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

Diagnosis: Digestive Syndrome/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Motegrity. The health plan's denial is upheld. 

The patient is a female who has previously tried laxatives, stool softeners and Linzess and Trulance. She has responded to Motegrity. Therefore, the attending provider would like to continue to use Motegrity to treat her chronic idiopathic constipation. The health plan's determination is upheld. 

The formulary drug lubiprostone (generic amitiza) has not been tried by this patient and has been shown in numerous studies to be efficacious in treating chronic idiopathic constipation. This patient has tried and failed Linzess. Constipation is a common symptom that may be primary (idiopathic or functional) or associated with a number of disorders or medications. There is strong evidence that stimulant and osmotic laxatives, intestinal secretagogues, and peripherally restricted Mu-opiate antagonists are effective and safe; the latter most drugs are a major advance for managing opioid-induced constipation. Chronic functional constipation and irritable bowel syndrome with constipation are common digestive disorders that negatively impact quality of life. Related to the heterogeneity of pathogenesis that underlie these disorders and the failure of symptoms to reliably predict underlying pathophysiology, traditional therapies provide relief to only a subset of affected individuals. The Rome III classification system treats functional constipation (FC) and irritable bowel syndrome-constipation (IBS-C) as distinct disorders, the primary distinction involving the presence of abdominal pain as a primary complaint in IBS-C but not in FC.  Based on the clinical data provided it is reasonable to try lubiprostone (Amitiza).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left nostril abscess and facial cellulitis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

This is a patient with a past history of a left nostril abscess. He presented to the emergency room with a recurrence of a left nostril abscess and facial cellulitis after non-response to outpatient treatment with amoxicillin. He had purulent yellow discharge from the left nostril. The exam details a non-obstructing abscess on the nasal septum with crusted discharge. Inflammatory markers C-Reactive Protein (72) and WBC (white blood cells) (17.9) were markedly elevated. 

Note that "Facial infections are implicated in septic cavernous sinus thrombosis, especially those that involve the so-called danger zone (medial third of the face [i.e., the areas around the nose]) that drains into the ophthalmic veins. Nasal furuncles are the most common facial infection to produce this complication, particularly if the furuncle is squeezed or drained in the absence of antibiotic coverage." [Reference 2].
The patient had a nasal furuncle, with facial cellulitis. The pathogenesis of cavernous sinus thrombotic infection is that the cavernous sinus receives blood from the facial veins and the ophthalmic veins. Consequently, there is a risk of loss of vision, as well as involvement of a number of cranial nerves located within the Dural sleeve lateral to the cavernous sinus: oculomotor nerve, trochlear nerve, and ophthalmic (V1) and maxillary branches (V2) of the trigeminal nerve, and the abducens nerve more medially within the cavernous sinus and which adjoins internal carotid artery. 

The reasons it was imperative to treat with an intravenous antibiotic regimen: 

-The infection was in the danger zone to the face (Reference 2, see section on Septic Cavernous Sinus Thrombosis 
-There was worsening on oral antibiotic prescribed 2 days prior, moreover amoxicillin was an inappropriate choice given that the etiology was most likely Staph. aureus and all staphylococci are resistant to penicillin. 
-The furuncle had been self-drained by the patient, which increases the risk of venous spread (Reference 2) 
-Intravenous (IV) antibiotics should be instituted emergently and directed at the probable organisms causing this type of infection. (Reference 2, Treatment recommendations) 

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

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

Diagnosis: Alzheimer's dementia, insomnia, osteoarthritis of multiple joints, type 2 diabetes mellitus, diabetic neuropathy, hypertension. 

Treatment: Consumer Directed Personal Assistance Services (CDPAS) of 56 hours per weekday and 56 hours per weeknight for a total of 112 hours per week. 

The insurer denied coverage for Consumer Directed Personal Assistance Services of 56 hours per weekday and 56 hours per weeknight for a total of 112 hours per week. 

The denial is overturned. 

This patient has Alzheimer's dementia, diabetic neuropathy and hypertension.  She recently fell that include sustaining multiple rib and pelvic fractures and was hospitalized.  Under review is a requested increase for Consumer Directed Personal Assistance Services (CPAS) of 56 hours per weekday and 56 hours per weeknight for a total of 112 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient requires extensive to maximal assistance for activities of daily living including bathing, personal hygiene, dressing and toilet transfers/use.  She is occasionally incontinent of bladder and continent of bowel.  The clinical records confirm her significant cognitive deficits, consistent with Alzheimer's dementia.  The multiple fractures and associated pain have also contributed to her continued functional decline.  The combination of the patient's significant cognitive and functional impairments support the requested Consumer Directed Personal Assistance Services of 56 hours per weekday and 56 hours per weeknight for a total of 112 hours per week, as medically necessary.  The increased CPAS will allow her to continue living safely at home.  

The healthcare did not plan acted reasonably, with sound medical judgment or in the best interest of the patient. 

The insurer's denial of coverage for Consumer Directed Personal Assistance Services of 56 hours per weekday and 56 hours per weeknight for a total of 112 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary heart disease, heart failure, dementia, hypertension, hyperlipidemia (HLD)

Treatment: PCA (personal care assistant) services for 24 hours a day, 7 days a week (split shift) per week

The insurer denied coverage for PCA services for 24 hours a day, 7 days a week (split shift) per week

The denial is overturned.

This elderly female has multiple medical conditions, including recent right hip fracture.  As per UAS (Uniform Assessment System), patient has substantial functional impairment and needs assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient has been receiving Personal Care Assistant (PCA) services 56 hours per week. She also receives informal support from family. After the patient returned home from the hospital s/p (status/post) hip fracture and open reduction internal fixation (ORIF), the patient's grandson requested increase of PCA services to 24 hours per day, 7 days per week split shift, which was denied; but the insurer approved PCA 24-hour live-in services. The insurer's final denial letter reported that the grandson (as patient designee) refused live-in services, and PCA services continue with 56 hours per week. An external appeal was requested. 

Functional decline in older people is often the result of cumulative effects of multiple medical conditions affecting physical and/or cognitive function. Other contributing factors include economic and social circumstances, e.g., caregiver support. Functional decline is often accelerated by an acute change in medical status. The patient has several chronic medical conditions which progressively have contributed to functional impairment; and recently exacerbated by an acute event (hip fracture and surgery). 

MLTC (Managed Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all the patient's care needs throughout the day and night must be considered in the determination of the patient's personal care service hours.

Considering the patient's medical history and recent acute event (hip fracture/surgery) associated with significant decline in cognitive and physical function and substantial dependence on caregivers for all daily activities, the prudent course of action at this time is to implement a plan that can address all the patient's personal care needs throughout the day and night. The patient is probably still experiencing effects from her hip fracture, including impaired mobility, pain, cognitive decline, and it is not known whether there will be full return to the patient's previous level of physical and cognitive function. If the patient's condition improves, services can be modified. 

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 personal care assistant (PCA) services for 24 hours a day, 7 days a week (split shift) per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angioedema
Treatment: Xolair (J2357)
The insurer denied the Xolair (J2357)
The denial is upheld

The patient is a female with a history of myeloma and severe refractory idiopathic angioedema. Symptoms include severe facial angioedema. Her initial symptoms began seven years ago and have increased in frequency and intensity. She has failed antihistamines at maximum dosing, steroids, Singulair, and epinephrine. She has also trialed and failed Takhzyro. Danazol was initially helpful but later did not help. It was also noted that the patient had several episodes of tongue swelling that all improved with icatibant use.

No, the proposed treatment with Xolair is not medically necessary.
The patient does not have a diagnosis that meets the Food and Drug Administration (FDA)-approved indication for the use of Xolair. The patient has had no response to high-dose H1 (histamine 1) antihistamines, suggesting against histaminergic angioedema. It is unclear whether Xolair will help. The patient has responded well to icatibant, raising questions about whether she has acquired angioedema, especially given her myeloma (as the treating physician pointed out). The use of Xolair in idiopathic angioedema is not supported by robust studies.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The patient does not have a diagnosis that meets the Food and Drug Administration (FDA)-approved indication for the use of Xolair.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angina
Treatment: Inpatient admission

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. His PMH (past medical history) is pertinent for HTN (hypertension), DM (diabetes mellitus), HLP (hyperlipidemia) and smoking. He presented for elective, staged PCI (percutaneous coronary intervention) to the circumflex (Cx). He was being evaluated for effort angina. He had an abnormal NST (non-stress test) showing inferior ischemia and EF (ejection fraction) 51%. Cardiac catheterization done showed CTO (coronary total occlusion) Cx (circumflex) and collaterals from the RCA (right coronary artery).

The patient was brought back and underwent successful PCI (percutaneous coronary intervention) with stent to the Cx (circumflex) on the same day. There were no procedural complications and he was discharged to home the next day. This is an appeal of the denied claim of the requested Acute Inpatient Hospital Stay was medically necessary for this patient.

No, the Inpatient admission was not medically necessary.
Based on the current published medical guidelines, the Inpatient Hospital Admission  was not medically necessary. In this particular case, the patient underwent elective, successful and uncomplicated cardiac catheterization with coronary angiography and PCI (percutaneous coronary intervention) on the same day. The information provided does not support the medical necessity for admission after his coronary intervention. This procedure is routinely performed in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like AMI (acute myocardial infarction), contrast nephropathy, acutely decompensated CHF (congestive heart failure), life-threatening cardiac arrhythmia, procedural complications, or other medical instability or acute care needs that would require acute inpatient management. Since hospitalization for patient, physician or hospital convenience does not establish medical necessity, this reviewer agrees with upholding the denial for care in the acute setting when the same care can be provided in a lesser intense setting. Therefore, the inpatient admission was not medically necessary, based on the submitted information and the current standard of medical care.

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: Menorrhagia and pelvic pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a woman with a history of menorrhagia and pelvic pain. She was admitted to the hospital for an abdominal myomectomy. The procedure was performed without complications. The patient was transferred to the PACU (post anesthesia care unit), where she recovered uneventfully. She was transferred to the inpatient service where she recovered without incident. The patient was discharged.

Yes, the Inpatient admission was medically necessary.
The medical records and medical literature were thoroughly reviewed. The patient underwent an exploratory laparotomy. Exploratory laparotomy is not an ambulatory procedure. The postoperative care of patients who have undergone laparotomy includes inpatient observation for postoperative complications including intra-abdominal hemorrhage, postoperative pelvic infection and progression to normal bowel function. The patient underwent an uncomplicated laparotomy procedure. The patient was tolerating liquids and was transitioned to oral pain medications by the end of the first postoperative day. Her vital signs were normal and she was afebrile throughout the inpatient admission. She was normally voiding and ambulating at the end of the first postoperative day. Her bowel function was normal by postoperative day 2. The patient required inpatient admission per the standard of care. Therefore the inpatient admission was medically necessary.

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: Hypoglycemia.
Treatment: Genetic testing.
The insurer denied Whole Exome Sequencing (WES). 
The health plan's determination is overturned. 

The patient is a female with the diagnosis Hypoglycemia, Hyperinsulinemia, Metabolic Disorder, Bilateral Adrenal Adenomas. Her provider Whole Exome Sequencing. This was denied by the health plan and is the subject of this review.

The requested Whole Exome Sequencing (WES) would be medically necessary for this patient. Etiology of the patient's multiple medical problems has not been established. Due to complexity of her history, genetic etiology is likely. Finding genetic mutation that could explain her hypoglycemia, hyperinsulinemia, metabolic disorder and bilateral adrenal adenomas would be crucial for the patient's management, prognosis and recurrence risks. For instance, finding a mutation if one of the genes predisposing for hypoglycemia may actually change therapy to decrease the frequency of hypoglycemic episodes which was not possible before. Furthermore, several areas of possible health concerns may not be addressed if the patient's doctors don't know where to look (in case if other organ systems are involved) and therefore potentially life-threatening complications may not be prevented.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Osteoarthritis of the Knees

Treatment: Vimovo (naproxen-esomeprazole)

The insurer denied coverage for Vimovo (naproxen-esomeprazole).

The denial is upheld.

The patient has a history of knees osteoarthritis and has failed Motrin and meloxicam. The treating provider prescribed Vimovo, which is the topic of this review.

Formulary alternatives are celecoxib, diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam tablet, nabumetone, naproxen, oxaprozin or sulindac with lansoprazole delayed release, omeprazole delayed release, pantoprazole delayed release, or Dexilant.

There is no evidence in the records that the patient can have or had an adverse reaction to the alternatives.      

The patient failed Motrin and meloxicam per the records submitted.     

There is no data showing that the drug requested is more effective than the formulary drugs. Therefore, the request for Vimovo (naproxen-esomeprazole) is not medically necessary.

According to da Costa, B. R., et al, "We identified 8973 manuscripts from our search, of which 76 randomised trials with a total of 58,451 patients were included in this analysis. 23 nodes concerning seven different NSAIDs (Non-steroidal anti-inflammatory drugs) or paracetamol with specific daily dose of administration or placebo were considered. All preparations, irrespective of dose, improved point estimates of pain symptoms when compared with placebo. For six interventions (diclofenac 150 mg (milligrams)/day, etoricoxib 30 mg/day, 60 mg/day, and 90 mg/day, and rofecoxib 25 mg/day and 50 mg/day), the probability that the difference to placebo is at or below a prespecified minimum clinically important effect for pain reduction (effect size [ES] -037) was at least 95% (percent). Among maximally approved daily doses, diclofenac 150 mg/day (ES -057, 95% credibility interval [CrI] -069 to -045) and etoricoxib 60 mg/day (ES -058, -074 to -043) had the highest probability to be the best intervention, both with 100% probability to reach the minimum clinically important difference. Treatment effects increased as drug dose increased, but corresponding tests for a linear dose effect were significant only for naproxen (p=0034). We found no evidence that treatment effects varied over the duration of treatment. Model fit was good, and between-trial heterogeneity and inconsistency were low in all analyses. All trials were deemed to have a low risk of bias for blinding of patients. Effect estimates did not change in sensitivity analyses with two additional statistical models and accounting for methodological quality criteria in meta-regression analysis."

The requested drug is not likely to be more effective than the formulary alternatives.

The insurer's denial of coverage for Formulary Exception for Vimovo (naproxen-esomeprazole) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ruptured Ovarian Cysts

Treatment inpatient emergency admission

The insurer denied coverage for inpatient emergency admission

The denial is upheld

The patient is a pregnant female who presented to the emergency room (ER) with complaints of 10 out of 10 left lower quadrant (LLQ) abdominal pain. Human chorionic gonadotropin (HCG) level was 489. There was a concern for an ectopic pregnancy versus a ruptured ovarian cyst. Imaging revealed hemoperitoneum. The patient was admitted for care. Hemoglobin (Hgb) and hematocrit (Hct) levels were trended. The patient was given an intravenous (IV) fluid bolus, oral (PO) Tylenol, and Motrin. The repeat abdominal examination had improved. The patient was discharged. 

This patient was stable; there was no evidence of hemodynamic instability, no elevated temperature, good hematocrit, and no peritoneal signs. The patient was tolerating oral intake. If an ectopic was high on the list, then a laparoscopy should have been performed to rule it out. It is not clear why the patient was admitted. There was no indication for admission as nothing was done in the hospital that could not have been done as an outpatient. The patient could have easily been observed in the emergency room. Once the provider ascertained that the patient was stable, she could have been sent home with follow up as needed with serial HCG levels.

Again, nothing was accomplished in the hospital. Since the patient was stable with no evidence of any acute condition, she could have been sent home. Based on all the information submitted, the admission was not medically necessary. 

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

The inpatient emergency admission is not considered medically necessary for this patient. 

The insurer's denial of coverage for the inpatient emergency admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient presented to the hospital for elective cardiac catheterization after complaining of intermittent chest pain and dyspnea on exertion.  Past medical history was significant for coronary artery bypass graft (CABG).  The patient underwent cardiac catheterization with stent placement to the proximal left anterior descending artery and first diagonal artery. No perioperative complications were noted, and the patient was discharged the following day.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented for elective percutaneous revascularization.  He underwent an uncomplicated procedure and stents were placed in the left anterior descending (LAD) artery and diagonal arteries. He was subsequently discharged the following day.  Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.