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

Diagnosis: Moderate-Severe Psoriasis Vulgaris

Treatment Taltz 80mg/mL (milligram per milliliter) SC (subcutaneous)

The insurer denied coverage for Taltz 80mg/mL SC.

The denial is overturned.

The patient is a female with a past medical history significant for systolic heart failure, hypertension, and anemia with a diagnosis of moderate-severe psoriasis vulgaris. The patient has failed topical therapy as well as systemic biologic therapy with Cosentyx, Siliq, methotrexate, and ultraviolet (UV) therapy. The requested medication is Taltz.  

Based on the submitted documentation, Taltz is medically necessary. The patient has failed topical therapy and requires systemic therapy for control and management of her psoriasis diagnosis. The patient has tried and failed numerous biologics, including Siliq and Cosentyx. Other systemic agents, including the tumor necrosis factor (TNF) inhibitors Humira and Enbrel are contraindicated due to the pre-existing heart failure diagnosis. Taltz is Food and Drug Administration (FDA) approved for treatment of psoriasis vulgaris and it is reasonable to attempt this treatment option.  

The joint American Academy of Dermatology (AAD) - National Psoriasis Foundation (NPF) guidelines for psoriasis treatment with biologics states that Taltz is recommended for monotherapy in the treatment of psoriasis with a strength of recommendation of "A" -the highest recommendation. In this case, Taltz is a reasonable next therapy for the treatment of the patient's disease and is medically necessary. As such, Taltz is approved, and the decision is overturned in whole based on the current evidence-based medical literature.

The healthcare plan did not act reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for Taltz 80mg/mL SC is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Rheumatoid arthritis.
Treatment: Formulary exception for Duexis
The insurer denied the Formulary exception for Duexis
The denial is overturned.

This patient is a female with history of rheumatoid arthritis.  The patient has previously tried and failed ibuprofen, duloxetine, diclofenac and naproxen.  She has been treated with Duexis with good clinical benefit.  Duexis was initially denied due to the patient not having tried and failed at least three formulary alternatives including celecoxib, diclofenac, diflunisal, etodolac, ibuprofen, meloxicam, nabumetone, naproxen, oxaprozin or sulindac with lansoprazole, omeprazole, pantoprazole or Dexilant.  The reason for the appeal is because the patient has been on Duexis and doing well.

Yes, the health plan should cover the proposed treatment.
It is not known if a formulary drug would be as effective as the requested drug Duexis.  It is not known if the patient would have adverse effects to a formulary alternative.  In addition, the patient has tried and failed three formulary non-steroidal anti-inflammatory drugs (NSAIDs) but documentation does not support that these have been tried and failed in combination with one of the formulary proton pump inhibitors (PPIs).  

The patient has been on Duexis with good clinical benefit.  Clinical studies do show that non-medical switching was more often associated with negative or neutral effects than positive effects on an array of important outcomes. Among patients with stable/well controlled disease, non-medical switching was associated with mostly negative effects. There are no clinical studies comparing formulary options to Duexis to indicate whether formulary alternatives would be more efficacious or safer than the current requested drug Duexis.  It is not known if the patient will respond as well to a formulary alternative if she were to switch or if she would have worsening disease due to switching.  It is known that the patient is stable and responding well to the requested drug Duexis and therefore the health plan should cover the proposed treatment.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Refractory Migraines

Treatment Ubrelvy (ubrogepant)

The insurer denied coverage for Ubrelvy (ubrogepant)

The denial is overturned

The patient has refractory migraines and has tried multiple prophylactic and abortive medications, including multiple formulary agents.  In the appeal note, Ubrelvy is included in the long list of medications she has tried and failed, though perhaps this is a typo.  Ubrelvy was denies by the insurer and the patient and her physician are appealing.  There is mention in the office note about requesting approval for Vyepti.

The formulary drug(s) will not cause the patient an adverse reaction.

There is documentation that multiple formulary drugs have been ineffective or poorly tolerated.

The patient has tried many formulary migraine medications without sufficient benefit.  Ubrelvy will be more effective than these prior medications.  Ubrelvy is highly effective and FDA [Food and Drug Administration]-approved for migraine.

The insurer's denial of Formulary Exception for Ubrelvy (ubrogepant) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: tracheomalacia and chronic lung disease of prematurity with bronchopulmonary dysplasia (BPD).

Treatment: Synagis 50MG/0.5ML IM (intramuscular)
 
The insurer is denied coverage for Synagis 50MG/0.5ML IM

The denial is upheld. 

This male patient has a history of developmental delay, premature infant around 20 weeks gestation, and severe bronchopulmonary dysplasia (BPD).

Although the patient was born as an extreme premature infant with a diagnosis of BPD the medical record indicates that he has been medically stable off oxygen and pulmonary medications. There is no record of need for hospitalization or ER visits in the past 9 months despite exposure to the Covid 19 virus. The medical record does not support the need for a second series of Synagis injections.

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 Synagis 50MG/0.5ML IM is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overweight; hyperlipidemia.
Treatment: Saxenda 18MG/3ML Pen.
The insurer denied the Saxenda 18MG/3ML Pen.
The denial is overturned.

The patient is an adult female with anxiety who is overweight.  The request for Saxenda is under review.  The prior request was denied by the insurer, as approval  requires a body mass index of at least 30 kg/m2 (kilograms per meters squared). The attending physician is appealing this determination, as the patient has a body mass index of 28.9 and this is complicated by familial combined hyperlipidemia.

Yes, the requested Saxenda 18MG/3ML Pen is medically necessary.

The Endocrine Society guidelines on the management of obesity recommend the use of approved weight loss medication to ameliorate comorbidities and amplify adherence to behavior changes, which may improve physical functioning and allow for greater physical activity in individuals with a BMI (body mass index) 30 kg/m2 (kilograms per meters squared) or in individuals with a BMI (body mass index) of 27 kg/m2 (kilograms per meters squared) and at least one associated comorbid medical condition such as hypertension, hyperlipidemia, type 2 diabetes, and obstructive sleep apnea.

This patient is overweight with a body mass index of 28.9 kg/m2 (kilograms per meters squared), and this is complicated by hyperlipidemia. Therefore, Saxenda, is indicated in this patient.  Without Saxenda, this patient will be at increased risk of complications of untreated excess weight, which can include uncontrolled hyperlipidemia.  As such, based on the patient's clinical scenario,  the requested Saxenda 18MG/3ML Pen is considered to be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Angioplasty.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with known coronary artery disease (CAD) and history of multiple percutaneous coronary interventions (PCIs). Comorbidities include hypertension, diabetes, hyperlipidemia, and gastroesophageal reflux disease (GERD). 

The patient presented with chest pain and dyspnea on exertion (DOE). Catheterization showed progression of the left main disease as well as re-stenosis.  He underwent percutaneous coronary intervention (PCI) to left main and circumflex. The next day he had a scheduled percutaneous coronary intervention (PCI) of the right coronary artery (RCA), uncomplicated with three stents placed. He was observed in telemetry overnight, received standard therapy and hydration.  The patient was discharged on optimal medical therapy.

No, inpatient level of care was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care.

In this case, there was known coronary artery disease (CAD), uncomplicated catheterizations and percutaneous coronary intervention (PCI), and hemodynamic stability. The post intervention care was standard without need for complex or advanced therapy. He received intravenous fluids (IVF) and telemetry as well as continuation of his medications. 

Radial catheterization was developed with one of its advantages being the safety in early ambulation and discharge. The overnight stay for observation and telemetry does not change that determination. While possible, bleeding post radial artery intervention is not seen, nor does it require extended monitoring.

The letter of appeal was carefully considered but offered no evidence to support a higher level of care. The only care provided was telemetry, frequently performed in observation and outpatient status.  The patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no "complex" care that was required in this patient's care post catheterization.  While there is always a potential for an adverse event, one did not happen and no actual treatment was needed. While the risk post left main (LM) and multiple vessel stenting may be higher, no actual adverse events were seen, and thus, there was no need for inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea.

Treatment: inpatient level of care.

The insurer is denied coverage for inpatient level of care.

The denial is upheld. 

This patient presented to the emergency department with complaints of feeling like he cannot breathe.  The documentation indicated he had a trach inserted 2 weeks prior.  He also stated he has had a low-grade fever.  The documentation indicated on physical exam blood pressure was noted to be 120/82.  The documentation indicated his heart rate was 112 bpm (beats per minute).  Oxygen saturation was 98% (percent) with a respiratory rate of 26 breaths/minute.  The nursing assessment indicated the patient did have rhonchi throughout.  The documentation indicated the patient was admitted for further treatment.  According to appeal documentation the patient underwent a computed tomography (CT) scan showing an enlarging laryngeal tumor with significant airway narrowing at the level of the tumor.  The trach was placed in good positioning.  Intravenous (IV) antibiotics or steroids were given in the emergency department and pulmonology was consulted.  The patient was treated with multiple intravenous (IV) medications and after swallow evaluation he was switched to a regular/thin diet.  He was discharged the following day due to continued stability.

According to referenced literature, a patient may be admitted to inpatient services when there is evidence of severe airflow or ventilation abnormalities, severe respiratory findings, chronic lung disease with severe deterioration when there is evidence of high-risk pulmonary infection as indicated by complications of tracheostomy that remain after observation care.  The submitted documentation does not detail the above.  While it is noted the patient was admitted for further treatment, there is a lack of specific emergency department notes detailing severe hemodynamic instability or complications that needed further treatment despite care within the observation level.  There are no laboratory studies or imaging providing indication that an inpatient admission was needed. Therefore, the health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Pulmonary Embolism.

Treatment: inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.	

The denial is overturned.

This patient presented to the emergency department with complaints of possible seizure versus syncope.  He indicated he was standing in the restroom when he had an increase in headache, felt dizzy and everything went black.  He indicated the next thing he knew he woke up on the floor.  He was able to wake up and stand up without feelings of tiredness.  He was able to speak in full sentences.  He does have a past medical history that includes headache as well as anxiety and history of Lyme disease.  He had a respiration rate of 21 breaths/minute on physical examination with a blood pressure of 143/84.  Oxygen saturation was 96% (percent).  He was able to move all extremities and he was alert and oriented to person, place, and time.  There are no focal deficits.  The recommendation was made for laboratory diagnostic studies.  The laboratory studies did reveal an elevated D-dimer at 950.  Furthermore, he had serial troponins of .27, .22, .09 and .05 with normal less than (<).04.   He did undergo a computed tomography (CT) angiography of the chest revealing a small hypodensity in one of the proximal branching small pulmonary arteries.  The documentation indicated this may reflect partially occlusive pulmonary embolism versus possible artifact from the adjacent contrast.  Electrocardiogram (EKG) performed did not reveal any ST (interval on EKG) elevation; however, there was some change in the inferior leads.  He did have an elevated D-dimer and a CT angiography showed the possibility of pulmonary embolism.  He was given 1 dose of Lovenox and it was recommended he be admitted for cardiac monitoring and additional treatment.  He was admitted and continued treatment.  

The patient presented to the hospital after a bout of syncope. In the emergency department (ED), sequential Troponin levels showed initial elevation followed by progressive decrease.  A systematic review of the role of cardiac biomarkers in patients with syncope showed that high sensitivity troponin was associated with an increased rate of death, cardiopulmonary resuscitation, myocardial infarction, structural heart disease and pulmonary embolism. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Multiple Sclerosis.
Treatment: Formulary exception for Zeposia.
The insurer denied the Formulary exception for Zeposia.
The denial is upheld. 

The patient is a female with multiple sclerosis (MS). She has been treated with Avonex and Copaxone in the past. The provider is requesting Zeposia. The requested medication was denied coverage, as the patient has not tried and failed fingolimod and two other preferred medications.

No, the health plan should not cover the Formulary exception for Zeposia.
There is no documented reason as to why the patient cannot be treated with fingolimod or the other formulary agents for her condition. All of the preferred agents are FDA (United States Food and Drug Administration)-approved for her condition, based on high-quality clinical trials published in the peer-reviewed medical literature (Rae-Grant et al.). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Zeposia relative to the preferred agents.  There is no evidence that switching to a preferred agents would jeopardize her clinical stability.

Therefore, given the above, the health plan should not cover the Formulary exception for Zeposia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic Anemia.

Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a past medical history of seizure, acute cystitis, acute liver failure (related to Lamictal use), gastritis, migraine, heavy menses, and recent COVID (coronavirus) 19 pneumonia and pulmonary embolism. She presented to the emergency department (ED) from urgent care for evaluation of headache and vaginal bleeding for 1 week. The patient was on Xarelto, and she was on day 7 of her menses. She was admitted for management of requiring blood transfusion. Her hemoglobin was 6.8. She received 2 units of packed red blood cells (PRBC) and an infusion of iron and was discharged home.

This patient was symptomatic. In addition, she fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 so, 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). So, the need for transfusion is not a reason for admission.

The transfusion could have been completed in the 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.

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 include active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. 

The patient was stable and did not have any of the above indications for admission.
Based on all of the above, admission was not medically necessary.

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

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

Diagnosis: Tooth decay.
Treatment: White glass with metal crown, tooth #4.
The insurer denied the request for placement of white glass with metal crown, tooth #4.
The denial is overturned.

The patient is an adult female requesting a crown on tooth #4.  Tooth #4 has had a root canal procedure previously performed.  It currently has severe recurrent decay under an existing amalgam filling.

Yes, the white glass with metal crown, tooth #4 is medically necessary.  The pre and post-operative x-rays describe the condition of the tooth. 

The tooth has an existing amalgam restoration with much recurrent decay underneath.  The root canal procedure was done due to the decay entering the nerve.  Both the decay and the root canal procedure have weakened the tooth.  A crown is necessary to prevent this tooth from fracturing and thereby requiring extraction.

The insurer states that the patient must have four upper teeth touching four lower teeth before benefits can be applied.  This is not in the best interest of the patient, as the more teeth the patient can save, the more teeth the patient has to chew.  In this patient's situation, the white glass with metal crown, tooth #4 is considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Radiculopathy, low back pain and left leg .

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.	

The denial is upheld.

The patient has a history of low back pain and left leg for two months. His neurosurgeon sent him to the emergency department for left lower extremity pain not relieved with outpatient care over the last five days. He was seen in the emergency department for 10/10 left leg pain, left lower extremity strength rated 4/5. He was admitted with a note that he requires surgery and will be going to the operating room, admit for neurological changes in setting of known low back pain with new radiculopathy. His exam noted decreased fine sensation to left leg, strength 5/5. He was started on intravenous (IV) sodium chloride at 100 ml/hr [milliliter per hour]. He received intravenous [IV] morphine once.  He underwent a left L(lumbar)5-S(sacral)1 foraminotomy. He was on 5 liters oxygen via face mask post procedure weaned down in Post Anesthesia Care Unit (PACU). He had initial relief of left leg pain but returned to preoperative levels. 
The plan was for magnetic resonance imaging (MRI) of the left hip and electromyography (EMG) outpatient. Comorbidities of chronic obstructive pulmonary disease (COPD), heavy smoker. American Society of Anesthesiologist (ASA) score of 2.

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

In this case, there are no office notes to show that he had failed six weeks of conservative treatment, no radiology report for nerve root compression and no severe or progressive weakness on exam that would require immediate surgery. He did not require more than 24 hour postoperative care. His pain management could have been provided at an observation level. The inpatient stay is not medically necessary.

Milliman Care Guidelines (MCG) - Inpatient: nonelective or multilevel procedures or patients with need for prolonged (eg, more than 24 hours) postoperative care (2)

The insurer's denial of coverage for the inpatient is upheld. Medical Necessity is not substantiated.