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

Diagnosis: Relapsing-Remitting Multiple Sclerosis (RRMS)

Treatment Vumerity DR [diroxmel fumarate] 231 mg [milligrams]

The insurer denied coverage for Vumerity DR 231 mg.

The denial is upheld.

The patient is diagnosed with relapsing-remitting multiple sclerosis (RRMS).  The patient had been using Tecfidera which was being well-tolerated. The patient switched medications to avoid injectables.  The patient had previously utilized Avonex. The magnetic resonance imaging (MRI) of the brain was stable.  The provider was requesting the medication Vumerity.

While the carrier has requested that the medication Vumerity is compared to the formulary drugs listed on the FAD (final adverse determination letter), there are no formulary medications listed on the final adverse determination letter.  The FAD states that the health plan includes a formulary with a list of prescribed drugs that the health plan covers and if a prescribed drug is not on the formulary it is called a non-formulary drug, which is not covered in most cases.  The list of the preferred formulary drugs was not provided.  

Both of the medications Tecfidera and Vumerity are appropriate for the treatment of relapsing-remitting multiple sclerosis.  The Letter of Medical Necessity stated the provider is requesting Vumerity.  The letter did not provide a rationale.  There was no documentation as to whether the patient was being switched to Vumerity from Tecfidera.  The records indicated the patient was stable on Tecfidera.  Note that both are fumarates, both are oral agents and both are shown to be approved for RRMS. (Up to Date). Without clarification of the above the need for a formulary exception for Vumerity DR 231 mg capsule is not supported.

The insurer's denial of coverage for Formulary Exception for Vumerity DR 231 mg capsule is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: acute sickle cell vaso-occlusive pain crisis.

Treatment: inpatient admission.

The insurer is denied coverage for inpatient admission.

The denial is overturned. 

This male patient has a history of sickle cell anemia, and on a hypertransfusion program status post splenectomy.

According to InterQual, "Patients with VOC [vaso-occlusive pain crisis] present with severe pain. The diagnosis is based upon the history and physical examination...Aggressive and timely pain management is key to rapid resolution of VOC. In order to avoid undertreatment of pain, use of patient-controlled analgesia if age appropriate or scheduled analgesic administration is recommended. Additional supportive measures include hydration....  

The patient clearly meets this description.  He presented with severe pain, and administration of intravenous (IV) fluids and scheduled IV Toradol was within standard of care.

It is commonly understood and widely published that in children and young adults with sickle cell disease the description of pain is often the only sign of sickle cell crisis. As such, for a patient in whom ambulatory analgesia has not been sufficient, or in patients who are non-compliant with home treatments, hospitalization for management of pain is standard of care. Hospitalization for management of pain with IV analgesia, IV hydration and to monitor for escalation of care as needed was within standard of care.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

According to the documentation submitted, the patient has a history of a heart murmur. He presented to the emergency room (ER) as a transfer from another facility with complaints of 9 out of 10 abdominal pain in the setting of acute appendicitis. Toradol and an intravenous normal saline (IV NS) bolus was given prior to arrival. An abdominal ultrasound (US) confirmed the diagnosis of acute appendicitis. White blood cell (WBC) count was elevated. The patient was admitted. He was kept on nothing by mouth (NPO). IV fluids, IV Ceftriaxone, and IV Flagyl were given as ordered. Cardiology cleared the patient for surgery and no bacterial endocarditis prophylaxis was needed. The procedure was performed without complications. The patient was transferred to the post anesthesia care unit (PACU) after surgery. He was monitored after surgery. The patient remained stable during the hospitalization and was discharged. 

This patient had uncomplicated appendicitis. This procedure is outpatient level of care unless a complicating factor is documented. A heart murmur of no hemodynamic significance was evaluated but this does not change level of care. Leukocytosis, fever, and need for antibiotics- none of these are inpatient care criteria.

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

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

Diagnosis: Cancer 
Treatment: Radiation Therapy 
The insurer denied proton beam therapy. 
The denial is upheld. 

This is a male with history of clinically localized intermediate risk adenocarcinoma of his prostate gland. He has opted to proceed with a course of definitive external beam radiotherapy with curative intent. The subject under review is the medical necessity for proton beam radiation therapy.

The health plan's determination is upheld in whole. 

The requested proton beam radiotherapy is not medically necessary for this patient. There is currently insufficient high quality clinical outcomes reported in the peer reviewed medical literature to allow definitive conclusions to be made regarding the relative safety/efficacy of proton beam radiotherapy for management of localized prostate cancer as compared to standard of care options. The American Society for Radiation Oncology (ASTRO) Model Policy for proton radiation therapy does not support its use in the patient's case outside the context of a high quality prospective clinical trial. There are a number of ongoing clinical trials being conducted to define the role of proton beam radiotherapy for management of prostate cancer (e.g. [for example], the COMPPARE [A Prospective Comparative Study of Outcomes With Proton and Photon Radiation in Prostate Cancer] trial). A high quality review (Royce, et al) concluded: "we await the results of a large prospective randomized clinical trial currently accruing and also a large prospective pragmatic comparative study which will provide more rigorous evidence regarding the clinical and comparative effectiveness of proton therapy for prostate cancer." There are not any extenuating circumstances present in the patient's case that would necessitate the use of proton radiation (e.g., prior receipt of pelvic radiotherapy or presence of a comorbid/genetic condition which increases his risk for radiation toxicity).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She presented with abdominal pain.

The patient was found to have elevated WBC (white blood count). Imaging showed appendicitis with findings of a tiny focus of extraluminal air suggesting early appendiceal perforation. She was admitted and underwent appendectomy the day of admission, finding an inflamed and dilated appendix.  Later that evening after surgery, she had fever to 103 degrees Fahrenheit.  She was given IV (intravenous) antibiotics and IV (intravenous) fluid.

The patient was discharged home on the first postoperative day doing well.  The pathology report confirmed perforated appendicitis.

No, the proposed treatment is not medically necessary.
While the patient did have perforated appendicitis, she did not require inpatient level of care as she did not stay overnight two nights.  She was discharged the day following the operation without complications other than a brief fever, which did not affect the course of her care during this admission. She could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe overjet, overbite, and anterior crowding

Treatment D8080 (braces)

The insurer denied coverage for D8080 (braces)

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, and letters it appears that this patient presented for evaluation for orthodontic care. The Orthodontist, identified several clinical findings including severe overjet, overbite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labia-Lingual Deviation (HLD) index attaining 26 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 17 points on the HLD index. The patient's mother is appealing the decision on behalf of the patient.

It is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating Orthodontist completes the second portion of the index arriving at 26 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 17 points on the HLD index (5 overjet, 4 overbite, 5 anterior crowding and 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

The clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria.

The healthcare plan did act reasonably and with sound medical judgment and in
the best interest of the patient. The coverage of D8080 braces is not considered medically necessary for this patient.

The insurer's denial of coverage for D8080-braces is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of endometriosis and right ovarian cystectomy. She presented to the emergency room with complaints of right lower quadrant pain and associated nausea. 

The patient was afebrile and her vital signs were normal. The medical record documents that her abdominal exam revealed left lower quadrant pain with no rebound or guarding. A four centimeter (cm) right ovarian cyst was noted on pelvic ultrasound. A gynecology consult was obtained and her pelvic examination was reported as normal and nontender.  Intravenous (IV) morphine and intravenous (IV) ondansetron were administered. The patient reported no pain a couple hours later. The gynecologic consultants reported that ovarian torsion was an unlikely diagnosis. Later in the day, the patient reported no pain and she was resting comfortable. 

The patient was admitted to the inpatient service. Intravenous (IV) Toradol was administered and she was made nothing by mouth (NPO). Her vital signs were normal and she had no nausea. On Day 2 she was tolerating a regular diet and her vital signs were normal. She was discharged on Day 2.

No, the proposed inpatient admission was not medically necessary.
The medical records and medical literature were thoroughly reviewed. The patient had a diagnosis of a symptomatic right ovarian cyst. This condition may cause pelvic pain, as in this case. Her condition was stable with no evidence of hemodynamic instability, and continued stable throughout her admission. Patients with the diagnosis of symptomatic ovarian cyst are typically admitted in the emergency room setting for the purpose of observation and pain management. Most patients with this condition will improve with time and pain management, as noted in this case. Inpatient admission can usually be avoided, and patients can typically be discharged from the emergency room or from a unit of a lesser level of care. This patient was appropriately observed and given pain medication in the emergency room, and her condition significantly improved with narcotic and subsequent non-narcotic medication. There was no evidence of significant infection, hemorrhage or ovarian torsion which could have indicated inpatient admission. She could have been observed and given the supportive care she received in the emergency room or a unit providing a lesser level of care than an inpatient service. Follow up care could then be performed as was planned at her discharge. Therefore there was no indication for inpatient admission. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left anterior cruciate ligament (ACL) injury

Treatment: Removal of one knee cartilage using an endoscope and repair of ACL of knee with assistance of an endoscope 

The insurer is denied coverage for removal of one knee cartilage using an endoscope and repair of ACL of knee with assistance of an endoscope.

The denial is overturned. 

This male patient has a history of left anterior cruciate ligament (ACL) injury.

The operative procedure was medically necessary and appropriate. The medical record demonstrated consistency of subjective complaints and objective findings for diagnosis. The diagnosis is a recurrent tear to the ACL status post surgery. The condition is complex as distortion to anatomy has already occurred. The patient noted recurrent episodes of instability. The physical examination was dramatic for a 3 B Lachman. This indicates gross laxity and failure of secondary restraints to hold knee in place. The imaging report of tunnel widening and placement was also of concern. This would indicate necessity of a complex revision procedure. The physician noted the person was a professional athlete. This by itself would indicate an extreme high level of function which would require a well-functioning knee. 

Based upon clinical record and recent documentation provided by attending physician, this operation would be medically necessary i.e. (that is) defined pathology and no likelihood that conservative treatment would provide benefit. The joint surgery removal of one knee cartilage using an endoscope and repair of anterior cruciate ligament (ACL) of knee with assistance of an endoscope is considered medically necessary for this patient.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The carrier's denial of coverage for the removal of one knee cartilage using an endoscope and repair of ACL of knee with assistance of an endoscope is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sedative hypnotic use disorder

Treatment: Substance use disorder services 

The insurer denied coverage for substance use disorder services.

The denial is overturned. 

This male patient has a history of sedative hypnotic use disorder.

The medical records provided enough specific evidence to support that he required at least this level of care then. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that partial hospitalization programs (PHPs) can provide an intensive, structured treatment experience for individuals with substance use disorders who require more services than those generally available in traditional outpatient settings. It also is used in patients who are at a high-risk period for relapse because of life circumstances or recurrence of a co-occurring medical or psychiatric symptom. In this case, this patient was in need of at least this structured and supervised treatment with multimodal treatment. He was considered a high-risk patient who had large amounts of serious substances of use putting him at risk medically as he had past life-threatening withdrawal including delirium tremens (DT's) and 2 past withdrawal seizures and also was at high risk for overdose due to large amounts of benzodiazepine and cocaine use. He also had a past history of multiple arrests due to substance use, including stealing Oxycontin and prescription pads, and had a significant amount of time incarcerated. He reportedly had minimal social supports, did not have self-help involvement or a sponsor. He reportedly could not maintain abstinence despite multiple past treatments including 12 inpatient substance rehabilitation treatments of which he only completed 2, 3 past outpatient substance treatments, 5 past detoxification treatments so he required at least this PHP 5 days per week level of care which was a step down from inpatient detoxification treatment. He had comorbid psychiatric diagnoses including depression as well. He reportedly had a long history of abusing substances and had several significant relapses. He reportedly did require substance partial hospital program (PHP) treatment at least several hours per day 5 days per week in this multimodal supervised and structured treatment so he was considered a candidate for this treatment which was consistent with level of care for alcohol and drug treatment referral (LOCADTR) criteria as well.  

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The carrier's denial of coverage for the substance use disorder services is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperlipidemia
Treatment: Vascepa
The insurer denied Vascepa.
The determination is upheld.

The patient has a diagnosis of hyperlipidemia. He was started on a high intensity statin with rosuvastatin 20 milligrams (mg). He presented for outpatient evaluation. His low density lipoprotein (LDL) was noted to be improved, but he had significant hypertriglyceridemia. Vascepa was added and is under review for medical necessity.

In this case, the patient is under 45 years of age and does not have established atherosclerotic cardiovascular disease, based on the information provided.

Vascepa is not medically necessary in this case. The patient does not have established atherosclerotic cardiovascular disease or high risk factors that would indicate the need for this medication. He does not have diabetes. Per the American Heart Association (AHA) guidelines for the treatment of blood cholesterol, Vascepa is not a recommended treatment for hypertriglyceridemia based on these guidelines (2). Therefore, it is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Rheumatoid arthritis and osteoarthritis
Treatment: Formulary exception for Naproxen CR (controlled release)
The insurer denied the Formulary exception for Naproxen CR (controlled release)
The denial is overturned. 

The patient is a female with rheumatoid arthritis (RA) and osteoarthritis (OA).  For treatment of her OA (osteoarthritis), she failed ibuprofen, diclofenac, Mobic, naproxen and etodolac.  Per attached documentation, naproxen CR (controlled release) has been helpful.

Per plan formulary, for treatment with naproxen CR (controlled release), the patient must fail all formulary alternative NSAIDs (nonsteroidal anti-inflammatory drugs), but not more than three.  This patient has failed five aforementioned NSAID (nonsteroidal anti-inflammatory drug) formulary alternatives.  The appeal is for continuation of naproxen CR (controlled release) for the treatment of OA (osteoarthritis).

Yes, the health plan should cover the Formulary exception for Naproxen CR (controlled release).
For treatment of OA (osteoarthritis), this patient failed five formulary alternative NSAIDs (nonsteroidal anti-inflammatory drugs): ibuprofen, diclofenac, Mobic, naproxen and etodolac. Per plan formulary, for treatment with naproxen CR (controlled release), the patient must fail all formulary alternative NSAIDs (nonsteroidal anti-inflammatory drugs), but not more than three. In accordance with plan formulary, this patient has already failed more than three formulary alternative NSAIDs (nonsteroidal anti-inflammatory drugs), and per attached documentation, the requested naproxen CR (controlled release) has been helpful for her for years. Switching this patient to a sixth formulary alternative NSAID (nonsteroidal anti-inflammatory drug) when she is already responding to naproxen CR (controlled release) would put her at unnecessary risk of symptomatic OA (osteoarthritis) flare and/or GI (gastrointestinal) intolerance. Therefore, the health plan should cover the proposed continuation of naproxen CR (controlled release) for this specific patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Plaque Psoriasis
Treatment: Formulary exception for TALTZ autoinjector (2 pack) 80mg/mL AUTO INJCT, Pre-service
The insurer denied the Formulary exception for TALTZ autoinjector (2 pack) 80mg/mL AUTO INJCT, Pre-service
The denial is overturned. 

The patient is a male with psoriasis for whom Taltz is requested. He has been on Taltz, and is clear of psoriasis, for approximately a year. He has tried Humira, Stelara and topical steroids in the past. Humira was discontinued due to infection. Stelara was discontinued due to insurance change.

Yes, the health plan should cover the Formulary exception for TALTZ.
The patient has been on Taltz for one year, and he is clear with no adverse effects and with complete clearance. He is stable after one year of treatment with Taltz, and it is medically appropriate and necessary to continue this treatment. Requesting for the patient to try a different treatment at this time is not medically appropriate, because he is being successfully treated with Taltz for a long period of time. Changing treatment would risk the patient's psoriasis flaring, and the disease could become less manageable. Taltz is medically necessary as continuation of therapy.