a 4- millimeter (mm) thick gallbladder wall. 
She was admitted to the hospital and initially treated with intravenous (IV) fluid and antiemetics. 

An inpatient level of care was not medically necessary in this case. This patient is a woman who presented to the hospital with abdominal pain and nausea. She was determined to have cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. The indication for cholecystectomy was established and surgery was performed. 

Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered at a lower level. A lower level of care would have provided for ED assessment, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care. This lower level of care would have satisfied the clinical needs of this patient and would have been consistent with the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer.
Treatment:  Genetic Testing.
The insurer denied the  Genetic Testing.
The denial is upheld.

The patient is a female. The patient in this case was diagnosed with lung adenocarcinoma based on pleural biopsy.  Guardant 360 testing was ordered.

No, the requested Genetic Testing is not medically necessary.

Guardant 360 is a next generation sequencing assay that is done to look for genomic alterations in circulating cell free DNA (deoxyribonucleic acid). This test includes many different genes. It is done to try to find potentially effective treatment options. There is currently no evidence based on the results of any prospective clinical trial that has shown use of broad molecular profiling can improve overall health outcomes. This test is not recommended as a standard test known to improve overall health outcomes by NCCN (National Comprehensive Cancer Network) guidelines. Therefore, this test has not been shown to improve overall health outcomes and it is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Beta-thalassemia

Treatment: Deferasirox

The insurer denied coverage for Deferasirox

The denial is overturned

The patient is a male with a history of beta-thalassemia that has been treated with Deferasirox. The patient's ferritin level was 1319.20 nanograms per milliliter (ng/ml). The patient's Hematologist recommended keeping ferritin levels below 1500 and continuing Deferasirox to prevent an increase in ferritin. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient has a history of beta-thalassemia that has been treated with Deferasirox which should be a continuous therapy. He has been stable while taking the requested medication for multiple years and discontinuation would cause harm to the patient with an increase in his ferritin level and hemolytic anemia.     

Deferasirox is used to remove excess iron from the body in patients who have had too many blood transfusions and in patients with non-transfusion-dependent thalassemia syndromes. Deferasirox is an iron chelator (binder) and it combines with iron in the blood. Clinical trials have studied as long as five years of continuous administration of this drug. Continued therapy is necessary to prevent a rise in ferritin levels and organ damage, and the benefit of it outweigh the possible toxicity.

"Conclusion: Long-term treatment with deferasirox is effective and safe in patients with transfusion-dependent haemoglobinopathies monitored in the clinical practice setting." 
(Fragomeno, et al., 2015). 

"Deferasirox is an oral iron chelating agent used to treat chronic iron overload." (LiverTox 2017). 

"Beta-thalassemia is an inherited disease with a wide phenotypic severity of the disease. Manifestations of the disease occur in the form of chronic anemia as well as significant pathology associated with bone marrow expansion and extramedullary hematopoiesis." (Needs T, et al., 2022). 

"Deferasirox is a once-daily, oral iron chelator that has been shown to efficaciously reduce iron burden with a clinically manageable safety profile in patients with -thalassaemia and other transfusion-dependent anaemias." (Vichinsky, E., et al., 2011).     

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

The insurer's denial of coverage for Deferasirox is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Mood disorder
Treatment: Formulary exception for Fanapt
The insurer denied the Formulary exception for Fanapt
The denial is upheld.

The patient is a adolescent male. He is diagnosed with mood disorder of the depressed type with associated symptoms of anxiety. He was prescribed Fanapt (iloperidone). He had failed to respond to Latuda and to Vraylar with lack of effect and/or adverse effects. There is a comorbid condition in this case, intermittent explosive disorder. The patient is prescribed Intuniv at a dose of 4 mg (miligrams) daily. There are no reported symptoms of mania, thought disorder, psychosis, or severe cognitive impairment. There is no substance use disorder in this case.

The health plan has denied coverage for Fanapt on the basis of plan guidelines and criteria indicating that three formulary alternatives must be tried and fail before a coverage exception would be allowed. Suggested formulary alternatives include aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone, as well as Latuda and Vraylar.

The prescribing clinician appeals the denial of coverage of Fanapt indicating that all suggested formulary alternatives are not appropriate, as noted in the prior authorization questionnaire. Progress note including the most recent visit with plan for the use of Fanapt is provided and submitted in support of the appeal and outlining the patient's treatment with treatment failure two formulary alternatives (Vraylar and Latuda) and with lack of response or with adverse effects.

No, the health plan should not cover the Formulary exception for Fanapt.
Formulary alternatives are available, including several known to benefit patients with mood disorder of the depressed type or unspecified mood disorder, as in this case. Moreover, Fanapt is indicated for the treatment of schizophrenia, and use in treatment of a mood disorder is considered off label or unproven. The health plan's formulary alternatives are just as likely or more likely to address the patient's mood disorder and would not be more likely to be ineffective for this patient, and would be as effective as the requested non-formulary drug. Formulary alternatives would be no more likely to pose a risk for adverse effects for this patient with the exception of clozapine, which is a second-line treatment option. This answer is in keeping with NY (New York) State instruction for this mandatory review, and is consistent with the published guidelines and scientific literature.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Type 2 Diabetes Mellitus, hypertension, memory loss, cervical/lumbar radiculopathy, osteoarthritis, urinary incontinence

Treatment: Increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 (hrs)hours per week.

The insurer denied coverage for an increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 hours per week

The denial is modified

This patient is a female with multiple medical problems including diabetic neuropathy, atrial fibrillation and hypertension. The insurer approved a PCW increase from 7 hours/day (49 hours/week) to 8 hours/day (56 hours/week). Under review is the request for an increase in PCW services to 12 hours/day (84 hours/week). 
 
According to the Uniform Assessment System (UAS) report, the patient is modified independent with making decisions and has appropriate short-term memory that has not changed over the prior 90 days. She can direct her own care and activate a personal emergency response system in case of an emergency. However, her functional status has declined; particularly with activities of daily living (ADL). She requires extensive to maximal assistance for bathing personal hygiene and dressing. She requires limited assistance for toilet transfer and extensive assistance for toilet use. She is frequently incontinent of bladder and infrequently of bowel. She has vision and hearing deficits that also continue to decline. The PCW hours were increased to 7 days per week, 8 hours per day: 56 hours per week.  However, increasing PCW to 10 hours/day (70 hours/week) is a more reasonable clinical decision in order to allow the patient to continue living safely at home.   
 
The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 
 
The insurer's denial of coverage for an increase in Personal Care Worker services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 hours per week is modified. Medical Necessity is substantiated for 10hrs/day (70 hrs/week).
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Type 2 Diabetes Mellitus, hypertension, memory loss, cervical/lumbar radiculopathy, osteoarthritis, urinary incontinence

Treatment: Increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 hours per week.

The insurer denied coverage for an increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 hours per week

The denial is modified

This patient is a female with multiple medical problems including diabetic neuropathy, atrial fibrillation and hypertension. The insurer approved a PCW increase from 7 hours/day (49 hours/week) to 8 hours/day (56 hours/week). Under review is the request for an increase in PCW services to 12 hours/day (84 hours/week). 
 
According to the Uniform Assessment System (UAS) report, the patient is modified independent with making decisions and has appropriate short-term memory that has not changed over the prior 90 days. She can direct her own care and activate a personal emergency response system in case of an emergency. However, her functional status has declined; particularly with activities of daily living (ADL). She requires extensive to maximal assistance for bathing personal hygiene and dressing. She requires limited assistance for toilet transfer and extensive assistance for toilet use. She is frequently incontinent of bladder and infrequently of bowel. She has vision and hearing deficits that also continue to decline. The PCW hours were increased to 7 days per week, 8 hours per day: 56 hours per week.  However, increasing PCW to 10 hours/day (70 hours/week) is a more reasonable clinical decision in order to allow Ms. Bortnovskaya to continue living safely at home.   
 
The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 
 
The insurer's denial of coverage for an increase in Personal Care Worker services from 7 days per week, 7 hours per day, 49 hours per week to 12 hours per day, 84 hours per week is modified. Medical Necessity is substantiated for 10hrs/day (70 hrs/week).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Skyrizi. 
The insurer denied Skyrizi. 
The denial is upheld. 

The patient is a male with a diagnosis of psoriasis. His scalp and back are affected. He has tried and failed triamcinolone, clobetasol, betamethasone, and ketoconazole shampoo. His provider has recommended Skyrizi.
At issue is the medical necessity of Skyrizi.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Skyrizi is not medically necessary for this patient.
Based on the evidence-based literature, Skyrizi is not medically necessary. There is no comparative, controlled studies showing that Skyrizi has a superior efficacy and safety profile to  conventional alternatives such as methotrexate. Skyrizi is not considered medically necessary based on the current peer-reviewed literature.
According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines such as methotrexate, are effective treatments for the management of psoriasis. (1, 2) Within the peer-reviewed literature, West et al 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. It was 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 Psoriasis Area and Severity Index (PASI 75) at primary endpoint. Thus, methotrexate is an effective first-line treatment for the management of psoriasis. (3)
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided the request for Skyrizi is not necessary. It is noted that the patient has failed clobetasol. However, there is no documentation provided that the patient has tried and/or failed methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Skyrizi medically more appropriate than the other options. The liver test results showed a normal alkaline phosphatase and normal alanine aminotransferase. The administration of Skyrizi is not strongly supported for this patient, and Skyrizi is not medically necessary for this patient based on the current evidence-based medical literature.
Therefore, the requested health service/ treatment of Skyrizi is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent 200 milligrams per 2 milliliters (200 mg/2 ml) subcutaneous (SC) solution prefilled syringe (SOSY).

The insurer denied coverage for Dupixent 200 mg/2 ml SC SOSY.
The denial is overturned.

This is a female with a diagnosis of severe atopic dermatitis. The patient has continued to flare despite every (Q) 2-week Dupixent therapy. The request is for weekly Dupixent dosing to improve efficacy.  

Based on the current peer-reviewed literature, Dupixent weekly is medically necessary. The patient has tried and failed biweekly Dupixent. In 2019, Thibodeaux et al published "A review of dupilumab in the treatment of atopic diseases" in which they demonstrated that weekly dosing of Dupixent had significant efficacy. (1) Beck et al also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to 3 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis". (2) Therefore, it is appropriate, based on the patient's clinical findings and refractory disease, to approve weekly Dupixent in this patient.

The unique clinical circumstances to this particular individual that would make it medically necessary is that the patient is not currently controlled with biweekly Dupixent. Chronic use of oral steroids has detrimental side effects. Therefore, weekly Dupixent is warranted in this case.  

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

The insurer's denial of coverage for Dupixent 200 milligrams per 2 milliliters (200 mg/2 ml) subcutaneous (SC) solution prefilled syringe (SOSY) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion; Crowding.
Treatment: (D8080) Orthodontic Treatment and Monthly Visits.
The insurer denied the (D8080) Orthodontic Treatment and Monthly Visits.
The denial is overturned.

The patient is a male. The patient has Class III skeletal malocclusion and has mild upper and lower crowding. The health plan's reason for prior denial of the requested orthodontic treatment was the handicapping index score was only 11, which is below the 26 threshold.

Yes, the orthodontic treatment and monthly visits are medically necessary.
The patient has an anterior crossbite between teeth # (numbers)s 10 and 22 with gingival attachment loss. This is an "automatic qualifier' according to the Salzmann index.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cough, fever
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy who presented with a worsening cough. He was well until 3 days prior to presentation when he developed a cough. He then developed fever to 100.7. His cough worsened and he also had upper respiratory symptoms and an episode of emesis. Due to worsening of his symptoms, he was initially brought to an outside hospital where he was diagnosed with a viral upper respiratory illness and was sent home with ibuprofen and acetaminophen. However, his symptoms continued to worsen, so he returned to the emergency department the following morning.

The Inpatient Hospital Admission was medically necessary for this patient.
Indications for hospitalizing children with bronchiolitis include toxic appearance and hypoxemia. This patient was ill appearing at the time of presentation and had oxygen saturations in the 80s. He required supplemental oxygen in an inpatient setting as well as monitoring for potential complications including dehydration and respiratory failure.
 
This is a very young boy who presented with bronchiolitis and hypoxemia. He was ill appearing at the time of presentation and had an oxygen saturation down to the mid-80s. He was seen twice in the emergency department and his symptoms continued to worsen. He required prompt initiation of treatment with ongoing care in an inpatient setting, including supplemental oxygen, saline nebulized treatments, suctioning, and monitoring.