Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer- Breast Cancer.
Treatment: Diagnostic Testing (other than Radiology)- BIS assessment. 
The insurer denied Diagnostic testing-bioimpedance spectroscopy (BIS) assessment using ImediMedL-Dex testing. The denial is overturned. 

The patient is a female who underwent bilateral mastectomy and right sentinel node biopsy with deep inferior epigastric perforators (DIEP) flap reconstruction for right sided multifocal invasive lobular carcinoma. Three sentinel nodes were removed. One node was positive for micrometastases. Final pathological stage was mpT1cN1mi. She underwent post mastectomy radiation.
At issue is whether Diagnostic testing-bioimpedance spectroscopy (BIS) assessment using ImediMedL-Dex testing is likely to be more beneficial than any standard treatment.

The health plan's determination regarding the proposed health treatment is overturned in whole.

The proposed health service of Diagnostic testing- bioimpedance spectroscopy (BIS) assessment using ImediMedL-Dex testing is likely to be more beneficial than any standard treatment for the patient's condition.
BIS assessment has been shown in multiple recent studies to be more effective than standard methods such as circumferential monitoring. Early detection of lymphedema can improve patient outcomes and prevent the development of clinically significant lymphedema. BIS monitoring in this case where the patient is at high risk of developing lymphedema with 3 nodes removed, and post mastectomy radiation, it is appropriate to monitor her closely. BIS is appropriate for its early detection and early intervention of lymphedema.
Therefore, the proposed health service of Diagnostic testing- bioimpedance spectroscopy (BIS) assessment using ImediMedL-Dex testing is likely to be more beneficial than any standard treatment for the patient's condition.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Constipation. 
Treatment: Pharmacy/Prescription Drugs. 

The health plan denied the requested medication Motegrity as not medically necessary. 
The health plan's determination is overturned. 

The patient is a female with diabetes mellitus type 1. She has had chronic nausea and vomiting requiring hospitalization; she is suspected to have diabetic gastroparesis. The patient has reportedly failed Linzess, Amitiza, and Trulance. The formulary alternatives are Lubiprostone (generic Amitiza) and Linzess. 

At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects. 

The health plan's determination is overturned, in whole. 

The request for Motegrity is supported. The patient has had chronic constipation symptoms, and has failed multiple advanced agents (Amitiza, Linzess, and Trulance), including the listed formulary alternatives [1,2]. The patient has failed multiple agents recommended by guidelines for the treatment of chronic constipation. Motegrity has shown efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain [3-5]. For these reasons, including failure of the formulary alternatives, the request is supported as medically necessary in this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Eliquis. 
The denial is overturned. 

The patient is a female with a history of submassive pulmonary embolism. After receiving second dose of Moderna coronavirus (COVID) vaccine, she presented with shortness of breath. She was diagnosed with bilateral pulmonary embolism. She was started on Enoxaparin therapy which was switched to Eliquis (apixaban) 5 milligrams (mg) twice daily. Her treatment was changed to rivaroxaban (Xarelto) due to denial of coverage of apixaban. She experienced fatigue and dizziness after starting rivaroxaban. She switched her therapy to apixaban. The treating physician is requesting Eliquis (apixaban) which the patient has used in the past without any significant side effects. Apixaban is non formulary. 

At issue is whether the formulary drug (warfarin, Xarelto) will be or has been ineffective, would not be as effective as the non-formulary drug (Eliquis) or would have adverse effects. 

The health plan's determination is overturned in whole. 

The formulary drug (warfarin, Xarelto) has been ineffective and would not be as effective as the non-formulary drug (Eliquis) and would have adverse effects.
The patient has already tried the formulary drug (Xarelto) and has experienced side effects of dizziness and fatigue. Therefore, the formulary option has already been proven to not be clinically helpful but rather harmful to the patient. Therefore, the treating provider is requesting the non-formulary option of apixaban. In addition to the issue of intolerance in this particular patient, the peer reviewed publications have reported apixaban to be more effective than rivaroxaban in preventing the development of recurrent venous thromboembolism and major bleeding events. 

Therefore, the formulary drugs would not be as effective as the non-formulary drug.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Idiopathic Constipation. 
Treatment: Formulary exception for Motegrity. 

The insurer denied the formulary exception for Motegrity. 
The denial is upheld. 

The patient is a male with chronic idiopathic constipation. He has failed Amitiza and Linzess and has done well with Motegrity in combination with Amitiza. When he stops Amitiza, he has recurrent symptoms. The patient's provider is requesting Motegrity. 

No, the health plan should not cover the Formulary exception for Motegrity. 
While the patient has failed the two preferred formulary alternatives Linzess and Amitiza, there is no medical literature to support the use of Motgerity in combination with Amitiza. Without support in the literature, it cannot be determined that the health plan should not cover the formulary exception for Motegrity in combination with Amitiza.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: inpatient stay.
The insurer denied inpatient stay. 
The health plan's determination is upheld. 

The patient is a male with a past medical history significant for seizures, head injury, obstructive sleep apnea, hypertension, diabetes mellitus, and syncope who presented to the hospital after he passed out at work on the day of admission. There were no warning signs, including aura before this happened.
The patient stated that he was behind his desk at work, and the next thing he remembered was being in the emergency department. It was reported that the patient had similar episodes requiring admission.
When the patient was seen by the admitting physician, he denied headache, chest pain, shortness of breath, diaphoresis, dizziness, nausea, vomiting, focal weakness, or numbness. In the emergency department, the patient underwent a computed tomography (CT) scan of the head, which demonstrated no acute intracranial changes.

The inpatient hospital admission is not medically necessary.
There are no clear indications for admission at the acute inpatient level of care, since there were no signs of hemodynamic instability or severe or persistent altered mental status. The imaging studies did not reveal evidence of acute stroke, brain mass, or hydrocephalus. There was no indication that the syncopal episode was related to pulmonary embolism, arterial dissection, acute congestive heart failure (CHF) exacerbation, acute blood loss anemia, or acute coronary syndrome.
There were no indications for immediate electrophysiological study or other intervention such as automatic implantable cardioverter defibrillator (AICD) placement.
Based on the telemetry monitoring and loop recorder interrogation, there was no evidence that the patient had a high degree of atrioventricular block, bradycardia with sinus pauses, and bursts of supraventricular tachycardia. Furthermore, there was no evidence that the patient was severely dehydrated.
The review of the medical records revealed that the patient remained in stable clinical condition during the entire hospital stay, and did not require any treatment or testing that would justify admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: heat treatment of leg vein (endoluminal ablation of varicose veins).
The insurer denied heat treatment of leg vein (endoluminal ablation of varicose veins). 
The denial is overturned. 

The patient is a female with symptoms of chronic venous insufficiency in the right leg. The patient wears compression hose without relief of symptoms. Daily activities are affected by her leg pain. A right leg ultrasound showed reflux in the right (R) great saphenous vein. Her physician recommended endovenous ablation of the R greater saphenous vein (GSV).
At issue is the medical necessity of Heat treatment of leg vein (endoluminal ablation of varicose veins).

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

The requested health service/treatment of Heat treatment of leg vein (endoluminal ablation of varicose veins) is medically necessary for this patient.
Endovenous ablation is medically necessary for this patient. This is the recommended treatment for a patient, as this one, who has leg pain, ultrasound (US) findings showing reflux in superficial veins and failure of conservative measures. The health plan is not acting in the best interest of the patient because the endovenous ablation is what is generally recommended to treat this patient's leg symptoms and is recommended by national clinical guidelines.
Therefore, the requested health service/treatment of Heat treatment of leg vein (endoluminal ablation of varicose veins) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: braces and monthly visits x 12. 
The insurer denied braces and monthly visits x 12. 
The denial is overturned.

The patient is a female with an anterior crossbite on teeth 7 and 10. Teeth 4 and 5 are also in crossbite. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for orthodontics to address the crowding and crossbite. The subject under review is the medical necessity for braces and monthly visits x12.

The health plan's determination is overturned.

The requested treatment with braces and monthly visits is medically necessary for this patient.
This patient presents with an anterior crossbite on teeth 7 and 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.1,2,3
Teeth 7 and 10 are in a traumatic crossbite with their mandibular antagonists. If this is not corrected the damage that will likely occur to the patient's teeth will be much more complicated to correct than the patient's existing orthodontic problem. Orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a female with chronic obstructive pulmonary disease (COPD), without prior history of intubation and with no home oxygen dependence, who presented to the emergency department (ED) with shortness of breath for three days. It was associated with cough and mild orthopnea, along with leg swelling. She denied chest pain or palpitations but reported 5 out of 10 intensity of epigastric pain without radiation. She continues to smoke seven cigarettes/per day and uses marijuana and crack cocaine.

The principal admitting diagnosis is an acute exacerbation of COPD/asthma, with peak expiratory flow rates of 250 with an unknown baseline. The patient was given duo nebs, Solu-Medrol, ceftriaxone, and doxycycline based on the chest x-ray; mycoplasma and Legionella antigens were ordered, and a repeat echocardiogram.
The following day, repeat labs showed correction of the potassium to 3.7, similar creatinine, resolution of elevated liver enzymes. Vital signs appeared stable. The patient requested to leave the hospital, was found to have the capacity to leave the hospital and signed herself out against medical advice (AMA). She was given prednisone taper, oral doxycycline for three days, and an albuterol inhaler.
The question is whether inpatient stay is medically indicated for this presentation.

The health plan's determination is overturned.

The inpatient stay is medically necessary for this patient. The patient presented with multiple pathologies, including COPD, with major complications that include pulmonary vascular congestion worrisome for newly developed heart failure in the presence of cocaine in her bloodstream. Furthermore, there was evidence of pulmonary infiltrates, suggestive of pneumonia, further complicating the clinical picture. There was a new onset of hypoxemia, with a 3 liter (L) oxygen requirement based on the ED documentation. Clinical criteria for admission to inpatient care are satisfied.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Hyperglycemia
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a female who initially presented to the emergency department with concerns for vomiting and non-compliance with insulin. Pertinent history included insulin dependent diabetes mellitus type 2. Initial vital signs revealed a temperature of 98.3 degrees Fahrenheit (F), heart rate (HR) 105, blood pressure (BP) 120/81, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 97% (percent) on room air. Initial examination documented the patient as alert, oriented, and without abdominal tenderness. 

Based on the clinical documentation provided, evidence-based literature and standards of care, the inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. 

In this particular situation, the patient did not meet criteria for the diagnosis of diabetic ketoacidosis. The patient had a history of diabetes mellitus type 2 and presented with vomiting. Initial evaluation revealed sinus tachycardia, hyperglycemia, high anion gap metabolic acidosis, mild hyponatremia, and radiographic findings of bibasilar infiltrates all in the setting of a positive (coronavirus disease 2019) COVID-19 PCR (polymerase chain reaction). Following emergency department care, the admitting physician had an impression of hyperglycemia without diabetic ketoacidosis and COVID-19 not requiring treatment. The infectious disease physician also recommended no treatment for COVID-19. The treatment plan essentially consisted of supportive care, subcutaneous insulin, and diagnostic testing. Following observation care, documentation noted the patient was tolerating oral intake and laboratory abnormalities of clinical significance had resolved or become acceptable for next level of care. The hospital course was prolonged due to a liver lesion of unknown clinical significance without clear reasoning why outpatient services could not further address such.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have diabetic ketoacidosis, hemodynamic instability, hyperglycemic hyperosmolar state, mental status changes, severe or persistent dehydration, significant electrolyte abnormality not responsive to observation care, or severe or persistent vomiting. 

The health plan's determination is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Taltz autoinjector (AUTO INJCT) 80 mg/ml (milligram/milliliter) 
The insurer denied coverage for Taltz autoinjector (AUTO INJCT) 80 mg/ml (milligram/milliliter) 
The denial is overturned

The patient is a female with a diagnosis of inverse psoriasis involving the axilla and scalp who has failed therapy with multiple topical medications. The patient was given a sample of Taltz by the dermatologist and noted immediate clearance of her psoriasis. The request is for continuation of Taltz therapy for inverse psoriasis.  

The patient has failed topical therapy and requires systemic therapy for control and management of her inverse psoriasis diagnosis. 

The joint AAD-NPF (American Academy of Dermatology-National Psoriasis Foundation) guidelines for psoriasis treatment with biologics, states that Taltz is recommended for monotherapy in the treatment of psoriasis with a strength of recommendation "A" - the highest recommendation. In this case, Taltz is a reasonable next therapy for the treatment of the patient's disease and is medically necessary. It is noted in the documentation that the patient has a history of IBD (Inflammatory bowel disease) and as such should be monitored closely by the treating physician for signs of exacerbation while on Taltz. As per Hong, et al. methotrexate has limited use with limited data supporting its role in inverse psoriasis. In contrast, "Currently, ixekizumab, a high-affinity monoclonal antibody targeting interleukin (IL)-17A, is the only drug that contains data on genital psoriasis in its Food and Drug Administration (FDA) label (grade of recommendation: B) [49]. Several papers have demonstrated significant improvement in genital lesion appearance, itch, sexual health, and quality of life in resistant genital psoriasis treated with ixekizumab. [49-52] A randomized, placebo-controlled, phase III clinical trial demonstrated the long-term efficacy and safety of ixekizumab for up to 52 weeks [51] ... In total, 73% of patients in the initial treatment arm were reported to achieve clear or almost clear genital skin (sPGA-G (Static Physicians Global Assessment) 0/1) by the end of week 12, and 75% by the end of week 52. Similarly, 79% of patients who were in the initial placebo group also achieved sPGA-G0/1 at the end of week 52, showing rapid improvement." 

Based on the submitted documentation, the denial of Taltz is overturned in whole based on the current evidence-based medical literature.

The insurer's denial of coverage for Formulary Exception for Taltz autoinjector 80 mg/ml (milligram/milliliter) is overturned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Paroxysmal atrial fibrillation

Treatment is Savaysa	

The insurer denied coverage for Savaysa
 
The denial is overturned

This is a patient with paroxysmal atrial fibrillation, which has been documented via his implantable loop recorder, with his most recent atrial fibrillation burden of 0.8%. He reports episodes that can last for several hours. His rhythm is controlled with dronedarone (Multaq), and rate is controlled with metoprolol tartrate.

Reduction of risk for thromboembolism has been attempted with apixaban (Eliquis) and rivaroxaban (Xarelto), both of which are approved under the health plan in which the patient participates. Unfortunately, both led to headaches and were not tolerated. At his last cardiology visit, the patient's electrophysiologist, noted the intolerance and prescribed a third anticoagulant instead, edoxaban (Savaysa), 60mg (milligrams) daily by mouth.

In this case, according to the submitted documentation, the formulary drugs of apixaban and rivaroxaban did, in fact, cause an adverse reaction. The headache that was attributed to both medications led to their discontinuation.

The formulary drugs, apixaban and rivaroxaban, were ineffective because they could not be taken by the patient. According to the submitted documentation, both of the drugs that are on formulary were tried, and both were not tolerated due to headache. 

Anticoagulation reduces the risk of associated stroke by 64% with warfarin, and head-to-head trials have demonstrated improved efficacy over warfarin with direct oral anticoagulants (DOAC), including rivaroxaban, apixaban, and specifically edoxaban. These three medications (along with betrixaban) are in a subclass of DOACs known as oral direct factor Xa (clotting factor) inhibitors, and all are FDA (food and drug administration) approved for this indication. 

Additionally, there is evidence that edoxaban (Savaysa) demonstrates improved efficacy and similar safety when compared to apixaban and rivaroxaban in a real-world setting.  

Therefore, edoxaban is more effective than the formulary drugs in this context; this is particularly true since the formulary drugs are not tolerated and are therefore completely ineffective from a clinical perspective.

In summary, edoxaban is a medically appropriate next step in treating the thromboembolic stroke risk for the patient, after failure of the formulary options, apixaban and rivaroxaban.

The insurer's denial of coverage for Formulary Exception for Savaysa is overturned.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a boy with a history of wheezing who presented with wheezing and coughing. He was well until the night prior to presentation when he developed a cough with wheezing. His symptoms worsened during the night and he also developed shortness of breath. He also developed generalized abdominal pain and had 2 episodes of emesis. He was given albuterol every 4 hours at home with little relief, and subsequently developed retractions and increased wheezing. He was therefore brought to the emergency department for care.

Inpatient Hospital Admission was medically necessary for this patient.

This is a young boy with a significant history of wheezing including emergency visits and hospitalizations who presented in status asthmaticus. He was in respiratory distress at the time of arrival, and continued to have significant symptoms despite appropriate and intensive treatments in the emergency department setting. In addition, upon admission he initially required every 3 hour bronchodilator treatments. This level of treatment requires an inpatient setting.
The decision making at the time of admission for this patient was consistent with his young age, the presence of status asthmaticus with respiratory distress that continued despite appropriate treatment at home and in the emergency department, and the need for continued intensive treatments including bronchodilator therapy every 3 hours and intravenous fluids, along with close monitoring for potential deterioration of clinical status.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 25th edition, Asthma, Pediatric; hospitalization is indicated for patients with respiratory findings (wheeze, retractions) that persist despite observation care and with an inadequate response to therapy. This patient continued to have significant respiratory symptoms despite appropriate and intensive treatments and required ongoing care in an inpatient setting.