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

Diagnosis: Acute Renal Failure and Dehydration
Treatment: Inpatient hospital services
The insurer denied coverage for inpatient hospital services
The denial is upheld

The patient was admitted for worsening abdominal pain and was found to have elevated creatinine likely secondary to dehydration.  The abnormal creatinine level was reversible with intravenous (IV) fluid and had no signs of severe renal injury such as acute tubular necrosis.
The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per Kidney Disease Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent ATN.  This patient's kidney function improved back to baseline in under 48 hours.
The patient was admitted. and was started on IV fluid. Diagnostic imaging revealed mildly distended mid small bowel loops in the left abdomen. The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or irreversible change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. He reported a good urine output, was able to tolerate oral diet and did not require total parenteral nutrition. He was discharged.

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 services is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe atopic dermatitis
Treatment: Dupixent 200 milligrams (mg) / 1.14 milliliter (ml) subcutaneous (SC) solution prefilled syringe (SOSY)
The insurer denied coverage for Dupixent 200 milligrams (mg) / 1.14 milliliter (ml) subcutaneous (SC) solution prefilled syringe (SOSY)
The denial is overturned

This is a patient with a history of severe atopic dermatitis who has failed therapy with multiple topical steroids and tacrolimus. The requested medication is Dupixent pediatric dosing, 200mg.

Dupixent is medically necessary for the treatment of the patient's diagnosis, atopic dermatitis. The patient is a child with decreased systemic treatment options available which could safely be administered given her age and chronic medical conditions. The patient has failed topical therapy with steroids as well as non-steroidal anti-inflammatory, tacrolimus. The extent of disease involvement requires systemic therapy. Dupixent represents a safe and effective FDA (Food and Drug Administration) approved treatment option which is within the standard of care for treatment of severe atopic dermatitis in a child. Dupixent is approved for use in the treatment of the patient's atopic dermatitis under close medical supervision and at an appropriate dosing schedule at the discretion of the treating physician. The decision is overturned in whole.

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 Dupixent 200 milligrams (mg) / 1.14 milliliter (ml) subcutaneous (SC) solution prefilled syringe (SOSY) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe atopic dermatitis
Treatment: Dupixent 200 milligrams (mg) / 1.4 milliliter (ml) subcutaneous (SC) solution prefilled syringe (SOSY)
The insurer denied coverage for Dupixent 200 milligrams (mg) / 1.4 milliliter (ml) subcutaneous (SC) solution prefilled syringe (SOSY)
The denial is overturned

The is a patient with a history of severe atopic dermatitis who has failed therapy with multiple topical steroids and tacrolimus. The requested medication is Dupixent pediatric dosing, 200mg.

Dupixent is medically necessary for the treatment of the patient's diagnosis, atopic dermatitis. The patient is a child with decreased systemic treatment options available which could safely be administered given her age and chronic medical conditions. The patient has failed topical therapy with steroids as well as non-steroidal anti-inflammatory, tacrolimus. The extent of disease involvement requires systemic therapy. Dupixent represents a safe and effective FDA (Food and Drug Administration) approved treatment option which is within the standard of care for treatment of severe atopic dermatitis in a child. Dupixent is approved for use in the treatment of the patient's atopic dermatitis under close medical supervision and at an appropriate dosing schedule at the discretion of the treating physician. The decision is overturned in whole.

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 Dupixent 200 milligrams (mg) / 1.4 milliliter (ml) subcutaneous (SC) solution prefilled syringe (SOSY) is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, end stage renal disease and coronary artery disease.
Treatment: Consumer directed personal assistance program (CDPAP), 12 hours per day, 7 days per week; total amount of 84 hours per week.

The insurer denied coverage for CDPAP, 12 hours per day, 7 days per week; total amount of 84 hours per week.  The denial is overturned.

This is a patient with chronic medical problems including dementia, end stage renal disease and coronary artery disease. She lives with her daughter in a 2-bedroom elevator building. An increase in consumer directed personal assistance program services (CDPAS) from 9.5 hours per day, 7 days per week (total of 66.5 hours per week) to 12 hours per day, 7 days per week; total amount of 84 hours per week is requested and currently under review.  

The most recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as severely impaired. She is confused, oriented only to person and non-self-directing. This patient requires maximal assistance for activities of daily living including personal hygiene, bathing, and dressing. Toilet transfers/use also requires maximal assistance. She is frequently bladder incontinent and occasionally bowel incontinent. Patient is maximal to total dependent for functional mobility and has fallen on 2 separate occasions over the past 90 days. The combination of the patient's severe cognitive deficits with diagnosed dementia and functional deficits requiring maximal assistance, support the requested increase in CDPAS of 12 hours/day, 7 days/week; total amount of 84 hours per week.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested CDPAS, 12 hours/day, 7 days/week; total amount of 84 hours per week is 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 consumer directed personal assistance program (CDPAP), 12 hours per day, 7 days per week; total amount of 84 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied the braces.
The determination is upheld

The patient has a Class I occlusion with a 2-millimeter (mm) overbite and 2 mm overjet. He has minor maxillary and moderate mandibular crowing. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion. At issue is the medical necessity of braces.

There is no medical reason to correct his malocclusion with braces.
While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) However, this patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a skeletal Class I occlusion. (2) If his teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent Pen 300MG (milligrams)/2ML (milliliters) Pen Injector
The insurer denied Dupixent Pen 300MG/2ML Pen Injector.
The denial is overturned.

The patient is a female diagnosed with severe atopic dermatitis, body surface area (BSA) ten percent, involving the hand.  The patient has tried and failed Topicort, Eucrisa, Hydrocortisone, Aclovate, oral and intramuscular (IM) steroids and has now been prescribed Dupixent.  

The request for Dupixent was denied by the plan so the provider is appealing the denial.

The proposed treatment is medically necessary.

The patient has tried and failed several topical and systemic treatment options.  Per the Food and Drug Administration (FDA) approval, the patient is a candidate for Dupixent.

Dupixent is Food and Drug Administration (FDA) approved for patients with moderate to severe atopic dermatitis who have failed topical therapy.  The approval is not contingent on a specific topical agent.  

This patient has tried and failed several medium to high potency topical steroids as well as Eucrisa in addition to systemic therapy.  Standard of care would not be to require an additional topical medication that has not shown to have demonstrable superior efficacy over medication already tried and failed.  To delay effective systemic therapy in this patient that has severe disease in order to fulfill the coverage policy requirements puts the patient at risk for further destabilization.  The patient has tried and failed several topical medications as well as systemic steroids and per FDA approval, is a candidate for Dupixent.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: UTI (urinary tract infection)
Treatment: Inpatient admission 
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This is an infant with no past medical history who was brought to the emergency department (ED) with complaints of fevers for 2 days. She received her routine vaccines 4 days prior to admission. The maximum fever was 104 degrees F (Fahrenheit) at home, 103.4 degrees F in the emergency department (ED). A diagnosis of urinary tract infection (UTI) was considered, correctly, based upon urinalysis (23 white blood cell count (WBC), leukocyte esterase positive) and the organism was later identified as E. (Escherichia) coli (greater than 100,000 colonies/ml, which was pan-susceptible). WBC was 18.1, with slight neutrophil predominance, 62%. Physical exam was unremarkable. A renal ultrasound was unremarkable. A dose of ceftriaxone was administered. 

Per AAP (American Academy of Pediatrics) Guidelines, criteria for continued parenterally administered therapy for UTI (pyelonephritis), which would be done in the hospital intravenously, are a child whom a clinician judges to be "toxic" or who is unable to retain oral intake and can also be considered when compliance with an oral antibiotic is uncertain (1). The AAP guidelines have not changed in this regard since their publication (2). Neither of these criteria were documented in the medical decision making or other sections of the chart. All that is stated in the explanation for decision to admit is a diagnosis of suspected pyelonephritis. Notably, the baby was assessed as in "no acute distress." 

The reviewer agrees with the insurer that the infant could have been managed without a full hospital admission. A full hospital admission could have been considered after a period of observation in the ED and documentation of an inability to lower the temperature with antipyretics or an inability to take fluids or antibiotic orally. 

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 full hospital admission services is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Severe nausea and vomiting associated with menstrual cycle.
Treatment: Orilissa 200mg.
The insurer denied: Orilissa 200mg.
The denial is overturned.

The patient is an adult female with a diagnosis of severe nausea and vomiting associated with her menstrual cycle. The patient has tried multiple oral contraceptive formulations including progestin-only pills to no avail. The patient was started on Orilissa with some improvement in her condition. 

The patient and provider are requesting coverage for Orilissa.

The health plan should cover the proposed treatment.

Orilissa is a gonadotropin-releasing hormone (GnRH) receptor antagonist indicated for the management of moderate to severe pain associated with endometriosis. The request for Orilissa was denied because the patient does not have endometriosis. The health plan suggested the use of formulary medications - ibuprofen, meloxicam, naproxen - but none of these will shut down the ovaries as those are pain medications and will have no effect on the symptoms of nausea and vomiting.

This is a very rare case where the patient's symptoms are associated with her menstrual cycle. The treatment for that condition is to control her cycle. In other words, the treatment is to prevent the ovaries from producing hormones that cause this patient's symptoms.  The patient has failed treatment with oral contraceptives. The next step is to shut down ovarian function. This can be accomplished using either a gonadotropin-releasing hormone (GnRH) agonist or a gonadotropin-releasing hormone (GnRH) antagonist like Orilissa.  The patient has had a good response to Orilissa.  While Orilissa is not specifically approved for this rare condition, it is used to shut down the ovaries which is what is needed in this patient's condition and will be beneficial for this patient and should be approved.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Paroxysmal atrial fibrillation
Treatment: Eliquis (apixaban)
The insurer denied coverage for Eliquis (apixaban).
The denial is overturned.

This is an adult male with a past medical history of multiple strokes, patent foramen ovale (PFO) closure, paroxysmal atrial fibrillation, and pacemaker implant for sick sinus syndrome. He presented to his physician complaining of bruising and hemorrhoidal bleeding while taking Xarelto. He was transitioned to Eliquis therapy with resolution of symptoms. 

The 2019 American Heart Association, American College of Cardiology and Heart Rhythm Society Guidelines list a Class I (level of evidence A) recommendation for treatment with novel oral anticoagulant regimen instead of warfarin. This recommendation was based on several randomized clinical trials that enrolled thousands of patients. The direct thrombin inhibitor medications and the Factor Xa inhibitor medications (including Xarelto/Rivaroxaban) were at least non-inferior and in some cases superior to warfarin therapy. When Xarelto was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated non-inferiority to warfarin in preventing stroke or systemic embolism (Reference 2). This patient had clear evidence of bleeding while treated with Xarelto necessitating the use of an alternative such as apixaban (Eliquis). In fact, when Eliquis was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated superiority to warfarin in preventing stroke or systemic embolism. In addition, patients treated with Eliquis had less bleeding and a lower mortality than those treated with warfarin (Reference 3). 
 
In conclusion, the patient should be treated with Eliquis/Apixaban. The formulary drug Xarelto caused bleeding (harm). Warfarin, another formulary alternative may also cause harm. As the patient had no bleeding with apixaban therapy, it is clear that the requested drug would be more effective.

The carrier's denial of Request for Formulary Exception for Eliquis (apixaban) for anticoagulation therapy is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Small Intestinal bacterial overgrowth. 
Treatment: Xifaxan 550 mg (milligrams) OR (oral) tabs (tablets). 

The insurer denied coverage for Xifaxan 550 mg OR tabs. 

The denial is overturned. 

The patient has had a workup for abdominal pain, bloating, and diarrhea. She was diagnosed with IBS (irritable bowel syndrome) and small bowel intestinal overgrowth. She has failed treatment with antispasmodics and antidiarrheals. 

UpToDate has an article titled "Small Intestinal bacterial overgrowth (SIBO): Management." The article states that the mainstay of therapy for SIBO are antibiotics to reduce small intestinal bacteria. In patients with SIBO we use rifaximin for 14 days. It is well tolerated and has been demonstrated to be effective in the treatment of SIBO. 

UpToDate has an article titled "Treatment of Irritable bowel syndrome in adults." Under the section What's New: Guidelines on pharmacologic management of irritable bowel syndrome with diarrhea there is an updated American Gastroenterological Association clinical guidance on the pharmacological management of irritable bowel syndrome with diarrhea (IBS-D). It is suggested to use rifaximin as an option for initial treatment of patients with IBS-D and to retreat if there are recurrent symptoms. 

The patient's nurse practitioner is now requesting Xifaxan for SIBO. Xifaxan is an advised medication for SIBO and can also be used for IBS-D. It is a medically necessary treatment. Xifaxan is a more appropriate antibiotic for SIBO and IBS-D as compared to the other formulary antibiotics that have been offered. 

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 Xifaxan 550 milligrams (mg) OR tabs services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Radiofrequency ablation
The insurer denied radiofrequency ablation.
The denial is upheld.

The patient is a female diagnosed with low back pain, vertebrogenic low back pain. The treating provider recommended the patient undergo the Intracept procedure (intraosseous basivertebral nerve ablation), which was denied by the insurance carrier as this procedure is considered not medical necessity. The provider is appealing this determination, which is the subject of this review. The subject under review is the medical necessity for the requested radiofrequency ablation.

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

The requested radiofrequency ablation is not medically necessary for this patient. The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). Magnetic resonance imaging (MRI) did show degenerative endplate marrow edema at the right lumbar (L)5 - sacral (S)1. However, it was also noted the patient has impingement of the exiting right L5 nerve root which could also be a likely pain generator.
This procedure is not the standard of care, as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. Additional studies are needed to evaluate long-term risks and benefits of this procedure. The requested procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Hospital Admission
The insurer denied: Hospital Admission
The denial is upheld.

The patient was a male with unremarkable past medical history who was walking up the stairs and had a brief episode of loss of consciousness. He then acted bizarrely for approximately 20 minutes and Emergency Medical Services (EMS) was called. Subsequently, he lost consciousness and had clonic movements. The patient denied any trauma, tongue biting, or incontinence. When EMS arrived, his symptoms improved dramatically, and he was back to his baseline state. The patient had no further episodes and denied previous seizures in the past.
It was mentioned that the patient used alcohol socially and his last drink was one day before his presentation. He used marijuana daily and was vaping regularly.
On the physical exam, the patient was afebrile. Pulse rate was 64 beats per minute (bpm), respiratory rate 20 breaths/minute, blood pressure 121/79, oxygen saturation 99% room air. He was awake, alert, and oriented times 3. His pupils were reactive to light and the breath sounds were normal.
Laboratory evaluation revealed that white blood cell count was 9.9, hemoglobin 16.7, hematocrit 52.0, and platelets 392. Sodium was 140, potassium 3.7, chloride 102, bicarbonate 19, blood urea nitrogen (BUN) 17.0, creatinine 1.3, glucose 80.
The patient was admitted to the hospital with new onset of seizures. He underwent a computed tomography (CT) scan of the head that demonstrated no acute pathology.
In the hospital, the patient was seen by a neurologist who stated that the patient most likely had a partial seizure with secondary motor generalization.
It was reported that the patient underwent a magnetic resonance imaging (MRI) of the brain, which was normal.
Electrocardiogram (EKG) was performed but the result was not available at the time of discharge.
The patient was cleared for discharge by a neurologist.
In the hospital, the patient was also diagnosed with erythrocytosis, and some additional laboratory studies were sent.
During the hospital stay, the patient remained in stable clinical condition and was transitioned to outpatient care.

The health plan's determination is upheld in whole.

The hospital admission was not medically necessary for this patient.
At the time of the initial evaluation, the patient was awake and alert. He was hemodynamically stable and had no signs of central nervous system (CNS) infection. There was no evidence that he had focal neurologic signs. Per history, he had only one single episode of seizure on the day of admission. Reportedly he totally recovered from the seizure by the time he was seen by the admitting physician, and the imaging studies did not show any acute abnormalities that required intervention.
There was no evidence that the seizures were associated with significant electrolyte abnormalities. There was no evidence that the patient had any unstable concomitant conditions that would necessitate admission at the acute inpatient level of care. Taking into consideration all these facts, the patient could have been managed at a lower level of care status.