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

Diagnosis: Cytomegaloviral disease.
Treatment: Formulary exception for Prevymis (letermovir) 480mg.
The insurer denied the formulary exception for Prevymis (letermovir) 480mg.
The denial is overturned. 

Yes, the health plan should cover the Formulary exception for Prevymis (letermovir) 480mg.

The patient is a female with T-PLL (T-Cell Prolymphocytic Leukemia) undergoing SCT (stem cell transplantation).  Her AP (attending physician) has requested letermovir for CMV (cytomegalovirus) prophylaxis.  

While the plan claims that valganciclovir is a preferred formulary alternative to the use of letermovir for CMV prophylaxis during bone marrow transplant, only the drug letermovir has FDA approval for this indication.  The drug valganciclovir is not FDA-approved or compendia-supported to be used in this fashion, and therefore would not be considered an acceptable formulary alternative.  Therefore, valganciclovir cannot be used as a formulary alterative medication.

Valganciclovir is only labeled/compendia-supported as therapy for CMV and for preemptive therapy, not as prophylaxis. Preemptive therapy is for monitoring patients who show signs of developing infections, but do not have infection. Prophylaxis is for providing therapy to everyone without disease. In this case, the letermovir is requested for CMV prophylaxis. Therefore, the proposed Formulary exception for Prevymis (letermovir) 480mg is appropriate, and it should be covered by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache, visual field complaints and right sided paresthesia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She presented after the acute onset of headache, visual field complaints and right sided paresthesia. 

The patient's NIH (National Institutes of Health) stroke scale score was 4 at presentation. CT (computerized tomography) brain and CT (computerized tomography) angiogram were both negative at presentation. MRI (magnetic resonance image) brain showed left PCA (Posterior Carotid Artery) territory infarct.  She was continued on aspirin and statin. 

No, the acute inpatient admission was not medically necessary. 

The patient presented with hemibody numbness and visual field deficits but did not undergo MRI (magnetic resonance image) for four days. By the time stroke was diagnosed with imaging, diagnostic tests (echocardiogram, CT [computerized tomography] angiogram) had been performed. Without the delay in diagnostic testing, the diagnosis, testing, treatment and monitoring could have been completed at a lower level of care. The patient's neurological deficit did not warrant acute inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic running sinusitis and rhinitis associated with headache

Treatment: Functional Endoscopic Sinus Surgery (FESS), codes 31254-LT/RT and 31256-LT/RT

The insurer denied coverage for Functional Endoscopic Sinus Surgery (FESS), codes 31254-LT/RT and 31256-LT/RT. 

The denial is overturned. 

This is a female patient with a long history of chronic running sinusitis and rhinitis associated with headache. The patient's sinus disease had been continuously documented in her medical records. There are numerous notes concerning this patient's nasal edema, nasal congestion, purulent discharge, nasal stuffiness, and headaches. The patient was continuously treated with Depo Medrol and Allegra. The patient was seen for allergy and has been continuously under the care of the allergists. The patient has undergone desensitization and placed on various medications during this period including Singulair tablets, nasal saline and fluticasone propionate spray. The patient's otolaryngologist documented that when he performed the nasal endoscopy and used topical anesthetic mixed with decongestant, the patient's headaches completely disappeared.

Peer reviewed literature supports the diagnosis of contact point headache noted by the responsiveness to local anesthesia, and the role of Functional Sinus Surgery to cure most of these patients. The guidelines of the American Academy of Otolaryngology - Head Neck Surgery States that adults with possible sinusitis for greater than 12 weeks, who had signs and symptoms of chronic sinusitis, with documenting sound nasal inflammation, who have undergone saline and/or topical intranasal corticosteroids, and have had allergy and immune function testing can undergo surgical management.

In this case, the patient fulfills the clinical guideline for Functional Sinus Surgery. There is documentation that when a portion of the patient's intranasal cavity was anesthetized, her headache disappeared. In addition, for at least 8 years, the patient had been taking appropriate medications and had a complete allergic workup for chronic sinusitis. Thus, the Functional Endoscopic Sinus Surgery (FESS), codes 31254-LT/RT and 31256-LT/RT was considered medically necessary for this patient as the patient fulfilled all the criteria for the surgery based upon peer-reviewed literature on contact point sinus headache; for instance, the patient's headache disappeared when part of the nose was anesthetized and with chronic rhino sinusitis, for which the patient had been cared for appropriately over 12 years using various medications, steroids, and allergic desensitization.

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

Based on the above, the medical necessity for Functional Endoscopic Sinus Surgery (FESS), codes 31254-LT/RT and 31256-LT/RT is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Skin Disorders. 
Treatment:  Dupixent. 

The health plan denied Dupixent as not medically necessary.  The reviewer has upheld the health plan's determination in whole. 

The patient has moderate to severe atopic dermatitis (up to 40% body surface area involvement) of the arms, legs, and back.  The patient has tried and failed topical triamcinolone, clindamycin, and fluocinonide, as well as oral prednisone and cephalexin. 

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children.  However, it can persist in adulthood and/or start at older ages.  Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors.  Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations, and improve quality of life.  However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient.  Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. 

The patient has not tried and failed standard topical and oral medications that are second-line therapies prior to use of third-line and less cost-effective treatments, such as Dupixent.  For young patients, such as this one, the need to combine such oral and topical medications is often indicated as per all modern dermatology literature reviews, even with or without use of Dupixent.  The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, or standard, first-line oral medications such as Methotrexate, Azathioprine, or Mycophenolate Mofetil.  Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies.  Consistent with medical literature reviews, the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Problems-Other-pain.
Treatment:  Dental/Orthodontic Procedure - white glass gold crown post filling and nerve treatment on tooth # (number) 18.

The health plan denied the service of white glass gold crown post filling and nerve treatment on tooth # (number) 18 as not medically necessary.  The reviewer has upheld in whole the health plan's determination.

The patient presented to the office of dental provider for evaluation and treatment of tooth #18.  Provided for review are previous letters of appeal and denial, clinical notes, a single radiographic image of the maxillary anterior teeth, one page of American Dental Association (ADA) claim forms for tooth #28, a referral for evaluation of teeth #7 and #18, and clinical notes from several years ago. 

As there is no documentation submitted for review to support the treatment, the presence of any decay, or any issue with the tooth in general, there is no reason to perform the procedure.  Therefore, the requested service of white glass gold crown, post filling and nerve treatment on tooth #18 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Nutropin AQ Nuspin 20. 
The denial is overturned in whole.

The patient is a female who has been receiving growth hormone (GH) treatment for idiopathic short stature with poor growth velocity. Pre-treatment height was 136.1 centimeter (cm) (height standard deviation score [SDS] -2.9) and weight was 29 kilograms (kg) (weight SDS -2.8). Mid-parental target height was 62.25 +/- 3.5 inches. Workup showed insulin-like growth factor one (IGF-1) of 213 nanograms per milliliter (ng/mL), insulin-like growth factor binding protein-3 (IGFBP-3) 4.52 milligrams per liter (mg/L). Provocative GH testing showed a peak GH response of 23.2 ng/mL. Complete blood count (CBC), chemistry panel, celiac screen, thyroid function tests and erythrocyte sedimentation rate (ESR) were normal.  

The patient experienced an improvement in growth velocity on GH therapy. Height was 154 cm (11th percentile ) and weight was 40.8 kg (5th percentile). IGF-1 level was 470 ng/mL. Growth velocity was greater than (>) 5 cm/year. She has had no adverse effects of therapy.

The subject under review is the medical necessity for Nutropin AQ Nuspin 20.

The health plan's determination is overturned in whole.

The patient does meet Food and Drug Administration (FDA) criteria for GH treatment on the basis of idiopathic short stature. Her pre-treatment height was 2.9 SDs below the mean for age and gender, her bone age was delayed, and she had poor growth velocity prior to treatment. Therefore, the patient meets the FDA criteria for GH therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission.

The denial is upheld. 

This is a male patient with a history of osteoarthritis and obesity. The patient was admitted to the hospital for an elective right total hip replacement. The patient's operation was non-complicated. The patient's blood loss was 300 milliliters (ml). The patient's hemoglobin and hematocrit was stable. The patient had a hypotensive episode and received intravenous (IV) normal saline (NS) bolus. The patient received physical therapy (PT) and was able to walk 450 feet. The patient was discharged on day 3 of admission. 

Based on the review of the medical record, the patient had a non-complicated post-surgical course. Although the patient had a hypotensive event in the morning on day 2 of admission, he was able to complete his PT session that afternoon. There were no additional episodes. There were no problems with the patient's wound, and his vital signs were stable. The patient was able to tolerate medication by mouth. The patient's pain level was tolerable. The patient was able to walk over 400 feet. The patient did not require treatment for other underlying medical conditions. There were no extenuating circumstances to substantiate the level of service provided. Thus, the full hospital admission is not considered medically necessary for this patient. 

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

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

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied: increase in personal care services to 24 hours per day live in.
The denial is overturned.

The patient is a female with past medical history of cognitive decline, bowel incontinence, bladder incontinence, gait abnormality, hearing loss, vision impairment, hypertension, congestive heart failure, hyperlipidemia, history of pressure ulcers, and osteoarthritis who had been assigned Personal Care Assistance (PCA) services 9 hours/day, 7 days/week to total 63 hours/week. The patient had a fall with injury and hospitalization and was diagnosed with dehydration and pneumonia. The patient was transferred to rehabilitation and was discharged to home.

The patient had an assessment tool performed over the telephone. The patient was assessed at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, and shopping while assessed at maximal assistance with tasks of managing medication, phone use, transportation, equipment management, bathing, and dressing lower body. With tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with task of bed mobility. The patient was assessed at supervision with task of eating. The notes from the assessment noted patient has an unsteady gait and poor balance, ambulates with a walker with some weight bearing support, has difficulty getting up from sitting position due to weakness in her legs, needs help with cleaning herself after toilet use and changing pull-up due to difficulty bending over, and needs reminders with eating and drinking.

The subject under review is the medical necessity for the home care/personal care HHC level 2 personal care services per 15 minutes increase to 24 hours per day (live in).

The health plan's determination is overturned.

The patient is a female with multiple medical problems including progressive medical conditions of cognitive decline and osteoarthritis with documented need for assistance with all ADL/Instrumental activities of daily living (IADL) tasks. The patient has ADL/IADL care needs that span over 24 hours and therefore the tasking tool should not be utilized in assigning PCA hours. The patient has unpredictable and unscheduled care needs for which she needs assistance. The patient's PCP provided a letter of medical necessity for PCA services 24 hours/day. PCA hours for this patient are not solely for supervision and safety but to assist the patient with safe completion of all ADL/IADL tasks. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders - Psoriasis
Pharmacy/Prescription Drugs

The patient is a female with moderate to severe psoriasis (10% body surface area involvement) that includes the hands, palms, and feet. The patient has tried and failed topical steroids (such as halobetasol) and psoralen-ultraviolet A (photochemotherapy) (PUVA) light therapy. The patient does not consume significant amounts of alcohol, as per the clinic records. The subject under review is the medical necessity for Otezla.

The health plan's determination is upheld.

The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line such as either Methotrexate or Acitretin. In particular, Acitretin is particularly appropriate for hand/foot psoriasis, and would be well-suited for this patient's particular clinical scenario. Therefore, the requested Otezla [1] is not medically necessary.
Modern dermatology literature [2-4] supports use of the health plan preferred medications as similarly if not more efficacious compared to the requested Otezla and recommend use of these preferred agents as appropriate for this patient's diagnosis.
Therefore, as per current medical standards of care, Otezla is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Aneurysm
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned, in part. 

The patient is a female with obesity, fibromyalgia. She was admitted for flow diverter stent placement with left MCA (middle cerebral artery) lenticulostriate origin 3x2mm (millimeter) aneurysm. 

The patient was recommended flow diversion based upon location. The patient underwent this procedure and was admitted to stepdown postoperatively. She received an aspirin load due to platelet mapping levels being low. The patient was discharged home on postoperative day 2.

Yes, in part. The Inpatient admission was medically necessary, in part.

Specifically, inpatient admission for admission day 1 was medically necessary. Inpatient admission for subsequent admission days was not medically necessary.

On admission day 1 date of service, the patient was immediately postprocedure. It was appropriate to keep the patient on this date to perform adequate neurological checks and monitor for any complication that would warrant further neurosurgical intervention.

On admission days 2 and 3 there is insufficient evidence provided that these dates required acute inpatient level of care. The patient did not have any issues that would warrant acute inpatient stay, such as severe pain requiring IV (intravenous) medications, close neurochecks, or other issues that would warrant acute stay. These dates were not medically necessary at the acute inpatient level, based upon clinical documentation provided.

The immediate postoperative period does require acute inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Presumed abscess to the left heel.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a female patient with no significant past medical history, who was seen in her podiatrist's office for a wart. The patient then continued to complain of severe pain and tenderness, prompting the podiatrist to have her admitted to the Emergency Department (ED) for evaluation and possible emergent incision and drainage of a presumed abscess to the left heel, after he had attempted this in the office the day prior. Per the records submitted, the patient was afebrile with a normal white blood cell (WBC) count. The patient's radiographs were unremarkable. The History & Physical (H&P) assessment of the patient states that there was "no erythematous around, mild tenderness present, no pus drainage noted." Per the operative report, the patient's abscess measured 1 centimeter (cm) x 1 cm and upon exploration of the abscess location only mild hemorrhage with serosanguinous drainage was noted. Furthermore, there was no depth to the abscess location. Cultures taken from the abscess resulted in Finegoldia magna, Prevotella bivia and Coagulase Negative Staphylococcus. The pathology report's final diagnosis showed a benign warty lesion with cystic degeneration, focally ruptured. The patient was discharged the following day with Bactrim DS [double strength] prescribed for 10 days outpatient.   

As per literature review, there has been an increase in the number of admissions for Skin and Soft Tissue Infections (SSTI), however, study shows that the majority, especially in the case of no co-morbidities can be treated on an outpatient basis.1 In addition, in the case of this patient where there is clear lack of severity, a single dose intravenous (IV) antibiotic could have been attempted, with the patient admitted to observation prior to any further intervention. This patient's care could have been safely provided in the observation status followed by outpatient follow-up.

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

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

Diagnosis: Pneumonia.
Treatment: Inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is overturned. 

This is a female patient with a history of hypertension (HTN), diabetes mellitus (DM), asthma, and colon cancer.  The patient presented to the Emergency Department (ED) with complaints of fever, chills, body aches, weakness, dizziness and falls for the past 3 days. The patient had called her primary medical doctor (PMD) who prescribed some antibiotics. The patient did not improve with medications so she presented to the hospital. In the ED, the patient's vital signs at presentation were: temperature 101.3, heart rate 112, respiratory rate 18, and oxygen saturations 98%-92%.  The patient had tachypnea with dry mucosa. The patient's lung exam revealed rales and rhonchi. The patient's white blood cell (WBC) count was elevated to 16.5.  The patient had hyponatremia with sodium of 125.  The patient's chest X-ray revealed right lower lobe (RLL) pneumonia. The patient was admitted with diagnosis of bacterial versus viral pneumonia.  The patient was started on intravenous (IV) antibiotics.  The patient's urinary Legionella antigen resulted positive. With these results, the patient was switched to levofloxacin.  The patient continued to have fevers even after admission. The patient finally defervesced on day 4 of admission and was discharged home on oral antibiotics to complete her course of treatment for Legionella.

Based on the review of the medical record and literature, the inpatient admission was medically necessary for this patient. This patient had failed to respond to outpatient antibiotics and was diagnosed to have Legionella pneumonia.  The patient was dehydrated and had a low blood sodium level of 125.  The patient had multiple underlying co-morbidities.  The patient was treated with antibiotics and IV fluids.  With treatment and fluids, the patient's blood sodium level gradually improved and her WBC count trended down.  When the patient became afebrile and her overall condition improved, she was appropriately discharged on oral antibiotics with follow-up as an outpatient.

The inpatient admission and length of stay were medically necessary for this patient.

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 should be overturned.  The medical necessity is substantiated.