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

Diagnosis: allergic rhinitis

Treatment: Xhance 93MCG/ACT NA EXHU

The insurer denied coverage for Xhance 93MCG/ACT NA EXHU

The denial is upheld. 

This patient is an adult with an extensive medical history inclusive of bacterial infections, allergic rhinitis, hyperprolactinemia, Lupus and hypertension. She has sinusitis and has failed Flonase, Nasacort, and Rhinocort.

The formulary drug(s) are not likely to cause the patient an adverse reaction. 

According to the documentation provided for review, the formulary medications are flunisolide nasal solution, fluticasone nasal spray, Omnaris spray and triamcinolone acetonide nasal aerosol suspension. There is no indication that flunisolide nasal solution, fluticasone nasal spray, Omnaris spray and triamcinolone acetonide nasal aerosol suspension would cause an adverse reaction.

"Flunisolide (marketed as AeroBid, Nasalide, Nasarel) is a corticosteroid with anti-inflammatory actions. It is often prescribed as treatment for allergic rhinitis and its principle mechanism of action involves activation of glucocorticoid receptors." (National Center for Biotechnology Information, 2023).      

The formulary drug(s) have not been ineffective based on the patient's clinical history. Documentation supports the patient has trialed and failed Flonase, Nasacort, and Rhinocort.     

The requested drug would not be more effective than the formulary drug. Research does not support that Xhance has been shown to be more effective than the formulary drugs.

"The exhalation delivery system with fluticasone (EDS-FLU; XHANCE ) uses a novel delivery system to create closed-palate, positive-pressure, bidirectional mechanics that significantly alter the deposition of the topically acting anti-inflammatory medication." (Ow et al., 2023)                                                       

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non- formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Xhance 93MCG/ACT NA EXHU is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: soft tissue recession

Treatment: Biologic materials (D4265) and non-autogenous connective tissue graft (D4275)

The insurer denied coverage for Biologic materials (D4265) and non-autogenous connective tissue graft (D4275)

The denial is overturned

Based on evaluation of the submitted documentation which includes copies of periodontal chartings, copies of periapical and bitewing radiographs, treatment notes and intraoral photographs, and insurer correspondence, it appears that this patient presented for evaluation of gingival recession affecting the right anterior maxilla number 6/7 area. The recommended treatment was allografts and biologic material placement at the site. The insurer has denied the services stating that the clinical circumstance does not fulfill the required criteria and therefore does not substantiate medical necessity. The patient is appealing.

Upon review of the documentation, in fact progressive gingival recession and gingival attachment loss is noted radiographically and clinically as noted in the periodontal charting. There does appear to be loss of attached gingiva with apical migration of the marginal remaining gingiva. Treatment in clinical practice of this gingival recession would include the recommended grafting procedures. There is ample peer-reviewed literature (see below) which substantiates and corroborates the usefulness of this procedure in addressing this clinical circumstance. As this is the case, the grafts are considered medically necessary. 

Further, in this case, for bone regeneration the treating dentist recommended the biologic material in association with aforementioned graft material. There is peer-reviewed literature (see reference below) which indeed does show improved outcome with use of this material. This type of procedure with this material is not considered experimental and has been documented in the literature to show significant aid in regenerating bony support. As the clinical and radiographic findings indicate and corroborate the bony defects, the biologic materials would be considered appropriate for this clinical circumstance. 

Biologic materials (D4265) and non-autogenous connective tissue graft (D4275) is considered medically necessary for this patient.

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 Biologic materials (D4265) and non-autogenous connective tissue graft (D4275) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: osteoarthritis
Treatment: Personal Care Worker Service: 13 Hours per Day, Live-In / 7 days per Week Totaling 91 Hours per Week.
The insurer denied Personal Care Worker Service: 13 Hours per Day, Live-In / 7 days per Week Totaling 91 Hours per Week. The health plan's determination is overturned. 

This is a case review for a female with medical history notable for osteoarthritis, low back pain, and wheelchair-bound status. The patient and her care team requested an increase to 13-hours per day (Live-in, 91 hours per week) and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that she is wheelchair dependent and cannot bear weight for any significant period of time. She is dependent on others for transfers, toileting, and other activities of daily living. The physician recommends increase home care services to meet her needs.

The requested Personal Care Worker Service: 13 Hours per Day, Live-In / 7 days per Week Totaling 91 Hours per Week is medically necessary for this patient.
The health plan denied the patient's request because they stated that they did not have sufficient information to determine her needs in part due to her lack of a 3 day evaluation. However, even in the absence of this evaluation, her needs can be reasonably expected to be continuous and unscheduled in nature and to require the requested services. Multiple physicians provided letters attesting to her need for hands-on support with transfers and toileting, which was also reflected in the Uniform Assessment System (UAS). Because her toileting needs cannot be scheduled to all occur within her 8 hours of personal care per day, she qualifies for the requested services. Failure to meet her personal care needs for toileting could result in skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: heart disease, hypertension and venous stasis ulcers

Treatment: personal care aide (PCA) level 2 - live-in per diem - 7 days per week

The insurer denied coverage for personal care aide (PCA) level 2 - live-in per diem - 7 days per week

The denial is modified 

This is an elderly female with diagnoses that include heart disease, hypertension and venous stasis ulcers.  She lives alone in a 1-bedroom apartment.  The insurer approved personal care aide (PCA) level 2: 5.5 hours/day - 7 days/week (38.5 hours/week) and the request is for personal care aide (PCA) level 2: live-in per diem 7 days/week.

On the Uniform Assessment System (UAS) report the patient's cognition is described as modified independent.  She reports requiring maximal assistance to total dependence for much of her Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping.  She reportedly requires extensive assistance for bathing, lower body dressing and toilet use.  Limited assistance is reportedly needed for upper body dressing, bed mobility, locomotion, toilet transfer and ambulation. She reports being independent for personal hygiene and eating.  The patient is reportedly frequently incontinent of bladder and continent of bowel.  

The patient's activities of daily living (ADL) status and self-sufficiency have declined over the prior 90 days.  The patient's condition and functional deficits are not at a level or unpredictable as to require the requested personal care aide (PCA) level 2: live-in per diem 7 days/week.  This physician would agree that the patient may benefit from monitoring for safety, particularly due to her progress weakness and balance deficits.  However, personal care services (PCS) for companion care or safety supervision without the direct provision of task assistance is not a covered service.  However, the approved personal care aide (PCA) 5.5 hours/day is insufficient, given her progressive clinical and functional deficits.  Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing personal care aide (PCA) to 10 hours/day, 7 days/week.    

From a physical medicine and rehabilitation perspective, the requested personal care aide (PCA) level 2: live live-in per diem 7 days per week is not medically necessary.  However, personal care aide (PCA) level 2; 10 hours/day, 7 days/week (70 hours total) is medically necessary.  

Based on the above, the insurer's denial must be modified. 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 personal care aide (PCA) level 2 - live-in per diem - 7 days per week services is not substantiated. However, personal care aide (PCA) level 2; 10 hours/day, 7 days/week (70 hours total) is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1:

Diagnosis: Complex regional pain syndrome of the left lower leg

Treatment: pain injection (64454 x 1)

The insurer denied coverage for pain injection (64454 x 1)

The denial is upheld

This is a patient with a history of complex regional pain syndrome of the left lower leg, left knee pain, and arthritis of the left hip. At an office visit it was noted that the patient had sharp shooting pain at the medial knee. The patient had a left lateral knee injection with no relief and the physician recommended right genicular nerve blocks. 

Additional records review included the list of 36 active medical problems. The reported previous surgery to the left knee. The description of playing softball and giving way. The absence of any symptoms referable to the right knee. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

The pain injection (64454 x 1) does have final approval from the appropriate regulatory bodies for this diagnosis. Food and Drug Administration (FDA) approval has been granted for this service but opinions of efficacy and guidelines are not present. 

This patient is not a good candidate for pain injection (64454 x 1).

The pain injection (64454 x 1) is not the best available treatment for this patient at this time. It would be important to establish the pain generator. There was lack of consistency in the medical record for any condition to require this service. Simply stated global complaints were made to several body sites. The procedure was completed on the left side without benefit. The procedure to the right side without documentation of pain or physical findings lacks credence. There would be no reason to recommend this service for an unconfirmed diagnosis. 

There are adverse risks increased over standard treatment/services. There would be the possibility of infection and/or broken hardware. 

The requested service is not likely to be more beneficial than any of the standard treatments for this patient.

A search was performed using PubMed and National Library of Medicine. The key word was knee and Genicular nerve block.  There were references which consisted of case reports and opinions. Most of the references dealt with osteoarthritis of the knee. There were no studies of comparison groups nor long term outcome. A pubmed search using knee and genicular nerve block and complex regional pain syndrome revealed no publications. The technique has been proposed to relieve chronic knee pain. There are no recommendations nor guidelines provided. The procedure is currently not the standard of care. 

In summary, the denial of pain injection (64454 x 1) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Glaucoma
Treatment: Lumigan
The insurer denied Lumigan. The health plan's determination is overturned.

The patient is a female with primary open-angle glaucoma, bilateral, mild stage, for whom coverage of Lumigan (bimatoprost) is the subject of review. Coverage was previously denied, as it was not identified that the patient had failed or could not use both formulary alternatives which include latanoprost, travoprost (generic Travatan Z).

A formulary exception is indicated for this patient. In this case, the patient reportedly tried and failed Xalatan (latanoprost) and Travatan Z. In addition, a review of the peer reviewed medical literature also confirms that the formulary alternatives would not be expected to be as effective as Lumigan (bimatoprost) at lowering intraocular pressures.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque Psoriasis
Treatment: Taltz
The health plan denied the requested medication, Taltz, as not medically necessary. The health plan's determination is upheld.

The patient is a female with severe psoriasis that includes the fingers and inner thighs. The patient has tried and failed topical Vtama, Calcipotriene, Betamethasone, Halobetasol, Hydrocortisone Triamcinolone, Tacrolimus, and Duobrii, as well as Skyrizi. The patient also has polyarthralgias involving the ankles, feet, neck, shoulders, and hands, and stiffness in the feet for 30-45 minutes in the morning is reported. The clinic notes also describe verrucae of the right third finger, and also molluscum contagiosum of the inner thighs.
At issue is the medical necessity for the requested medication, Taltz.

The health plan determination of Taltz coverage is recommended to be upheld, in whole.

No. The health plan formulary alternative Cosentyx has a very similar level of efficacy and safety, and a very similar mechanism of action, to the requested Taltz. The effectiveness and safety and outcomes of Cosentyx and Taltz are virtually identical. 
The patient has no documented treatment failure with, or true medical contraindication to, either Cosentyx or other treatments effective for this patient's condition (and the clinic notes make it difficult to discern whether the patient has psoriasis, or verrucae and molluscum, on the hands and thigh). These other alternative treatments include Humira, Stelara, or Tremfya, all of which are of similar potency and efficacy to the requested Taltz. In particular, however, the similarities of Cosentyx and Taltz are so great so as to support Cosentyx first if the provider strongly believes in the mechanism of action that Taltz has. These alternative medications are as medically appropriate for the treatment of this patient's particular clinical condition as is the requested Taltz. Therefore, as per the patient's health plan policy language, [1] and consistent with current dermatology literature for both psoriasis of the skin and joints, [2-9] the requested Taltz is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Cosentyx
The health plan denied the requested medication, Cosentyx, as not medically necessary. The health plan's determination is upheld.

The patient is a male with moderate to severe plaque psoriasis affecting up to 100% (percent) body surface area who has previously failed therapy with a topical corticosteroid in Triamcinolone 0.1% cream.

At issue is the medical necessity for the requested health service/treatment of Cosentyx. 

I recommend to uphold, in whole, the health plan's determination of medical necessity.

The requested health service/treatment of Cosentyx is not considered medically necessary for this patient.

Plan policy considers Cosentyx medically necessary for the treatment of plaque psoriasis if there is documentation of treatment failure or clinical contraindication to phototherapy, as well as one conventional systemic therapy such as Methotrexate or Cyclosporine. The patient has not yet tried treatment with any of these plan-preferred alternative therapies. Per Food and Drug Administration (FDA) label, contraindications to these therapies include hypersensitivity to any of the drugs, pregnancy, breastfeeding, concurrent nitrous oxide use, active peritoneal dialysis, history of immunodeficiency, history of alcohol abuse, hepatic disease or impairment, renal disease or impairment, history of blood dyscrasias, history of myelosuppression, active infection, uncontrolled hypertension, history of malignancy, concurrent use (for Cyclosporine), concurrent radiation therapy (for Cyclosporine), history of a photosensitivity, non-melanoma skin cancer, or cutaneous melanoma. The patient does not have documentation of any of these contraindications to Methotrexate, Cyclosporine, or phototherapy. These therapies are FDA-approved for the treatment of plaque psoriasis with improved efficacy over topical therapies and may provide adequate treatment for the patient's plaque psoriasis. Due to the availability of these alternative therapies, the use of Cosentyx for the treatment of this patient's plaque psoriasis is not considered medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic middle ear disease
Treatment: Eustachian tube, code 69706 Nasopharyngoscopy, surgical, with dilation of eustachian tube
The insurer denied coverage for Eustachian tube, code 69706 Nasopharyngoscopy, surgical, with dilation of eustachian tube
The denial is overturned.
 
This patient has bilateral chronic middle ear disease and chronic eustachian tube dysfunction. This eustachian tube dysfunction has resulted in retracted tympanic membranes, possible cholesteatoma, and conductive hearing loss. This patient requires tympanomastoidectomy to remove the chronic disease, to prevent further complications such as brain abscess and worsening hearing loss and restore hearing. If the ear surgery is done without addressing the eustachian tube dysfunction, then the surgery will not be successful, and the current issues will recur. A systematic review and meta-analysis published in 2020 in Otolaryngology Head and Neck Surgery showed that balloon eustachian tube dilation is an effective treatment in objective and subjective symptoms of chronic eustachian tube dilation. This is especially true in those patients who has evidence of conductive hearing loss and abnormal tympanogram on audiogram like this patient and those who have failed medical therapy.

Based on the review of the evidence available so far, the proposed indication for Eustachian tube dilation using Balloon Dilation of the Eustachian tube (BDET) is for a patient with ALL of the following: aural fullness greater than 12 weeks; type B or C tympanogram; Eustachian Tube Dysfunction Patient Questionnaire (ETDQ-7) mean score more than 2; and failed medical management including Valsalva maneuver and either 4 weeks of nasal steroids or 1 week of oral steroids. The patient meets all of the above criteria.  

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 Eustachian tube, code 69706 Nasopharyngoscopy, surgical, with dilation of eustachian tube services is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Glaucoma
Treatment: Prolensa (bromfenac)
The insurer denied coverage for Prolensa (bromfenac)
The denial is upheld.

According to the documentation submitted, this is the case of a patient with a history of Uveitis glaucoma of right eye, severe stage, and Chronic iridocyclitis of right eye. The patient had a Ophthalmology visit. The note stated that the patient presents for 4 months Uveitis glaucoma right eye follow up with Humphrey visual field (HVF) test. The patient reported that vision has remained stable since last office visit and is tolerating drops well. Tonometry pressure was 08 on the right and 12 on the left. The order stated Prolensa to right eye daily.

The formulary drugs (bromfenac, diclofenac, ketorolac) are not likely to cause the patient an adverse reaction.  These drugs are all non-steroidal drops and there is no documentation that the patient has had or will likely develop an adverse reaction to these formulary alternatives.

There is no documentation that the formulary drugs have been ineffective based on the patient's clinical history.  There is no documentation that the patient has tried and failed these formulary alternatives.

Based on the current literature, there is no evidence that the requested drug Prolensa would be more effective than the formulary drug.  Duan et al. showed that diclofenac, ketorolac and bromfenac demonstrated efficacy in the treatment of anterior chamber inflammation after cataract surgery.  In addition, Wilson et al. showed the formulary drugs demonstrated similar effectiveness for treatment of pain and inflammation.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non-formulary drug is not expected to be more effective that the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Prolensa is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Humerus fracture
Treatment: Physical Therapy, 2 visit(s)
The insurer denied coverage for Physical Therapy, 2 visit(s)
The denial is upheld.

This is an adult who sustained a left proximal humerus closed fracture. Treatment included physical therapy. Over the next several months, the patient participated in 25 physical therapy sessions. Under review is the medical necessity of 2 additional physical therapy visits.

The physical therapy treatment notes made available for review fail to provide objective clinical information to support the medical necessity for additional physical therapy. The physical therapy treatment notes do not establish the medical necessity of continuing a structured out-patient physical therapy treatment program. According to the physical therapy note and after more than 4 months of treatment; there is a lack of evidence regarding significant improvement. Left shoulder strength remains at the 2+ (plus) to 3+ out of 5. Shoulder range of motion compared to the prior evaluation is much the same and well within functional limits. Reported pain also remains at 3/5. The provision of extensive physical therapy, without documented functional improvement is essentially maintenance treatment and therefore not medically necessary. In addition, after more than 4 months of physical therapy, the patient should be independent with a home exercise program.

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 Physical Therapy, 2 visit(s) is not substantiated.