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

Diagnosis: Type 2 Diabetes. 
Treatment: Formulary exception for Janumet. 

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

The patient is a female with type 2 diabetes. Request for Janumet is under review. The prior request was denied as the coverage criteria requires that the patient has an inadequate treatment response or intolerance to or a documented clinical reason such as it would be expected to cause an adverse reaction or a documentation contraindication to Jentadueto and Jentadueto XR (extended release). The reason the attending physician is appealing this determination is because the patient had an allergic reaction with hives to Jentadueto. 

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

This request is for Janumet for the treatment of type 2 diabetes. The formulary alternatives are Jentadueto and Jentadueto XR (extended release). This patient has tried and was allergic to Jentadueto, which resulted in hives. The patient can be reasonably expected to have the same allergic response to Jentadueto XR (extended release). Without Janumet, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the health plan should cover the formulary exception for Janumet.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Aortic Syndrome (takayasu).
Treatment:  Actemra 400MG/20ML Vial.
The insurer denied the Actemra 400MG/20ML Vial.
The denial is upheld. 

The patient is a female with Takayasu's arteritis diagnosed.  She presented initially with multisystem inflammatory syndrome in children (MIS-C) after COVID exposure, complicated by congestive heart failure, and was treated with pulse-dose Solumedrol and intravenous gamma globulin.  She failed treatment with subcutaneous methotrexate and infliximab, with radiographic progression of arterial disease noted in multiple vascular territories.  At that time she was treated again with pulse-dose Solumedrol and cyclophosphamide, dosed according to the Euro-lupus protocol.  

At her follow up visits, the patient was doing very well.  She had stable lower extremity cramping with activity.  She remained on prednisone 30 mg (milligrams) daily.  No follow up imaging data or inflammatory markers are provided.  The provider now wishes to treat with high-dose intravenous Actemra, citing American College of Rheumatology published guidelines for the treatment of vasculitis.  Appeal is for Actemra 400MG (milligrams)/20ML (milliliter) Vial for the treatment of Takayasu's arteritis.

No, the requested treatment with Actemra is not medically necessary.

This female patient presented initially with heart failure due to MIS-C (multisystem inflammatory syndrome in children) and then developed Takayasu's arteritis failed treatment with subcutaneous methotrexate and infliximab.  She was noted to have radiographic progression of arterial disease noted in multiple vascular territories.  At that time, she was treated aggressively with pulse-dose Solumedrol and cyclophosphamide, dosed according to the Euro-lupus protocol.  

At her follow up visits, the patient was clinically doing very well on prednisone 30 mg (milligrams) daily.  No follow up imaging data or inflammatory markers are provided.  The provider now wishes to treat with high-dose intravenous Actemra, citing American College of Rheumatology published guidelines for the treatment of active Takayasu's arteritris.

However, this patient has already been treated aggressively for her radiographic arteritis flare noted, with high-dose steroids and cyclosphosphamide.  Since she is now clinically doing well, she is appropriate for cautious steroid tapering, close clinical and radiographic monitoring, and perhaps for consideration of maintenance therapy.  Since there is no evidence of any additional clinical or radiographic flare subsequent to her recent treatment with high-dose steroids and cyclosphosphamide, treatment with high-dose Actemra at this juncture is not clinically appropriate or in accordance with standard of care in the medical community.  Thus, the requested Actemra 400MG (milligrams)/20ML (milliliter) vial is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is upheld.

The patient has a history of heavy periods and anemia.  She presented to the emergency department (ED) for evaluation of difficulty breathing and shortness of breath (SOB) on ambulation for two weeks, anemia, and ankle pain secondary to fall. Her hemoglobin was 5.7.  On arrival, she reported that she had passed out that morning and fell on a few steps, after which she had difficulty walking. She denied SOB, dizziness or chest pain. She was admitted and received 2 units of red blood cells and was seen by Podiatry for an ankle sprain. X-ray did not show any fracture. The patient did not have any active bleeding. She was discharged.

It is unclear why this patient was admitted for 3 days. This patient was symptomatic for anemia. In addition, she fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 grams per deciliter (g/dl). Transfusion was necessary. Could transfusion be done as an outpatient? It is obvious that in this day and age, transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). The need for transfusion is not a reason for admission.  The transfusion could have been completed in the emergency department (ED) without the need for admission. Following transfusion, the patient could have been monitored for a few hours in the ED, her complete blood count (CBC) repeated and then discharged home with a follow up within 24 hours with her primary physician or gynecologist.

As to her ankle pain. The X-ray did not show any fracture. She had an ace (elastic bandage) bandage placed. An ace bandage does not require admission.  Nothing was done in the hospital that could not be done as an outpatient. Milliman care guidelines list the clinical indication for inpatient care for patients with anemia. These includes active massive hemorrhage, active hemolysis, cognitive impairment, or tachycardia. The patient was stable and did not have any of the above indications for admission.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Admission was not medically necessary.

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive Urgency

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This patient presented to the hospital with hypertension noted following elective colonoscopy.  On physical examination blood pressure (BP) was 196/120 and remained elevated following intravenous (IV) labetalol and IV hydralazine treatment.  No other pertinent positive findings were noted on examination. The patient did report a severe headache and computed tomography (CT) scan of the head revealed no intracranial pathology.  ECG (electrocardiogram) revealed normal sinus rhythm without ischemic changes and serum blood testing did not reveal evidence of cardiac or renal target organ damage. Past medical history was significant for diabetes mellitus and alcohol abuse. The patient was admitted to the hospital and treated for hypertensive urgency and ultimately released on oral antihypertensive medications.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  Hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1) This patient complained of headache and required CT scan of the head to rule out intracranial pathology. He had a hypertensive urgency. Treatment goals for hypertensive urgency are to institute antihypertensive medications in an outpatient setting. 

American Heart Association/ American college of Cardiology (AHA/ACC) guidelines state: "There is no indication for referral to the emergency department, immediate reduction in BP in the emergency department, or hospitalization for such patients." (Reference 1) 

Admission to the hospital for aggressive blood pressure management was not medically necessary. (Reference 1,2) 

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's Disease, Coronary Artery Disease, Dementia, Low back pain, dizziness and gait ataxia
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAS) Services to 42 Hours Per Week
The insurer denied the increase in consumer directed personal assistance program (CDPAS) services to 42 hours per week.
The denial is upheld.

The patient is a male with a history of Parkinson's disease, coronary artery disease, dementia, low back pain, dizziness and gait ataxia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 42 hours/week consumer directed personal assistance program services (CDPAS) to offer increased ADL support.

Yes, the requested 42 hours/week CDPAS is deemed medically necessary.

Although an assessment of the patient's functionality and ability to perform ADLs was completed and noted that the currently approved plan of 20 hours/week personal assistance services is sufficient to meet the patient's current needs, the patient's medical provider indicates that the patient has been demonstrating significant decline in functional mobility and overall medical status, now requiring assistance with bathing, dressing, grooming and meal preparation.

Hence, provision of 42 hours/week personal assistance services can reasonably be expected to be beneficial for the patient. Withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 42 hours/week CDPAS is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain on Exertion

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient presented to the hospital with dyspnea and chest pain on exertion.  He noted symptoms after climbing two flights of stairs.  He initially was seen in the office of his primary medical doctor (PMD) and was sent by ambulance to the emergency department (ED) for further evaluation.  Upon arrival, vital signs were stable (Blood Pressure 134/81, Pulse 79 beats per minute [bpm]).  There were no abnormal findings noted on physical examination.  Electrocardiogram (ECG) revealed normal sinus rhythm without acute ST (interval on ECG) or T (interval on ECG) wave abnormalities.  Q (interval on ECG) waves were noted in leads V1 (leads on ECG) and V2 (leads on ECG).  Echocardiogram revealed a normal left ventricular ejection fraction without regional wall motion abnormalities.  Serum troponin was not elevated (<0).  The patient was admitted to the hospital for observation and treatment.  He reported dysphagia, prompting gastroenterology and ear/nose/throat (ENT) evaluation that attributed symptoms to gastroesophageal reflux disease.  The patient was discharged home with outpatient follow up.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.  

This patient presented with chest pain and dyspnea on exertion and no significant past medical history.  His pretest probability of coronary artery disease is low (Reference 1).  Utilizing the HEART (history, ECG, age, risk factors, and troponin) score, he was considered low risk (Reference 2).  Utilizing the thrombolysis in myocardial infarction (TIMI) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3).  Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati, et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.  This patient could have been treated at a lower level of care; inpatient hospital admission was not medically necessary.

The insurer's denial of coverage for the inpatient hospital admission is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High Cholesterol
Treatment: Repatha 140mg/ml SC SOSY
The insurer denied the Repatha 140mg/ml SC SOSY
The denial is overturned. 

The patient is a female with a history of atherosclerotic heart disease and hyperlipidemia. Her LDL (low density lipoprotein) cholesterol has been uncontrolled on the maximum tolerated dose of statin in combination with Zetia. As per provider's letter, the patient had previously failed Praluent. She has been maintained on Repatha for several years with good control. Continuation of Repatha is being requested.

Yes, the requested treatment with Repatha was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Repatha is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low density lipoprotein cholesterol (LDL-C).

According to the records provided for review, this patient has a history of atherosclerotic cardiovascular disease (CVD) and dyslipidemia, and her LDL-C (low density lipoprotein cholesterol) levels are not controlled on maximal tolerated dose of rosuvastatin. As per appeal letter, the patient had prior therapeutic failure with Zetia and Praluent. According to the provided records, she had a good response to the requested medication, Repatha, for several years.  Given the history and the findings as documented in the attached medical records, the patient meets criteria for the use of the requested agent.

Therefore, given the above, the Repatha is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic bilateral lower extremity non-healing ulcers.
Treatment: inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission.
The denial is upheld. 

This male patient has a history of asthma, gastritis, migraines and chronic bilateral lower extremity non-healing ulcers.

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and ceftriaxone) for chronic venous stasis ulcers. Infectious Diseases consulted. Blood cultures were negative. Wound cultures grew methicillin-resistant Staphylococcus aureus (MRSA). X-ray of fibula/tibia was negative for fracture, dislocation, or osteomyelitis. Bilateral lower extremity (LE) venous duplex was negative for thrombosis. The ankle-brachial index/ pulse volume recording (ABI/PVR) was normal bilaterally. Surgery consulted, their impression was chronic venous insufficiency and venous stasis ulcers. Dermatology performed a biopsy. Impression was "very likely vasculitis/vasculopathy, do not appear infected, do not appear to be infectious... The patient remained afebrile, hemodynamically stable and was discharged to continue outpatient management on oral antibiotics (doxycycline). 
According to documentation, the patient presented with chronic lower extremity skin ulcers. Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. Their impression was possible vasculitis or a chronic vasculopathy. 
There was no evidence for a systemic infection and no surgical intervention was required. Their clinical impression was- "does not appear infected." Based on above findings, the patient met criteria for observation level of management. He did not meet criteria for acute inpatient hospital stay.

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Broken down tooth #7.
Treatment: Cleaning Inside Roots of Tooth (Root Canal), Post and Hard Material Under Cap (Post and Core) and Tooth-Colored Cap (Crown) on Tooth #7.
The insurer denied the Cleaning Inside Roots of Tooth (Root Canal), Post and Hard Material Under Cap (Post and Core) and Tooth-Colored Cap (Crown) on Tooth #7.
The denial is overturned. 

Yes, the proposed treatment is medically necessary.
Tooth #7 is broken and decayed into the nerve of the tooth. This will require a root canal procedure as well as a post/core and crown to restore the tooth. This treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease
Treatment: Sterile Water For Irrigation Solution (IRRIG, SOL), Pre-service
The insurer denied the Sterile Water For Irrigation IRRIG, SOL, Pre-service.
The denial is upheld.

The patient is a male with a history of sickle cell anemia. The patient is to receive hydroxyurea therapy but cannot swallow capsules. The provider is recommending syrup and Sterile Water for Irrigation IRRIG, SOL to make the hydroxyurea a suspension.

No, the proposed Sterile Water for Irrigational IRRIG, SOL is not medically necessary.
The patient has sickle cell anemia and requires hydroxyurea. The hydroxyurea can be dissolved in tap or bottled water. The patient does not have an immunodeficiency so there is no rationale for the use of Sterile Water For Irrigation IRRIG,  SOL.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Major Depressive Disorder.
Treatment: continuation of transcranial magnetic stimulation sessions.
The insurer denied coverage for continuation of transcranial magnetic stimulation sessions.
The denial is overturned.

The patient is diagnosed with depression.  The patient has been undergoing transcranial magnetic stimulation for the treatment of depression.  The request was made for continuation of transcranial magnetic stimulation.

There is not clear evidence via multiple peer reviewed articles that support continuation of TMS beyond protocol. Transcranial magnetic stimulation (TMS) is commonly extended when treatment response is partial.  Added treatment could help improve mood.

The patient has tolerated the first course and would be a good candidate for continued TMS.

This would be the best available option especially since there had already been a partial response.

There are no other treatments that would be considered superior at this time.  The patient has treatment resistant depression and a partial response to TMS.

There are no added adverse risks known.

The patient has a history of treatment resistant depression.  He has responded partially to the first course.  It is common in treatment to consider maintenance treatment for electroconvulsive therapy (ECT) and TMS. This is likely to be more beneficial than any standard treatment/procedures.

The carrier's denial of the continuation of transcranial magnetic stimulation sessions should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung Infection (pneumonia)
Treatment: Continued Stay Skilled Nursing Facility
The insurer denied the Continued Stay Skilled Nursing Facility.
The denial is upheld.

The patient is a male with history of chronic obstructive pulmonary disease (COPD) who developed COVID-19 (Coronavirus disease 2019) infection respiratory failure. After being treated in a hospital, the patient was transferred to an acute rehabilitation center. The patient does not have a tracheostomy and his condition has improved. The continued stay is denied. The denial is being appealed.

No, the proposed treatment is not medically necessary.

The patient was hemodynamically stable. The patient was tolerating oral diet. The patient was not on any invasive drips. The patient was on three liters supplemental oxygen. He had urine catheter for urine output that was discontinued.

The patient was mildly hypoxic to 87% (percent). The patient was to discharge home with supplemental oxygen. His discharge was held for durable medical equipment (DME) supplies to be delivered at home. Since the patient was awaiting discharge when oxygen is available at home, is not a medically accepted reason for continued rehab admission. The patient had been on oxygen during the stay. The discharge planning was underway well; DME (durable medical equipment) supplies could have been ordered prior to discharge and made available when patient reached home. The requested admission is not medically necessary. It is not the current standard of clinical practice to keep patient at a facility for oxygen supplies delivery to home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: E0478 - Insulin pump
The insurer denied the E0478 - Insulin pump.
The denial is overturned.

The patient is a male with type 2 diabetes complicated by neuropathy and coronary artery disease. He has tried and failed multiple daily insulin injections. His A1C (glycated hemoglobin) was 10.3%. The request for insulin pump therapy is under review.

The prior request was denied as approval requires the ordering provider to be an endocrinologist, that the patient is testing glucose four times daily for at least two months, that the patient has uncontrolled glucose levels despite three to four insulin injections per day that is not explained by poor motivation or compliance, and that the patient has completed a comprehensive diabetes education program and been on multiple injections with frequent self-adjustments for at least six months. The attending physician is appealing this determination as the patient's A1C (glycated hemoglobin) has remained above 10% for several months despite using multiple daily insulin injections.

Yes, the requested insulin pump therapy is medically necessary.
This patient has type 2 diabetes. He has been seen by a certified diabetes educator. He has also been seen by a nurse practitioner. He has tried and failed multiple daily insulin injections with an A1C (glycated hemoglobin) of 10.3% despite checking glucose two to four times per day and taking insulin prior to eating. Insulin pump therapy can be used for both people living with type 1 diabetes or type 2 diabetes.

In the OpT2mise study that compared insulin pump therapy with patients with uncontrolled type 2 diabetes to multiple daily insulin injections, insulin pump therapy resulted in a more significant improvement in HbA1C (glycated hemoglobin) as compared to injections. In another randomized study of 168 patients with type 2 diabetes, the use of insulin pump therapy improved A1C (glycated hemoglobin), reduced total daily insulin requirement, and improved treatment satisfaction irrespective of baseline C-peptide level [1].

Use of insulin pump therapy in this clinical situation is supported by the Endocrine Society guidelines [2]. Without insulin pump therapy, this patient is at risk of uncontrolled hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the requested insulin pump therapy is medically necessary.

The health plan denied coverage of insulin pump therapy, which is a medically necessary request.