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

Diagnosis: Hypertension, hyperlipidemia, neuropathy, metastatic uterine cancer and depressive disorder. 
Treatment: Home Health Care (HHC)/Personal Care - Level 2 Personal Care Services (PCS), per 15 minutes Increase to 42 Hour(s) per Week. 

The insurer denied coverage for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 42 Hour(s) per Week. 

The denial is overturned. 

This is an elderly patient with chronic medical problems including hypertension, neuropathy and more recent metastatic uterine cancer. She was hospitalized and underwent a hysterectomy. The patient lives with her spouse in a 1-bedroom apartment. She is currently approved for PCS 32 hours/week and requesting an increase to 42 hours/week, which is under review. 

According to the Uniform Assessment System (UAS), the patient's cognitive status is "Modified independence." She requires extensive assistance for bathing and lower body dressing. She requires only limited assistance for personal hygiene, bed mobility, toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel.  She uses a cane or walker with limited assistance for ambulation. This is an older patient who was recently hospitalized and underwent surgery for uterine cancer, and who is undergoing chemotherapy. 

From a physical medicine and rehabilitation perspective, the requested Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 42 Hour(s) per Week is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 42 Hour(s) per Week services is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Morbid Obesity.
Treatment:  Mounjaro 5 mg (milligrams)/0.5 ml (milliliter).

The insurer denied coverage for Mounjaro 5 mg/0.5 ml.  The denial is upheld.

This is the case of a patient with a history of morbid obesity. A formulary exception for Mounjaro 5 milligram (mg)/0.5 milliliter (ml) is requested.  Per the letter of medical necessity by the treating provider, the patient has tried and failed Wegovy. It was also noted that the patient has been on requested medication.

Per Consumer Value Store (CVS) Caremark letter, formulary alternatives include: Ozempic, Trulicity, and Victoza.

The formulary drugs, Ozempic, Trulicity, and Victoza, are not likely to cause the patient an adverse reaction. In this case, based on the review of the information, the available formulary alternatives are reasonable for the patient; there is no indication that they would cause a different set of side effects the requested medication. There was no information provided showing the patient has contraindications to formulary drugs. 

The formulary drugs have not been ineffective, based on the patient's clinical history. In this case, the records state that the patient has not tried formulary alternatives and has been taking the requested medication. 

The requested drug would not be more effective than the formulary drugs. In this case, research indicates that the requested medication may have overall a larger percentage of weight loss. However, all medications have the same indication. Also, the requested medication is not Food and Drug Administration (FDA) approved yet for weight management. 

Per the FDA (2022), "Today, the United States (U.S.) Food and Drug Administration approved Mounjaro (tirzepatide) injection to improve blood sugar control in adults with type 2 diabetes, as an addition to diet and exercise. Mounjaro was effective at improving blood sugar and was more effective than the other diabetes therapies with which it was compared in clinical studies."

In summary, the formulary drugs are not expected to cause adverse effects. The formulary drugs were not tried and the patient did not have an adverse reaction or contraindication.  The formulary drug is not expected to be ineffective and the not formulary drug is not expected to be more effective that the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Mounjaro 5 mg/0.5 ml is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Rinvoq.
The insurer denied: Rinvoq.
The denial is: Upheld.

The patient is a male with dermatitis to the hands and face (described as hyper and hypopigmented scarring, and his lupus is manifesting as atopic dermatitis), treated with topical steroids (Clobetasol, hydrocortisone, triamcinolone), prednisone, azathioprine, mycophenolate, Plaquenil, Tacrolimus topical and Opzelura. The treating provider is requesting Rinvoq. The patient also has a history of deep vein thrombosis (DVT) and systemic lupus. His clinical documentation discussed lupus only with no discussion of atopic dermatitis. The medical necessity for Rinvoq is the subject under review.

The health plan's determination is upheld.

Rinvoq is not medically necessary for this patient. Rinvoq is not Food and Drug Administration (FDA) approved for lupus. It is not currently first-line therapy for atopic dermatitis, which this patient does not appear to have. No evidence-based medical literature was found for Rinvoq in lupus. Rinvoq (upadacitinib) was evaluated in a 16-week, double-blind, placebo-controlled, parallel-group, dose-ranging portion of this 88-week trial in 8 countries. Adults with moderate to severe disease and inadequate control by topical treatment were randomized 1:1:1:1, using an interactive response system and stratified geographically, to once daily upadacitinib oral monotherapy 7.5, 15, or 30 milligrams (mg) or placebo. The trial showed a 74% improvement (achievement of the primary endpoint) at the 30 mg dose. Half of the patients receiving the 30 mg dose of upadacitinib achieved clear or almost clear skin based on the Investigator's Global Assessment (IGA) score and an improvement of at least 90% in Eczema Area and Severity Index (EASI) at week 16. Improvements in signs and symptoms of atopic dermatitis (AD) were shown after the first week in those receiving upadacitinib (7.5, 15, 30 mg), with a significant reduction in pruritus as well as clinical efficacy endpoints. There was no correlation between the occurrence of adverse events and the dose of upadacitinib. Therefore, there were no safety concerns to preclude further investigation of upadacitinib for AD, and phase III trials are currently underway. These agents offer a solution for patients who do not respond to dupilumab or cannot tolerate dupilumab side effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Taltz
The insurer denied the Taltz.
The determination is upheld.

The patient is a male with psoriasis. He also has psoriatic arthritis. He has tried and failed calcipotriene, clobetasol, halobetasol, and betamethasone. He has also failed Humira, Enbrel, and Stelara. The medication under review is Taltz.

The requested health treatment of Taltz is not medically necessary for this patient. According to the American Academy of Dermatology Psoriasis Guidelines and medical literature, the preferred medicines such as Cosentyx and Otezla are effective treatments for the management of psoriasis (1, 2). Within the peer-reviewed literature, Garnock-Jones writes "Subcutaneous secukinumab is an effective and generally well tolerated first-line treatment for moderate to severe plaque psoriasis" (3).

Zerilli, et al writes of Otezla that "The drug has been shown to be effective, even in patients with prior use of disease modifying anti-rheumatic drugs (DMARDs) and/or biologics and is generally well tolerated" (4). Keating, et al writes "orally administered apremilast is an effective, generally well tolerated and convenient option for the treatment of psoriasis and psoriatic arthritis" (5).

The preferred agents are appropriate agents for the treatment of the patient's psoriasis. The formulary medications should be tried and failed prior to initiating Taltz.

It is noted that the patient has failed numerous therapies, including Humira. However, there is no documentation provided that would justify the patient requiring treatment with Taltz prior to the formulary alternatives such as Cosentyx and Otezla.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hereditary Angioedema. 
Treatment: Berinert. 

The insurer denied Berinert. The health plan's determination is overturned. 

The patient is a male who is prescribed Berinert by an allergist/immunologist to treat hereditary angioedema type I. He has a documented low C4, C1 esterase quantity, and C1 esterase function with a positive family history of hereditary angioedema. He has not had a severe attack yet. He has not had access to either acute or prophylactic disease treatments. 

Berinert is medically necessary for this patient. 

Access to a rescue medication such as Berinert is medically necessary to treat acute angioedema attacks. Rescue medications such as Berinert are the standard of care for patients with hereditary angioedema. All patients with hereditary angioedema disease should have access to rescue medication in the case of an attack to prevent both morbidity and potential mortality.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Parkinson's disease
Treatment: Home health care
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 56 Hours per Week - 8 Hours per Day, 7 Days per Week .

 The health plan's determination is overturned.

The patient is a female with past medical history of Parkinson's disease, Parkinson's dementia, anterior cerebral aneurysm, chronic insomnia, chronic fatigue, aortic valve replacement, Barrett's esophagus, coronary artery disease, chronic obstructive pulmonary disease (COPD), migraine, hypertension, hyperlipidemia, irritable bowel syndrome, chronic kidney disease, and osteoporosis who had been assigned CDPAS (consumer directed personal care services) 4 hours/day, 7 days/week, based on telephonic assessment assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, stairs, shopping, and transportation while extensive assistance with tasks of managing medication, bathing, personal hygiene, and dressing upper/lower body. With tasks of equipment management, walking, locomotion, transfer toilet, and toilet use the patient was assessed at limited assistance while set up only with tasks of managing finances and phone use. 

Consumer Directed Personal Assistance Services (CDPAS): 56 Hours per Week - 8 Hours per Day, 7 Days per Week are medically necessary for this patient.
There is documentation from the patient's medical providers, specifically her neurologist, of worsening cognitive and functional status. The patient has a progressive neurologic disorder which is expected to worsen over time, and has, as documented by progress notes from her neurologist over the last year. The patient requires at least limited assistance with walking, locomotion, transfer toilet and toilet use as documented by the universal assessment. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer has failed to document a plan to meet these scheduled and unpredictable care needs. The plan assumed the patient had informal help from her family which is not the case. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). There is documented weight loss by the patient's medical providers due to her inability to cook and feed herself. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 8 hours/day, 7 days/week, to total 56 hours/week are medically necessary for this patient. 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

Diagnosis: Subglottic stenosis with tracheostomy

Treatment: Air ambulance services with advanced life support (ALS) transportation

The insurer denied coverage for air ambulance services with ALS transportation.
 
The denial is upheld.

This is a patient with a history of Pfeiffer syndrome, seizures, craniosynostosis, choanal atresia, hearing loss, subglottic stenosis, tracheal sleeve, tracheostomy, and a gastrostomy tube (GT). The physician is requesting an air ambulance transport for multiple medical appointments.

The insurer has denied coverage for air ambulance services with advanced life support (ALS) transportation as not medically necessary

Well-equipped ALS ambulances with appropriate personnel (physician or a provider) is as safe as an air transport. The duration of the trip is a maximum of 2 hours. During that 2 hours, ALS is equipped for TPN (total parental nutrition) or GT feedings. In those 2 hours, if there were any airway issues or any hemodynamic instability, the ambulance crew (most often with a critical care fellow or highly trained nurses) are available and able to address those eventualities. There is no documentation from a pulmonologist nor a GI (gastroenterology) specialist why ALS is not safe for this patient. Also, there is no EMS (emergency medical services) board certified physician that certified against ALS ground. Also, there is no acute transfer from the ED (emergency department) to the ICU (intensive care unit) or ICU to ICU. The transports are to elective procedures and clinics. There will be ample time to plan. Due to the above reasons, the medical necessity for an air ambulance cannot be established. 

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

Air ambulance services with ALS transportation is not considered medically necessary for this patient.

The insurer's denial of coverage for air ambulance services with ALS transportation is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Near syncopal event
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld.

This is a patient that was admitted to the hospital's psychiatric ward for disorganized behavior. While there he had a near syncopal event and fell. He was transferred to the internal medicine ward for work up and evaluation. The patient reported lightheadedness while walking to the bathroom followed by a fall.  Medical records document hypotension with a systolic BP (blood pressure) of 60mmHg (millimeters of mercury) at the time of the event. Upon arrival to the medicine ward, his vital signs were stable, and no abnormal findings were noted on physical examination. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm with a normal corrected QT (interval on an (ECG) interval of 417msec (milliseconds). Additional cardiac work up was performed including analysis of cardiac telemetry and echocardiography. Left ventricular ejection fraction was noted to be a normal (70%) and no rhythm abnormalities were noted on telemetry. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with near syncope that occurred shortly after standing up to walk to the bathroom. Symptoms were preceded by a period of lightheadedness. No significant cardiac findings were noted on serum blood testing, ECG or echocardiography. The patient was ultimately transferred back to psychiatry for further treatment. According to the European Society of Cardiology, this patient was a low-risk patient for future morbidity and mortality. (Reference 1) In a study of individuals presenting to the emergency room, patients that were low risk for cardiac events (no significant cardiac history of acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing. (Reference 2). In this case, the patient falls into a low-risk category and could be managed at a lower level of care. In conclusion, acute inpatient hospitalization was not medically necessary.

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 hospitalization is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System/ COVID-19 pneumonia.
Treatment: Ambulance/Air Ambulance.
The insurer denied Air ambulance.
The denial is upheld.

The patient at the time of presentation was a female, who was initially admitted for hypoxic respiratory failure secondary to coronavirus 2019 (COVID-19) pneumonia. During her hospital course, she required extracorporeal membrane oxygenation (ECMO) and a tracheostomy with eventual decannulation. She was subsequently discharged on 2 liters per minute of supplemental oxygen due to the resultant lung fibrosis. She represented a left-sided pneumothorax requiring the placement of two chest tubes and a high-flow nasal cannula. Based on the patient's request, she was transferred for a lung transplant work-up due to severe lung fibrosis secondary to the COVID-19 infection/pneumonia.
At issue is the medical necessity of an Air ambulance.

The health plan's determination of medical necessity is upheld as a whole.

No, the requested health service/treatment of Air ambulance was not medically necessary for this patient.
As per Medicare guidelines for an air ambulance transfer, coverage requirements apply to air ambulance transports if the service is medically reasonable and necessary; a beneficiary is transported; the destination is local, and the facility is appropriate. Medicare defines local transport as covering only mileage to the nearest appropriate facility equipped to treat the beneficiary. If two or more facilities meet this requirement and can appropriately treat the beneficiary, the full mileage to any of these facilities will be covered. This patient could have been treated at closer locations via ground ambulance for a lung transplant evaluation. The air ambulance does not meet the requirements for medically necessary air ambulance transport.
Therefore, the requested health service/treatment of an Air ambulance was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache
Treatment: Inpatient Hospital Stay
The insurer denied: Inpatient Hospital Stay
The denial is upheld.

The patient is a male who was admitted to the hospital with headache. The patient had a prior diagnosis of a cerebral spinal fluid leak, and he was treated with a blood patch. His symptoms did not improve, and he returned to the hospital. While in the hospital, the patient underwent a magnetic resonance imaging (MRI) of the thoracic and lumbar spine which showed no significant interval change since his prior imaging approximately one week before. The patient was noted to have a prominence of the posterior epidural space throughout the thoracic spine which possibly could represent an epidural fluid collection. The patient was offered nuclear medicine cisternogram but declined. He was scheduled to follow up with anesthesia for a repeat blood patch as an outpatient. He was discharged.

The health plan's determination is upheld.

No. The requested inpatient hospital stay is not medically necessary. The patient was admitted to the hospital with a known and previously treated problem. While in the hospital, the patient was treated with oral caffeine tablets and underwent repeat imaging that showed no interval change from approximately one week before. It is not required to admit a patient to the hospital to obtain an MRI of the spine and treat that patient with caffeine tablets. No interventions were performed for treatment of a possible cerebral spinal fluid leak while the patient was admitted, and further management was deferred to the outpatient setting. As such, there is no compelling reason that this patient required inpatient treatment. Treatment at the observation level of care was most appropriate. The patient did not have any significant vital sign, laboratory, or imaging studies that necessitated inpatient management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Persistent reactive airway disease
Treatment: Breo Ellipta
The insurer denied coverage for Breo Ellipta.
The denial is upheld.

This is a patient who was seen by a Pulmonologist for a cough. The patient was status post (S/P) COVID 19 (Coronavirus 2019). She was treated with oral steroids and responded well. Her PFT's [pulmonary function tests] were essentially normal. No prior history of Asthma.

This patient improved with steroids. She was diagnosed with post COVID 19 mild persistent reactive airways. The patient was subsequently prescribed a long-acting  (beta) 2-agonist (LABA)/inhaled corticosteroid (ICS) combo, Breo Ellipta (Fluticasone/Vilanterol). The patient's symptoms reportedly improved with them.

The patient was subsequently prescribed Wixela (generic LABA/ICS - Fluticasone/Salmeterol). As per her medical doctor (MD), the patient's symptoms were not well controlled after the switch.

The insurance company denied coverage for Breo as it is not on their preferred formulary. There are other medications on their preferred formulary which belong to the same class - LABA/ICS.

These drugs are generic Fluticasone/Salmeterol and Budenoside/Formoterol. Both are in the same class as Breo - LABA/ICS. Up to Date, regarding the different formulations, states that "Given the widespread agreement that LABAs should only be used in combination with inhaled GCs [glucocorticoids] to treat asthma, the use of combination GC-LABA inhalers (eg [for example], budesonide-formoterol, mometasone-formoterol, fluticasone-salmeterol, fluticasone furoate-vilanterol) is a practical way to ensure that patients do not omit the inhaled GC. Each combination is available in several strengths which contain a differing amount of inhaled GCs." [1] No preference is given to any one drug. 

There is no documentation in the MD notes to support that Breo is medically necessary. The patient can be treated with the same class of medication LABA/ICS which is in the insurance companies preferred formulary.

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

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

Diagnosis: Class II canine malocclusion with moderate upper and lower crowding
Treatment: D8080 Braces and D8670 Periodic Orthodontic Treatment
The insurer denied: D8080 braces and D8670 periodic orthodontic treatment.
The denial is overturned.

The patient is a young female. The request is for orthodontic benefits. The patient has Class II canine malocclusion with moderate upper and lower crowding. She has impacted upper right permanent canine. The health plan's prior coverage denial was due to an index score of 12.

The requested D8080 braces and D8670 periodic orthodontic treatment are medically necessary.

The patient has an impacted upper anterior tooth (number six, maxillary right permanent canine) where extraction is not indicated. The patient also has a very deep bite with impingement of the palatal gum tissue. Both of these conditions are "automatic qualifiers" for orthodontic benefits. The case has medical necessity and orthodontic treatment is needed to correct the problems.