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

Diagnosis: Hidradenitis suppurativa
Treatment: Humira 80mg (milligrams)/0.8ml (milliliter) Pen Injector
The insurer denied: Humira 80mg (milligrams)/0.8ml (milliliter) Pen Injector
The denial is overturned.

The patient is an adult female. She has a medical history of Hidradenitis suppurativa affecting her intertriginous areas. The patient has tried and failed Humira 80 milligrams biweekly, benzoyl peroxide, Clindamycin topical and oral doxycycline. The provider is seeking a dose escalation to Humira 80 milligrams weekly due to continued flaring on the current regimen. This request is under review.

The health plan should cover the requested health service.

Hidradenitis suppurativa is a notoriously difficult condition to treat, and dose escalation with biologics like Humira and Remicade is a commonplace practice for patients who cease to respond to more conventional dosing frequencies. Given that the patient has already tried and failed Humira 80 mg (milligrams) biweekly, she may stand to benefit from treatment with 80 mg (milligrams) weekly where other medications have failed. There is growing body of research supporting the use of this regimen for HS (hidradenitis suppurativa). Therefore, this request is approved given the lack of remaining viable treatment alternatives. It is recommended that Humira 80 mg (milligrams) weekly be approved for a total duration of 12 months.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hidradenitis suppurativa
Treatment: Humira 80mg (milligrams)/0.8ml (milliliter) Pen Injector
The insurer denied: Humira 80mg (milligrams)/0.8ml (milliliter) Pen Injector
The denial is overturned.

The patient is an adult female with hidradenitis, treated with oral and topical antibiotics as well as Humira. The patient has not achieved adequate control with Humira dosing every other week. Her provider is requesting Humira 80 mg (milligrams) every week. The health plan denied the request for the increased dosing.

The health plan should cover the requested health service.

The health plan denied the increased dose as it is not FDA (United States Food and Drug Administration) approved. In the review by Ryan et al, in patients with HS (hidradenitis 
suppurativa) or psoriasis, the safety of adalimumab EW (every week) and EOW (every other week) was comparable and consistent with the expected adalimumab AE (adverse event) profile. The safety of adalimumab EW (every week) dosing in patients with dermatologic conditions is supported by data comparing adalimumab EW (every week) and EOW (every other week) dosing for Crohn's disease, ulcerative colitis, and rheumatoid arthritis. Dose escalation is supported in current literature, and therefore the request is medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Methicillin Sensitive Staphylococcus Aureus (MSSA) bacteremia

Treatment: continued inpatient hospital admission

The insurer denied coverage for continued inpatient hospital admission

The denial is overturned

 
Patient is an adult female with past medical history significant for metastatic breast cancer, status post multiple lines of treatment who was referred to emergency department for fever, worsening shortness of breath and possible Mediport infection.

Vitals on presentation included: Temperature 99.5 degrees F, Blood Pressure-119/78, Pulse-124, Respirations-26, oxygen (O2) saturation-96% on room air. Laboratory results included the following: White blood cells (WBC-7.15), Hemoglobin (HGB)-10.5, Hematocrit (HCT)-32.9, creatinine-8.68, glucose-116.

Patient was started empirically on intravenous antibiotics (oxacillin) for Methicillin Sensitive Staphylococcus Aureus (MSSA) bacteremia. She was also treated for left chest wall mass, as well as a right pleural effusion. Mediport was removed as a possible source of infection. Patient underwent a thoracentesis. Ultrasound doppler revealed a right upper extremity deep vein thrombosis (DVT). Magnetic resonance imaging (MRI) of the spine showed lumbar 1 (L1) vertebral level metastasis. Plan was to continue a 6-week course of intravenous Oxacillin. She required radiation therapy (RT) to chest wall.

Regarding the medical necessity for continued length of stay, documentation supports that patient required medical intervention at an acute inpatient level of care. She required intravenous Oxacillin every 4 hours via peripherally inserted central catheter (PICC) line, radiation therapy, management of multiple chest wall masses, wound care, treatment of thrombosis, and laboratory monitoring. Additionally, medical records indicate placement was complicated by insurance authorization and bed availability. Due to the complexity of patient's numerous co-morbid conditions including metastatic breast cancer, she could not be safely managed as an outpatient during the period in question.

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 continued inpatient hospital stay is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Uncontrolled diabetes

Treatment: Bydureon BCise (exenatide extended release).

The insurer denied coverage for Bydureon BCise (exenatide extended release).

The denial is overturned

 
This is an adult female diagnosed with Type  2 diabetes with hyperglycemia. This request is for Bydureon BCise (exenatide extended release). As reported; she tried and failed Victoza due to glycated hemoglobin (A1C) levels increased; Trulicity due to intolerance; and Ozempic due to vomiting and nausea. As per visit note; she has gastroesophageal reflux disease (GERD). Her A1C is uncontrolled and increasing. She is on metformin 1000 milligrams (mg) twice a day (BID) and Farxiga 10 mg. 

The preferred formulary alternatives including Trulicity and Ozempic caused adverse reactions

Bydureon is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes[1-3].  The patients who would benefit most from Bydureon are adult patients with type 2 diabetes who have failed first line therapy with metformin[4]. There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The patient has failed Victoza due to uncontrolled A1C levels, Trulicity due to intolerance and Ozempic due to side effects such as vomiting and nausea. The request is consistent with generally accepted standards of medical practice. 

The requested medication would be more effective than the formulary alternatives as the patient has already failed three formulary alternatives.

The formulary drugs are expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non- formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Bydureon BCise (exenatide extended release) is reversed.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraines
Treatment: Diclofenac Potassium Powder 
The insurer denied Diclofenac Potassium Powder.
The determination is overturned.

This is a female patient with migraines. Treatment of acute migraine with diclofenac potassium is the subject of this review. The drug was denied by the plan because the member has not tried and failed the available formulary alternatives including diclofenac sodium, ibuprofen, and naproxen. The provider appealed the determination. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, diclofenac potassium powder, or would have adverse effects.

The patient tried and failed the available formulary alternatives based on the letter of medical necessity, therefore, continued treatment with diclofenac potassium is indicated. In a letter of medical necessity, the provider indicates that the patient has previously tried and failed all of the available formulary alternatives. The provider indicates that the use of these formulary alternatives resulted in a stomach ulcer. The provider knows that the patient was started on diclofenac potassium or Cambia and continues to use this medication without any gastrointestinal upset or ulcer. Because the member has tried and failed the available formulary alternatives based on the letter of medical necessity, continued treatment with diclofenac potassium is indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Ventilator-Dependent Respiratory Failure.
Treatment: Long term acute care hospitalization (LTACH).

The insurer denied coverage for long term acute care hospitalization (LTACH).  The denial is upheld.

This is a patient with a history of Spina Bifida, Arnold Chiari Malformation, Functional Paraplegia, Chronic ventilator-dependent respiratory failure (VDRF), chronic obstructive pulmonary disease (COPD), status-post tracheostomy. The patient was admitted to the hospital for ventilator malfunction. As per the last clinical notes, the patient was on assist control (AC)/continuous mandatory ventilation (CMV) Mode with respiratory rate (RR) 14, tidal volume (TV) 400, positive end expiratory pressure (PEEP) 5, and fraction of inspired oxygen (FIO2) 30% (percent).  The patient's vital signs were: Temperature 98.9 F (degrees Fahrenheit), heart rate (HR) 74, blood pressure (BP) 141/86, RR 18, oxygen saturations were 100% (percent).

The patient's white blood cell count (WBC) was 11.1, hematocrit (Hct) 35.8, and electrolytes were within normal limits. The patient completed treatment for Urosepsis. The patient was status post bilateral stents. The patient had completed intravenous (IV) antibiotics. Lithotripsy was planned. The patient has a history of psychiatric issues for which they are on medications. The patient had refused weaning trials, as they had failed in the past. The patient has Ventilator-Dependent Respiratory Failure (VDRF).

This patient does not need long term acute care hospitalization (LTACH) placement. The patients' needs are custodial in nature. The patient is medically stable to be placed in a skilled nursing facility (SNF) or long-term (LT) Custodial Care Facility. There are no acute needs.

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 for admission to long term acute care hospitalization (LTACH) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hereditary angioedema
Treatment: Orladeyo
The insurer denied: Orladeyo
The denial is upheld.

The patient is an adult male with a diagnosis of hereditary angioedema (HAE). The reason for prior denial was lack of family history or genetic testing. The reason the physician is appealing the determination is to provide further documentation.

The requested health service is not medically necessary.

Orladeyo is a plasma kallikrein inhibitor indicated for prophylaxis to prevent attacks of hereditary angioedema (HAE) in adults and pediatric patients 12 years and older. This recommendation was based in part on a pivotal double-blind randomized control trial enrolling approximately 120 participants with hereditary angioedema. Participants who received Orladeyo had reduced attack rates compared with placebo. This patient has had swelling of the face, lips, cheeks, and throat. The patient's C4 and C1 inhibitor level and function were normal. The patient has tried high-dose fexofenadine, famotidine, epipen, and steroids. It was documented that the patient had tried steroids, H2, and 
H1 antihistamines with reduction in swelling. However, the patient continued to have episodes of swelling despite using these medications. The patient has trialed Orladeyo and has seen clinical improvement. The patient does not have a low C4 level or low C1 inhibitor level or function. There is insufficient documentation to support a diagnosis of hereditary angioedema with normal C1. Per Busse et al. 2020, hereditary angioedema with normal C1 requires at least one of the following: 
(1) Demonstration of a mutation associated with the disease; OR (2) A positive family history of recurrent angioedema and documented lack of efficacy of high-dose antihistamine therapy (ie, cetirizine at 40 milligrams per day or the equivalent) for at least 1 month or an interval expected to be associated with three or more attacks of angioedema, whichever is longer. The patient does not meet either of these conditions. As the patient's presentation does not fully support a diagnosis of hereditary angioedema, it cannot be determined that the patient meets the Food and Drug Administration (FDA)-approved indication for the use of Orladeyo. The denial reason is in line with the medical literature.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis: Gender Dysphoria
Treatment: surgical services
The insurer denied Application of Skin Substitute with Use of Operating Microscope
The health plan's determination is upheld.

The patient is a transgender male who underwent left free radial forearm phalloplasty reconstruction. The radial forearm flap will be used for shaft only. The proposed health service in question is the application of skin substitute for the radial forearm donor site with the use of operating microscope.

The application of Skin Substitute with Use of Operating Microscope is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The radial forearm donor site is a common free flap donor site for a variety of reconstructions including phalloplasty. After the harvest of the radial forearm flap, the donor site is closed with a full thickness skin graft or a partial thickness skin graft. It is not the standard of care to apply Integra (skin substitute) for the closure of radial forearm donor site. Further, there is no reason for an operating microscope to be used for the placement of Integra. Operating microscopes are used for microsurgery such as connecting of blood vessels and nerves. They are not used for the application of skin grafts.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis: Gender Dysphoria
Treatment: surgical services
The insurer denied Application of Skin Substitute with Use of Operating Microscope
The health plan's determination is overturned in part. 

This patient is to undergo radial forearm flap phalloplasty for treatment of gender dysphoria. The surgeon plans the use of Integra to cover the donor site on the arm.

The Application of Skin Substitute is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Use of Operating Microscope is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Multiple studies support lessened donor site morbidity and improved functional and aesthetic outcomes when radial forearm free flap donor site is covered with Integra. According to Murray et al: " Composite reconstruction with Integra artificial dermis offers advantages over traditional methods of coverage for select cases of radial forearm free flap donor site closures." According to Gravvanis et al: 'In conclusion, suprafascial dissection of the forearm flap creates a superior graft recipient site, and the use of Integra artificial dermis is a valuable advancement to further minimize the donor-site morbidity, resulting in excellent functional and aesthetic outcomes."
Finally, according to Adani et al: "Favorable cosmetic and functional outcomes were obtained using a dermal regeneration template for the treatment of donor site defects. Despite the drawback of an additional surgical procedure (secondary skin graft), the use of this artificial skin produced soft-tissue augmentation and graft-skin quality, reducing donor site morbidity." Per Wirthman et al: " Long-term results show an esthetic and functional successful defect coverage of the RFF donor site by the use of Integra and split-thickness skin. "
Integra is medically necessary to cover the radial forearm donor site. A microscope is not required. Integra can be placed without a microscope.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Gender Dysphoria
Surgical Services

Diagnosis: Gender Dysphoria
Treatment: surgical services
The insurer denied Application of Skin Substitute with Use of Operating Microscope
The health plan's determination is overturned in part. 

This is a female to male transgender patient. The surgeon is proposing a shaft only radial forearm phalloplasty with Integra coverage of the donor site presumably followed by later skin grafting over the Integra. The dimensions of the expected area of coverage are not documented.

The Application of Skin Substitute is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Use of Operating Microscope is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Autologous skin grafting to the donor site in patients who undergo radial forearm free flap reconstruction (RFFF) is associated with cosmetic and functional morbidity. Integra artificial dermis (Integra Lifesciences, Plainsboro, NJ) is a bovine collagen based dermal substitute that can be used as an alternative to primary autologous skin transplantation of the donor site. Staged donor site reconstruction using Integra followed by ultrathin skin grafting results in highly aesthetic and improved functional outcomes for these defects and this has been documented as such in the medical literature for over 10 years beginning with radial forearm free flap reconstruction following head and neck cancer surgery. The Application of Skin Substitute is therefore likely to be more beneficial than any standard treatment or treatments involving singe stage skin grating for the insured. Given the typical dimensions of 15x17 centimeter (cm) or greater for such flaps, it is indicated.
The operating microscope is not used in the placement of the Integra and is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment:  Braces and monthly visits x (times) 12
The insurer denied Braces and monthly visits x 12.
The determination is overturned.


This is a female patient with impacted teeth number (#) 20 and #29. These teeth are unable to erupt due to crowding. She presented with a skeletal Class II malocclusion and moderate crowding. She is treatment planned for 30-36 months of orthodontics to address the crowding and to create space to bring the impacted teeth into the arch. At issue is the medical necessity of braces and monthly visits.

Approximately 10 percent (%) of all impacted teeth are premolars. Studies have shown almost 65% (percent) of untreated impacted teeth will cause some kind of pathology. (2) The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. (2) Given the proximity of tooth 29 to the root of tooth 28 there is already concern that tooth 28 may be damaged. If left untreated the damage that can occur to the patient's teeth will be more costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periodontal disease

Treatment: D6010 implant placement, tooth 3, D6059 abutment supported porcelain fused to metal crown (high noble metal), tooth 3, D6057 custom abutment, tooth 3

The insurer denied coverage for D6010 implant placement, tooth 3, D6059 abutment supported porcelain fused to metal crown (high noble metal), tooth 3, D6057 custom abutment, tooth 3

The denial is upheld
 

This patient lost a number of teeth including 3, 18, 19, and 20. The patient had treatment planned for dental implants in all four areas. The insurance approved implants in 18-20 but did not mention 3. Since that time, tooth 3 has been denied due to a lack of information to make a definitive decision. 

In an appeal letter it is noted the patient has moderate sleep apnea. The patient needs a dental appliance to treat his condition. He needs implants and the device has become a choking hazard.

Documentation provided for review does not support the requested treatment. There are no radiographs or comprehensive dental records to support the requested D6010 implant placement, tooth 3, D6059 abutment supported porcelain fused to metal crown (high noble metal), tooth 3, D6057 custom abutment, tooth 3. This documentation is necessary for proper evaluation of the patient's condition.

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 for D6010 implant placement, tooth 3, D6059 abutment supported porcelain fused to metal crown (high noble metal), tooth 3, D6057 custom abutment, tooth 3 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

This is a male patient who presented to the emergency department (ED) as a transfer patient from another ED with abdominal pain of one-day's duration. He had tenderness in the right upper quadrant. The white blood cell count (WBC) was elevated at 16.9 thousand (K). An ultrasound showed a gallbladder with gallstones and the bile duct was mildly dilated at 1-centimeter (cm). A magnetic resonance cholangiopancreatography (MRCP) showed gallstones, wall thickening and adjacent fluid and fat stranding. No common duct stones were seen.
He was admitted to the hospital and initially treated with intravenous (IV) fluid, antibiotics, and antiemetics. He was treated with a laparoscopic cholecystectomy. The operative dictation records completion of the procedure without complications with findings of cholecystitis.
The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, antibiotics, and antiemetics. The immediate post-surgical recovery was uncomplicated. Following surgery, he had a normal temperature and normal vital signs. His diet was advanced and the pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting with continuation of oral antibiotics for 4 more days.
At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically necessary in this case.
The patient was an otherwise healthy male who presented to the ED with abdominal pain. There is no documentation of a hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. 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. While the initial WBC was elevated, the patient was clinically stable. The diagnostic evaluation with ultrasound and MRCP was established the diagnosis of cholecystitis and the indication for cholecystectomy.  The treatment plan in this case included surgery. The progress notes state that the patient was stable for discharge from the hospital following the initial recovery period. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.