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

Diagnosis: Hypertension, coronary artery disease, hypothyroidism, asthma, depression, memory loss, and urinary incontinence
Treatment: Personal care aide for 168 hours per week, Consumer Direct, 1 Client
The insurer denied coverage for personal care aide for 168 hours per week, Consumer Direct, 1 Client
The denial is upheld
 
This is an elderly patient with coronary artery disease, hypertension, and dementia.  The insurer approved increasing personal care aide (PCA) to live-in; with 5 hours uninterrupted sleep. PCA 168 hours/week was requested due to her cognitive decline.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as moderately impaired. She is totally dependent to maximal assistance for Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. She requires maximal assistance for bathing, lower body dressing and toilet transfer. Extensive assistance is needed for personal hygiene, upper body dressing, locomotion, and toilet use. She is occasionally incontinent of bladder and continent of bowel. Limited assistance is needed for bed mobility and eating. She also requires extensive assistance for ambulation. However, she was observed ambulating with a cane and also wanders during the evenings. There have been no reported falls over the prior 90 days. The patient's medical condition and functional ability are not at the level or unpredictable as to require the requested PCA 168 hours/week. The patient may require additional monitoring; particularly due to her cognitive deficits and wandering. However, safety monitoring under PCA does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care service tasks are being provided. Based on the records reviewed, attention to the patient's functional needs are appropriately provided and maintained by the recently approved PCA live-in.  

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 of personal care aide for 168 hours per week, Consumer Direct, 1 Client is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Tremfya
The insurer denied Tremfya.
The health plan's determination is upheld.

The patient is a female with psoriasis. She has tried and failed Prednisone, Triamcinolone, Hydrocortisone, and Tacrolimus. The prescriber is a dermatologist.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of Tremfya is not medically necessary for the patient. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines such as Methotrexate and Cyclosporine covered by the patient's insurance plan 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. They concluded that Methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2 percent (%) [95% confidence interval 34.160.0] of patients achieve a psoriasis area and severity index (PASI) score of 75 at primary endpoint, thus, Methotrexate is an effective first-line treatment for the management of psoriasis (3). There is no documentation provided that would justify the patient requiring treatment with Tremfya prior to the formulary alternatives such as Methotrexate and Cyclosporine. The patient has no true contraindications to use of the preferred treatments. Therefore, Tremfya is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol and cannabis use disorder
Treatment: Substance Use-Inpatient Detoxification Treatment
The insurer denied the substance use-inpatient detoxification treatment.
The health plan's determination is overturned. 

The patient is an adult male who was admitted to acute inpatient treatment for detoxification and withdrawal management of severe alcohol and cannabis use disorder. The patient has a history of detoxification/substance use disorder treatment with relapse, as well as a recent two-day detoxification treatment episode two weeks prior to admission. He had no history of withdrawal seizures or delirium tremens. The patient presented with general medical issues that included mild withdrawal symptoms in the context of a blood alcohol level of 0.256 and in the context of tobacco dependence at one pack per day for 25 years. 

Substance Use-Inpatient Detoxification Treatment was medically necessary for this patient.

The inpatient services and detoxification treatment and withdrawal management for severe alcohol and cannabis use disorders, and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance use disorders and associated general medical complications and co-occurring disorder did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorder. Withdrawal symptoms were managed with tapering dosages of benzodiazepine requiring monitoring and prn medications, as well as comfort medications. The patient's history of alcohol and cannabis use (frequency and quantity) together with a co-occurring mood disorder does reflect the seriousness of this case such that an inpatient setting was necessary through discharge. The patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from alcohol or cannabis if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Cavities

Treatment: Professional Services, dental procedure (41899 x 32)

The insurer denied coverage for Professional Services, dental procedure (41899 x 32)

The denial is overturned

Based on the submitted clinical documentation including narrative letter, pretreatment clinical images, in addition to insurer correspondence, it appears this child with history of multiple cardiac surgeries, presented with severe dental decay, extensive dental needs, and situational anxiety for dental treatment. Due to poor compliance in the outpatient setting, it was recommended that all dental treatment be performed under deep sedation/general anesthesia. The insurer has denied services as not being covered under the benefit plan as they do not meet Dental Anesthesia and Facility Services guidelines. 

Upon review of the documentation submitted and as enumerated above, this patient had significant dental needs that would be difficult to provide in the outpatient setting due to significant dental disease, age of the patient and documented poor compliance/anxiety. Therefore, it was recommended that all treatment be performed in a controlled setting under deep sedation/general anesthesia. This provides the benefit of completing all dental needs at one time and anesthesia. This is a standard of care treatment for this clinical situation when dealing with pediatric patients. This treatment is supported in the literature (see below). Further, the treatment plan as recommended fulfills and meets all the insurer's medical necessity criteria. As such the services recommended are considered medically necessary.

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 the Professional Services, dental procedure (41899 x 32) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Cavities

Treatment: Professional Services, dental procedure (41899 x 32)

The insurer denied coverage for Professional Services, dental procedure (41899 x 32)

The denial is overturned

Based on the submitted clinical documentation including narrative letter, pretreatment clinical images, in addition to insurer correspondence, it appears this child with history of multiple cardiac surgeries, presented with severe dental decay, extensive dental needs, and situational anxiety for dental treatment. Due to poor compliance in the outpatient setting, it was recommended that all dental treatment be performed under deep sedation/general anesthesia. The insurer has denied services as not being covered under the benefit plan as they do not meet Dental Anesthesia and Facility Services guidelines. 

Upon review of the documentation submitted and as enumerated above, this patient had significant dental needs that would be difficult to provide in the outpatient setting due to significant dental disease, age of the patient and documented poor compliance/anxiety. Therefore, it was recommended that all treatment be performed in a controlled setting under deep sedation/general anesthesia. This provides the benefit of completing all dental needs at one time and anesthesia a sures patient compliance. This is a standard of care treatment for this clinical situation when dealing with pediatric patients. This treatment is supported in the literature (see below). Further, the treatment plan as recommended fulfills and meets all the insurer's medical necessity criteria. As such the services recommended are considered medically necessary.

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 the Professional Services, dental procedure (41899 x 32) is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Deep vein thrombosis
Treatment: Eliquis
The insurer denied Eliquis.
The denial is upheld.

The patient is a female with a history of deep vein thrombosis (DVT) treated with Xarelto. About one week later, she presented to the emergency room with vaginal bleeding. The vital signs were non-contributory, she was in no distress, and the physical exam revealed vaginal bleeding. The hemoglobin and hematocrit were normal. Ultrasound revealed a thickened endometrial stripe, and a right complex ovarian cyst. Rivaroxaban (Xarelto) was discontinued, and the patient was discharged on Lovenox.  The patient was evaluated by a hematologist. The medication history documented the discontinuation of Xarelto and the initiation of Lovenox and Eliquis. There were no complaints of continued bleeding or bruising noted, and there was no bruising noted on physical exam. Additional laboratory studies were ordered, and a plan was made to return to the clinic in about 2 months. The subject under review is the request for use of the non-formulary drug Eliquis.

The health plan's determination is upheld.

There is no clear evidence that the formulary drug warfarin will be or has been ineffective, would not be as effective as the non-formulary drug (Eliquis), or would have more adverse effects.

All oral anticoagulants have risks of bleeding. Studies have shown that the direct oral anticoagulant medications, such as apixaban (Eliquis) and rivaroxaban (Xarelto) are similar to warfarin in efficacy with a lower risk of intracranial bleeding. There is no clear evidence that the direct oral anticoagulants have a lower risk of other bleeding, such as vaginal bleeding. The patient's plan requires that the patient try and fail both preferred formulary agents, Xarelto and warfarin. The records show that the patient had vaginal bleeding on Xarelto. However, the medical records provided do not clearly document evidence that the patient has tried warfarin, and if she did, whether it was ineffective or caused significant complications.

Therefore, based on the plan formulary, the standard of care, as well as the peer reviewed literature, it cannot be stipulated that the formulary drug warfarin will be or has been ineffective, or that it will cause more adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic colon cancer, status post diverting ostomy

Treatment: consumer directed personal assistance program (CDPAP) services, live-in per diem; 24 hours per day - 7 days per week

The insurer denied coverage for consumer directed personal assistance program (CDPAP) services, live-in per diem; 24 hours per day - 7 days per week

The denial is overturned

This is an elderly female with recently diagnosed metastatic colon cancer and status post diverting ostomy.  She receives CDPAP 5 hours/day and requesting CDPAP services, (live-in per), 24 hours/day, 7 days/week.  

In the Uniform Assessment System (UAS) report, the patient's cognitive status is described as modified independent.  She requires maximal assistance for bathing and lower body dressing.  Extensive assistance is needed for personal hygiene, lower body dressing, toilet transfer/use and ambulating with a walker.  She is frequently incontinent of bladder and her caregiver changes her ostomy supplies.  Limited assistance is needed for bed mobility and eating.  According to palliative care nurse practitioner (NP) letter; the patient "is currently on a home hospice program, requires high care and symptom needs and is in the dying process.  She requires full assistance with all of her activities of daily living, and her symptom burden requires diligent management of her care needs."  Based on the clinical records, this physician is inclined to agree.  Given the patient's guarded prognosis and rapid decline, the CDPAP services, live-in per diem; 24 hours/day - 7 days/week, is medically necessary.  

From a physical medicine and rehabilitation perspective, directed personal assistance program (CDPAP) services, live-in per diem; 24 hours per day - 7 days per week is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for consumer directed personal assistance program (CDPAP) services, live-in per diem; 24 hours per day - 7 days per week services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer. 
Treatment: Verzenio. 

The insurer denied Verzenio. 
The determination is overturned. 

The patient has recurrent, metastatic breast cancer. The primary breast cancer was human epidermal growth factor receptor 2 (HER2) 3 plus (+) and she has received multiple lines of HER2 directed therapy in the metastatic setting. The patient has progressed and Verzenio has been been recommended; this is under review for medical necessity. 

The Verzenio is medically necessary. The benefit of Verzenio in patients with metastatic HER2+ breast cancer was evaluated in the Phase II monarcHER trial [a study of abemaciclib (ly2835219) in women with hormone receptor (HR) +, HER2+ locally advanced or metastatic breast cancer]. In this trial, 237 patients with unresectable locally advanced, recurrent, or metastatic disease who had previously received at least two lines of HER2-based therapy were randomly assigned to abemaciclib/fulvestrant/trastuzumab; abemaciclib/trastuzumab; or trastuzumab plus clinician's choice of standard-of-care single-agent chemotherapy. At a median follow-up of 19 months, median progression free survival (PFS) was 8.3 months in the abemaciclib/fulvestrant/trastuzumab group versus 5.7 in the other two groups (hazard ratio (HR) 0.67, 95 percent (%) confidence interval (CI) 0.45-1, in comparison with trastuzumab and chemotherapy). The overall response rates were 33 percent with abemaciclib/fulvestrant/trastuzumab, and 14 percent in each of the other arms. The differences in overall survival (OS) were not statistically significant, but results are still immature. 

This patient meets these criteria having received trastuzumab, fam-trastuzumab deruxtecan-nxki, and tucatinib in addition to multiple lines of cytotoxic therapy. There is no approved therapy for which better outcomes have been published. The use of this agent in this clinical scenario is supported in the peer-reviewed literature and by the authors of UpToDate. For these reasons, medical necessity for this service has been established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eosinophilic Esophagitis. 
Treatment: Dupixent Syn (syringe) 300. 

The insurer denied coverage for Dupixent Syn 300. 
 
The denial is overturned. 

This is an adult female patient with a history of celiac disease, eosinophilic esophagitis, and Hashimoto's hypothyroid disease. She has trialed proton pump inhibitors (PPI) for at least a few months without benefit and is on an elimination diet of milk and wheat with suboptimal results. The patient's Allergy and Immunology physician is recommending Dupixent. The denial letter states that the plan does not allow coverage of Dupixent unless the patient will not receive Dupixent concomitantly with other biologic drugs. There is no indication from the reviewed notes that the patient is receiving another biologic drug (or targeted synthetic drug). 

The patient has endoscopic evidence and symptoms consistent with the diagnosis of eosinophilic esophagitis, for which Dupixent is Food and Drug Administration (FDA) approved. 

The medical records include denial correspondence, outpatient, and endoscopy notes. The endoscopy report and the pathological findings are included. Eosinophils are noted in more than one biopsy sample. The patient is a female who has a history of hypothyroidism and celiac disease. There was a history of furrowing of the esophagus on a previous endoscopy. Pathology from upper gastrointestinal (UGI) endoscopy biopsies did not show eosinophilic esophagitis. According to notes, the patient had been treated with PPI and had tried elimination diets. Dupixent was prescribed. The patient's letter stated that she had tried swallowed corticosteroids but was unable to tolerate the treatment. 

Dupixent is an effective treatment for eosinophilic esophagitis and the reason for denial does not appear to be justified (namely that the patient is on another biologic drug). In a randomized study, "dupilumab reduced dysphagia, histologic features of disease (including eosinophilic infiltration and a marker of type 2 inflammation), and abnormal endoscopic features compared with placebo. Dupilumab increased esophageal distensibility and was generally well tolerated." (1) 

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

The insurer's denial of coverage for Dupixent Syn 300 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Personal care aide 56 hours/week, consumer direct, 1 client
The insurer denied Personal care aide 56 hours/week, consumer direct, 1 client.
The determination is upheld.


The patient has a past medical history notable for type 2 diabetes, congestive heart failure, hypertension, and stage 3 chronic kidney disease. The patient is approved for a consumer directed personal care aide. The patient and the care team requested an increase in hours per week.

Cognition is noted to be independent, with normal memory and procedural testing. From a functional standpoint, the patient requires total dependence for meal preparation, housework, and shopping. The patient requires limited assistance with finances and set up help only with medications. For activities of daily living (ADL), the patient requires extensive assistance for bathing and toilet transfer. The patient requires limited assistance for dressing upper and lower body. The patient is independent in all other activities of daily living (ADL). The patient ambulates with an unsteady gait. The patient has challenges with mobility due to fatigue and pain. The patient is occasionally incontinent of urine (less than daily), continent of stool and uses a diaper. A task tool associated with the assessment recommended the appropriate number of hours per week to address functional needs. 

An office visit note was provided for review. It does not specifically talk about which functional needs are not being met. The assessment and plan make no recommendations regarding home health hours. Physical exam does not make note of any functional limitations. At issue is the medical necessity of increased consumer directed personal care hours. 

The requested health service/treatment, personal care aide increased hours per week, consumer direct, has not been demonstrated to be medically necessary for this patient. The patient has current consumer directed personal care hours which match the hours recommended by the task tool. The patient notes needing assistance with bathing and using the bathroom, which is accounted for on the Uniform Assessment System (UAS) and task tool. There is no letter of medical necessity or recommendation from a treating physician regarding unmet personal care needs. Currently there is no documentation of medical necessity to increase personal care hours.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Sinus Bradycardia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned.

This is the case of an adult female that presented to the hospital complaining of generalized weakness and diarrhea. Past medical history was significant for diabetes mellitus, hypertension, and hepatitis C virus. Emergency medical services (EMS) found the patient bradycardic with a pulse of 30 beats per minute (bpm) and hypotensive [systolic blood pressure (BP) was 80]. Upon arrival to the emergency department, vital signs were: pulse 35 bpm, BP 88/62. Physical exam was unremarkable. A 12-lead electrocardiogram (EKG) revealed sinus bradycardia without ST (interval on EKG) or T (interval on EKG) wave abnormalities. Serum blood testing revealed an elevated white blood cell count of 26 and potassium of 4.9. The patient was admitted to the hospital and treated with atropine, intravenous (IV) fluids and antibiotic therapy for gastroenteritis. Antihypertensive therapy that was initially held was re-introduced. Following a period of monitoring and treatment the patient was discharged with cardiology follow up.

This patient presented with symptomatic sinus bradycardia, generalized weakness, diarrhea, and vomiting. The American College of Cardiology/American Heart Association guidelines on evaluation and management of patients with bradycardia define sinus node dysfunction as a non-physiologic sinus rate of less than 50 bpm (Reference 1). This patient required hospital admission for observation and treatment of symptomatic bradycardia. Such patients may require temporary pacemaker therapy while work up for reversible causes is performed (Reference 2). This patient ultimately recovered with cessation of atrioventricular (AV) verapamil and carvedilol therapy. However, she became hypertensive and required re-introduction of these medications while being carefully monitored. In conclusion, inpatient hospital admission was medically necessary.  

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 the inpatient admission is overturned. Medical Necessity is substantiated.