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

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent Pen 300mg/2ml PEN INJCTR 4.000 For 14 Days.
The insurer denied the Dupixent Pen 300mg/2ml PEN INJCTR 4.000 For 14 Days.
The denial is overturned.

The patient is a female with atopic dermatitis, 14% BSA (body surface area) to the trunk and extremities, treated with topical steroids and topical calcineurin inhibitors as well as methotrexate.  The provider is requesting Dupixent.  The health plan denied the request as the patient has not tried and failed Eucrisa.

Yes, the requested Dupixent is medically necessary.
This patient has tried and failed the appropriate therapies and has substantial disease. Eucrisa is only indicated for mild atopic dermatitis.  

Dupilumab is United States Food and Drug Administration indicated for treatment of recalcitrant atopic dermatitis, approved several years ago.  Two trials, SOLO-1 and SOLO-2, demonstrated that patients treated with Dupilumab experienced significant, clinically meaningful improvements in their atopic dermatitis at week 16 as measured by the EASI score (Eczema Area and Severity Index).  Dupilumab was well tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis.  Dupilumab is a novel interleukin-4 and interleukin-13 blocker, which inhibits the arm of the immune system responsible for atopic dermatitis. In clinical trials, after 12 weeks of monotherapy with dupilumab, 85% of patients had a greater than 50% reduction in eczema severity and pruritus scores decreased by 57.1%. In phase III clinical trials, dupilumab led to a 75% improvement in eczema severity, when compared to placebo, and decreased symptoms of anxiety and depression. It also led to a significantly decreased use of topical corticosteroids. The safety and efficacy were supported in a recent meta-analysis of all published dupilumab paper (Han et al.).

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genetic condition defined as 3q22.3q24
Treatment: Additional Speech Therapy Visits
The insurer denied the Additional Speech Therapy Visits.
The denial is overturned.

The patient is a male with a genetic condition defined as 3q22.3q24. The child has been receiving skilled speech therapy services for moderate cognitive and communication impairments defined in the medical records as difficulties to clearly and concisely express desires and necessities and evidence in increased errors in sound production with advancement from single word utterances to elongated utterances within conversation. The child's conditions have been defined as learning difficulties, childhood onset fluency disorder, as well as gross and fine motor delays.

The health plan denied the request for coverage of additional sessions of skilled speech therapy on an outpatient basis based on the fact that this child has been receiving school based services with valid IEP (Individualized Education Program) plan in place. In addition, clinical records point out only mild/moderate delays in speech. As per medical policy, only severe speech delays are subject for medical policy coverage. This denial is being appealed.

Yes, the Additional Speech Therapy Visits are medically necessary.
No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
In this case, the child has been receiving prolonged speech services in both outpatient and school based speech therapy interventions.

The child is bilingual and has chronic medical condition due to genetic disorder affecting cognitive and communication domain. Medical records clearly point out the fact that the school-based services are provided in English only, and are mainly related to educational needs and goals. This child requires bilingual services and skilled therapy sessions with a goal-oriented clinically-driven skilled and qualified speech and language provider that can address moderate to severe delays in developmental speech disorder. In addition, the request from the speech pathologist is reasonable in terms of the extent and duration of additional outpatient speech services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough; Chills.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male without any significant medical history who presented to emergency room with cough and chills. The emergency room evaluation included blood work and CT (computed tomography)-chest, which showed bilateral pneumonia. The patient was started on IV (intravenous) antibiotics, supplemental oxygen. Pulmonary consultation was requested. The patient was admitted for the management of pneumonia.

No, the Inpatient admission was not medically necessary.
The patient was being treated for pneumonia with IV (intravenous) antibiotics. During dates of service, patient was hemodynamically stable. Patient's oxygen levels were above 90% on room air. Patent was ambulating and was able to tolerate oral diet. The patient's blood work was with in normal range. The management of pneumonia with IV (intravenous) antibiotics could have been safely and effectively provided at a lower level of care. The proposed hospitalization was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty Controlling Urine.
Treatment: Posterior Tibial Neurostimulation.
The insurer denied the Posterior Tibial Neurostimulation.
The denial is upheld

The patient is a female with a diagnosis of overactive bladder. The provider discussed the options for treatment with the patient, including behavioral modification and physical therapy, medications, the InterStim procedure, Botox, and PTNS (Posterior Tibial Neurostimulation). The patient is interested in starting PTNS (Posterior Tibial Neurostimulation).

No, the requested Posterior Tibial Neurostimulation is not medically necessary.
Initial treatment for all patients with urinary incontinence (stress, urgency, or mixed) includes initiating pelvic floor exercises, modifying contributory medical and lifestyle (eg, obesity) factors, advising bladder training, and treating vulvovaginal atrophy if present.

For patients in whom the initial treatments are ineffective, a trial of medication is recommended.

Initial treatment with a beta-3 adrenergic agonist rather than an antimuscarinic agent is recommended. Efficacy is similar for the two drug classes, but antimuscarinic agents have more adverse effects. In addition, case-control and cohort studies have raised concerns for an increased risk of dementia with anticholinergic drugs.

For patients with an insufficient response to beta-3 adrenergic agonist drugs or antimuscarinic medication, dosing maximization and allow up to 12 weeks to achieve maximum response.

In individuals with persistent symptoms despite exercise and lifestyle therapies followed by a trial of at least two pharmacologic therapies (or inability to tolerate them) warrant referral to a specialist to consider third-line treatment options or surgery:  Third-line therapies range from noninvasive office-based acupuncture-like nerve stimulation (PTNS) and office-based injections of botulinum toxin A to surgically implanted nerve stimulation devices (SNM). 41 percent achieved success with PTNS (Posterior Tibial Neurostimulation) by 12 weeks.

In summary, the patient is not documented to have failed initial treatment or medication treatment. As of now, PTNS (Posterior Tibial Neurostimulation) is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The health plan relied on the latest scientific data for its decision.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post (s/p) Laparoscopic Hysterectomy, Bilateral Salpingectomy and Cystoscopy
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a woman. She was admitted to the hospital for a laparoscopic hysterectomy. The procedure was performed without complications with 100 cc (cubic centimeters) blood loss. She was admitted to the inpatient service and recovered uneventfully. She was discharged.

No, the Inpatient admission was not medically necessary.
The Health Plan documentation and medical literature were thoroughly reviewed. The patient underwent a laparoscopic hysterectomy without complications and low blood loss. Patients with no medical co-morbidities, who have undergone an uncomplicated laparoscopic hysterectomy, can be managed with a lower level of postoperative care than the acute inpatient service. Therefore there is no evidence that the patient's intra-operative and postoperative conditions and medical history indicated inpatient admission.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stage Four (IV) endometriosis, diminished ovarian reserve, tubal factor infertility

Treatment in vitro fertilization (IVF) procedure

The insurer denied coverage for in vitro fertilization (IVF) procedure

The denial is upheld 

The patient is a female with a history of stage IV endometriosis. The patient has a diminished ovarian reserve and tubal factor infertility. She has bilateral distal tubal blockage, hydrosalpinges and a low Anti-Mullerian hormone of 0.55. She underwent surgery to resect severe endometriosis but still has tubal damage and diminished ovarian reserve.

As part of education and informed consent before cancer therapy, gonadotoxic treatments and surgeries that may lead to decrease fertility (oophorectomy), health care providers should address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss fertility preservation options and/or to refer all potential patients to appropriate reproductive specialists. 

This patient, however, is not undergoing any treatment that will affect her future fertility. She does not have cancer and will not be receiving any chemotherapeutic agent or radiation therapy that may affect her ovaries nor is she undergoing any surgery that will lead to loss of ovarian function. When she is ready to conceive, she will have to undergo IVF due to the absence of fallopian tubes. 

While serum anti-mullerian hormone (AMH) remains the preferred ovarian reserve marker, little is known about endogenous and exogenous factors that influence serum AMH levels, which limits proper interpretation of AMH values in a clinical setting.
Based on the above, the fertility preservation services by egg freezing are not medically necessary at this time. The patient is appealing. In an undated appeal letter, she writes that the IVF procedure is medically necessary due to her diminishing ovarian reserve and tubal factor infertility from her stage IV endometriosis. 

The insurer's denial of coverage for an in vitro fertilization procedure (fertility preservation) (S4021) is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: constipation.
Treatment: Trulance.
The insurer denied Trulance. 
The health plan's determination is upheld. 

The patient is a female with chronic idiopathic constipation. She has attempted Metamucil and Miralax with ongoing constipation, incomplete bowel movements, and abdominal cramping. She failed Linzess 72 mcg (micrograms) daily, which caused diarrhea. 

A formulary exception is not indicated in this case.
Trulance is not supported over the formulary alternative Amitiza (lubiprostone). The patient has had chronic constipation, and failed fiber and osmotic laxatives, and an advanced agent (Linzess). The American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as Amitiza or Trulance should be used if non-pharmaceutical laxatives fail. Amitiza has shown safety and efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain. Trulance has not demonstrated higher safety or efficacy than Amitiza in a direct controlled comparison. For these reasons, the use of Trulance is not indicated in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied white glass with high gold content crown for Tooth 31. 
The denial is overturned.

The patient is a male who presented to the office of his dental provider for evaluation and treatment of tooth #31. Provided for review are previous letters of appeal and denial, full mouth radiographic images, one page of American Dental Association (ADA) claim forms, and health plan language. In question is the medical necessity of the planned treatment of porcelain fused to high noble metal crown for tooth #31.
Previous denials have been on the basis that there needs to be a significant breakdown of the tooth due to decay or trauma such that a direct restoration could not address the issue.

The health plan's determination is overturned.

The requested white glass with high gold content crown for Tooth 31 is medically necessary for this patient. Based on the radiographic image although there is not extensive decay, the current restoration involves a cusp and with the amount of removal, a full coverage restoration is now indicated in order to provide cuspal coverage and replace the amount of affected tooth structure which cannot be done with a direct restoration. Hence as a full coverage crown is the only proper restoration it is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atrial Fibrillation. 
Treatment: Eliquis. 

The insurer denied Eliquis. The health plan's determination is upheld. 

The patient is a female with a history of atrial fibrillation. She has been on Eliquis for years. There were no adverse side effects. The health plan denied the use of Eliquis as it requires a trial of its formulary drugs warfarin and Xarelto. 

A formulary exception is not indicated. 

Patients with atrial fibrillation (a-fib) can be at an elevated risk of an associated cerebrovascular accident (CVA) and in some individuals anticoagulation is indicated. Warfarin has been proven effective for a-fib stroke prevention. A new generation of anticoagulants, including Eliquis and Xarelto have been developed for a-fib stroke prevention. All agents have an associated increased risk of both major and minor bleeding. The newer medications have generally been demonstrated as or more effective than Warfarin for stroke prevention and are generally safer. 
Per the plan formulary, prior to considering Eliquis, there must be treatment failure, intolerance, or contraindication to warfarin or Xarelto. This is not present in this case. As such a formulary exception is not indicated. 
Additionally, Eliquis has not been definitively established as standard of care, compared to Xarelto, towards improved a-fib outcomes. Also, there was no contraindication to Xarelto in this case. Therefore, Eliquis is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impaired Fasting Glucose. 
Treatment: Ozempic 2MG/1.5ML SC SOPN. 

The insurer denied the Ozempic 2MG/1.5ML SC SOPN. 
The denial is upheld. 

The patient is a male patient. The request for Ozempic is under review. The prior request was denied coverage by the health plan, as the diagnosis was listed as impaired fasting glucose. The physician is appealing this determination as the patient has type 2 diabetes. He has tried metformin, Victoza, and Trulicity. He has been on Ozempic for several months. His A1C (glycated hemoglobin) was 5.4-6.1%. 

No, the Ozempic is not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient. 

This request is for Ozempic. The prior request was denied as the requested diagnosis was impaired fasting glucose and not a diagnosis of type 2 diabetes. The appeal letter indicates the patient has a diagnosis of type 2 diabetes. A diagnosis of type 2 diabetes is not supported by the submitted clinical documentation. The progress notes list a diagnosis of impaired fasting glucose. The patient does not have a documented elevated glucose or A1C (glycated hemoglobin) 6.5% or higher to support a diagnosis of type 2 diabetes. Ozempic is not Food and Drug Administration (FDA)-indicated for the treatment of impaired fasting glucose. Ozempic has risks, including nausea and vomiting. Therefore, the requested Ozempic is not medically necessary.  The health plan did act reasonably, with sound medical judgment and in the best interest of the patient as the requested Ozempic was not medically necessary and it was appropriately denied.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypertension. 
Treatment: Edarbyclor 40/25mg Tablet. 

The insurer denied Edarbyclor 40/25mg Tablet. The health plan's determination is overturned. 

The patient is a female with a history of essential hypertension and coronary artery disease who has been treated with Edarbyclor 40-25 milligrams (mg) for the last 4 years for hypertension control. The patient's treating physician has requested a prescription benefit exception request for continued authorization for Edarbyclor. Records indicate that the patient has previously failed treatment with amlodipine and losartan-HCTZ (hydrochlorothiazide). 

A formulary exception is indicated in this case. 
Given the patient's past history of treatment failure with Losartan-HCTZ it is unlikely that the other formulary drugs and combination therapy will be as effective as Edarbyclor for controlling this patient's blood pressure based on expert consensus guidelines on management of high blood pressure in adults (1). Edarbyclor 40/25mg Tablet is indicated to adequately control this patient's blood pressure and reduce her overall cardiovascular risk.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atrial Flutter. 
Treatment: Formulary exception for Eliquis. 

The insurer denied the Formulary exception for Eliquis. 
The denial is overturned. 

The patient is a male with history of atrial flutter, hypertension, hyperlipidemia, CAD (coronary artery disease), and OSA (obstructive sleep apnea). The patient had been on multiple medications, including Xarelto. There was a thrombus that developed while on Xarelto. Several years ago, the patient was on warfarin, later on Xarelto. There was also evidence of being on Eliquis. He has objective evidence of CAD (coronary artery disease), LAE (left atrial enlargement), and wall motion abnormalities. Eliquis was prescribed for atrial flutter "stroke prevention." It was denied coverage by the health plan as not on formulary. 

Yes, the health plan should cover the Formulary exception for Eliquis. 

Recent published studies in respected journals, including New England Journal of Medicine and JAMA (Journal of the American Medical Association) have concluded that Eliquis is the preferred anticoagulant for the condition for atrial fibrillation. Large population studies have shown that Eliquis is safer, with less bleeding, fewer strokes, and fewer complications than either Xarelto or warfarin. 

Atrial flutter and atrial fibrillation can be used interchangeably in the Class 1A for anti-coagulation. Any conclusion of a study of anti-coagulation for atrial fibrillation applies to Atrial Flutter.

Eliquis was found to be more effective than warfarin in lowering the risk of stroke and systemic embolism. People who took Eliquis also had significantly fewer bleeding episodes than those who took Warfarin. 

Eliquis is the only NOAC (non-vitamin K oral anticoagulant) that is better than Warfarin in the prevention of stroke and results in fewer bleeding complications. Overall, all-cause mortality from DOACs (directly acting oral anticoagulants) is evidenced to be lower than that from warfarin, driven primarily by a decrease in fatal intracranial bleeding risks. 

Among Medicare beneficiaries 65 years or older with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events. Apixaban versus Warfarin in Patients with Atrial Fibrillation for the ARISTOTLE Committees: "In conclusion, in patients with atrial fibrillation, apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality." 

The patient has tried Xarelto and Warfarin, but for stroke prevention it is evidenced that Eliquis is safer and more effective. Therefore, the health plan should cover the formulary exception for Eliquis.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history remarkable for hypertension, and diabetes, who was admitted due to his request for alcohol detoxification. The patient presented with signs and symptoms of alcohol withdrawal. Review of system was positive for anxiety, nausea, headache, and mild tremor of the hands.
The patient was afebrile (Temp of 98.6). His blood pressure was 153/85, pulse rate of 99, respiratory rate of 19, and oxygen saturation of 98% on room air. Physical examination was unremarkable for positive clinical findings. The patient was admitted for alcohol withdrawal and medical supervised withdrawal management. 

The inpatient hospital admission was not medically necessary. The patient was admitted for alcohol intoxication and withdrawal. The documentation does not support the necessity of an inpatient level of care since the patient was hemodynamically stable and had no evidence of instability or focal neurologic deficits. There were no objective clinical findings that were consistent with alcohol withdrawal or delirium tremens.
The Diagnostic and Statistical Manual of Mental Disorders defines alcohol withdrawal as 2 or more distinguishing symptoms which develop within several hours to days following a significant decrease in alcohol consumption after a prolonged period of heavy drinking. These symptoms include nausea or vomiting, autonomic hyperactivity, insomnia, increased anxiety and agitation, tremor, perceptual disturbances, and seizure. In this case, the patient had no objective signs of autonomic hyperactivity. A lower level of care would have been appropriate for clinical monitoring and intravenous (IV) fluids. His CIWA scores (Clinical Institute Withdrawal Assessment of Alcohol Scale) did not warrant treatment at the inpatient level of care.