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

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

This patient was admitted to this inpatient hospital on the medical unit due to alcohol related pancreatitis with abdominal pain 8 out of 10. Elevated lipase of 305, elevated creatine kinase (CK) of 293, and elevated amylase was noted. There was prolonged QT interval. The patient was drinking up to 10 beers every few days and reported agitation, restlessness, insomnia, nausea and vomiting, and inability to tolerate oral intake. There was a history of alcohol use disorder/withdrawal and polyarthralgia's. Magnetic resonance imaging (MRI) revealed an impingement of lumbar (L) L4 nerve root, and he was given an epidural steroid injection. The patient received a 3-liter intravenous (IV) bolus of fluid, IV morphine, Tylenol, IV thiamine and folic acid as well as ondansetron. Addiction psychiatry was consulted and started acamprosate for alcohol use. The patient was discharged after treatment.

The medical records provided enough specific evidence to support that the patient required acute inpatient level of care. The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification and patients with acute medical conditions related to alcohol or substance use are candidates for inpatient hospital treatment. In this case this patient had alcohol use contributing to pancreatitis and epigastric pain which put them at risk medically, so they required hospital treatment. It was not considered safe for him to be treated in a less restrictive setting other than a 24-hour acute hospital setting.  

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis Hypogammaglobulinemia
Treatment: Immunoglobulins
The insurer denied coverage for immunoglobulins
The denial is overturned.

The patient was seen by the nurse practitioner who noted that the patient last Rituximab infusion was a few months ago. The patient was followed for pneumonia and tinea pedis. It is noted that there was a concern regarding secondary immunodeficiency in setting of hypogammaglobulinemia and multiple infections. The plan was to initiate Natalizumab once the patient is off steroids as the patient was JCV (John Cunningham Virus) negative. The plan was to give intravenous immunoglobulin (IVIG) infusions until the patient could maintain natural levels to prevent infections. The treating provider noted that the patient suffered from frequent infections including pneumonia. The treating provider also noted that the intravenous immunoglobulin (IVIG) would be beneficial to the patient multiple sclerosis (MS). 

The patient has secondary hypogammaglobulinemia causing recurrent serious infections and treatment with intravenous immunoglobulin (IVIG) replacement is medically necessary. The patient has been having recurrent infections, some of these are serious and immunoglobulins replacement is medically necessary.
"Immunoglobulin (Ig) replacement therapy dramatically changed the clinical course of primary hypogammaglobulinemias, significantly reducing the incidence of infectious events. Over the last two decades its use has been extended to secondary antibody deficiencies, particularly those related to hematological disorders as lymphoproliferative diseases (LPDs) and multiple myeloma. In these malignancies, hypogammaglobulinemia can be an intrinsic aspect of the disease or follow chemo-immunotherapy regimens, including anti-CD20 [monoclonal antibody} treatment. Other than in LPDs the broadening use of immunotherapy (e.g., rituximab) and immune-suppressive therapy (steroids, sulfasalazine, and mycophenolate mofetil) has extended the occurrence of iatrogenic hypogammaglobulinemia. In particular, in both autoimmune diseases and solid organ transplantation Ig replacement therapy has been shown to reduce the rate of infectious events. Here, we review the existing literature about Ig replacement therapy in secondary hypogammaglobulinemia, with special regard for subcutaneous administration route, a safe, effective, and well-tolerated treatment approach, currently well established in primary immunodeficiencies and secondary hypogammaglobulinemias." (Compagno, et al., 2014).

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

The insurer's denial of coverage for the immunoglobulins is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis Vulgaris
Treatment Siliq 210 mg (milligrams)/1.5 ml (milliliter) SC (subcutaneous) SOSY (solution prefilled syringe)
The insurer denied coverage for Siliq 210 mg/1.5 ml (milliliter) SC SOSY
The denial is overturned.

The is a patient with a diagnosis of psoriasis vulgaris affecting the elbows, hands, feet, and knees affecting 60% (percent) TBSA (total body surface area). The patient has failed therapy with multiple topical treatments as well as skyrizi and cosentyx. The requested medication is Siliq.  Based on the submitted documentation, Siliq is medically necessary for the treatment of the patient's psoriasis vulgaris. The patient has failed numerous therapies, including light therapy and systemic biological therapy with Skyrizi and Cosentyx. The large surface area affected requires systemic biologic therapy for appropriate disease management. Siliq is FDA (Food and Drug Administration approved for moderate-severe psoriasis and is a reasonable alternative for the patient. The joint AAD- NPF (American Academy of Dermatology-National Psoriasis Foundation) psoriasis guidelines list Brodalumab with a strength of recommendation of "A" as monotherapy for adults with psoriasis. The use of Siliq is approved under the medical supervision of the treating dermatologist. The decision is overturned.

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

The insurer's denial of coverage for the Siliq 210 mg/1.5 ml SC SOSY is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: aortic stenosis
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day-7 day(s) per week (split shift) - a total of 168 hours per week
The insurer denied: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day-7 day(s) per week (split shift) - a total of 168 hours per week
The denial is upheld.

The patient is a female with past medical history significant for severe aortic stenosis, coronary artery disease status post stent x 2, chronic kidney disease stage 4, hypertension, and hyperlipidemia. She lives alone at home in an apartment with home health aide present for 8 hours per day. She was recently admitted to the hospital for decompensated congestive heart failure secondary to her (now severe) aortic stenosis. Due to her chronic kidney disease and risk of going on dialysis if she underwent intervention for her valve (balloon aortic valvuloplasty was offered by cardiology), the patient and her family elected for conservative medical management, and she was discharged home. The patient and her care team requested an increase in home health hours to 24 hours per day, 7 days per week (split shift) after the hospitalization. This request was denied by the insurance company, who kept her current level of assistance at 56 hours per week (8 hours per day). This denial is the subject of this review.

The health plan's determination is upheld.

The requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day-7 day(s) per week (split shift) - a total of 168 hours per week is not medically necessary for this patient.
The PCA services strictly for safety monitoring and supervision are not considered medically necessary by the plan. The only reference made by a physician regarding the medical necessity of this increase in hours is from the discharge summary, which referenced the family's request for additional supervision. 24-hour split-shift services are appropriate for patients that require around the clock needs, including significant turning and position changes overnight as well as frequent incontinence care. The patient does have some functional debilitation but does not have evidence of these needs which would warrant 24-hour split-shift personal care services.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: atrial fibrillation
treatment: Apixaban (Eliquis)
The insurer denied Apixaban (Eliquis). 
The health plan's determination is upheld. 

The patient is a man with a history of paroxysmal atrial fibrillation, hyperlipidemia, and stage 2 chronic kidney disease. Apixaban (Eliquis) has been prescribed for thromboprophylaxis. Coverage for the apixaban is at issue.

A formulary exception is not indicated in this case. The formulary alternatives include warfarin, a vitamin K antagonist, and rivaroxaban (Xarelto) which, like apixaban (Eliquis), is a direct oral anticoagulant (DOAC).
Warfarin would be expected to be less safe and less effective in this instance as compared to apixaban. Data from multiple randomized controlled trials have shown that the use of DOACs, as compared to warfarin, for thromboprophylaxis in atrial fibrillation has been associated with fewer ischemic events and fewer severe bleeding episodes. While retrospective studies have suggested that apixaban is superior to rivaroxaban when used for thromboprophylaxis in patients with atrial fibrillation, there have been no randomized controlled trials and direct comparison is confounded by differences in enrollment criteria in the different studies. Thus, to date, it is not clear that rivaroxaban would be less safe or less effective in this particular case. Current guidelines do not specify the use of one DOAC over another in this situation.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain.
Treatment: Radiofrequency Ablation of the Basivertebral Nerve (64628 and 64629).

The insurer denied: Radiofrequency Ablation of the Basivertebral Nerve (64628 and 64629).  The denial is upheld.

The patient is an adult male with a history of chronic low back pain. He has done physical therapy and taken non-steroidal anti-inflammatory drugs (NSAIDs). The patient's physical exam shows no neurologic deficits. An Intercept procedure has been recommended. He has failed epidural steroid injections.

The health plan should not cover the proposed treatment.

The patient is an adult male with a history of chronic low back pain. He has done physical therapy and taken non-steroidal anti-inflammatory drugs (NSAIDs). Physical exam shows no neurologic deficits. He has failed epidural steroid injections. An Intercept procedure has been recommended. The procedure has been denied as experimental/investigational. This is being appealed. 

The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, this patient has not failed or attempted facet or sacroiliac joint injections/interventions, which are common causes of axial low back pain. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed.  The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternative sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically necessary. 

The procedure is a Food and Drug Administration approved procedure for axial low back pain. It has been shown effective in randomized controlled trials (RCTs) with five-year results. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain.
Treatment: Radiofrequency Ablation of the Basivertebral Nerve (64628 and 64629).

The insurer denied: Radiofrequency Ablation of the Basivertebral Nerve (64628 and 64629).  The denial is upheld.

The patient is an adult male with chronic low back pain. The patient's pain is a six out of ten.  The patient has tried three lumbar epidural steroid injections without relief.  He has seen a spine surgeon and was told surgery was not needed.  The pain is a four to seven out of ten (4-7/10).  Magnetic resonance image (MRI) of the lumbar spine shows multilevel degenerative disc disease, disc bulges, and Modic type 1, 2 changes at L (lumbar) 2-L3 disc and to a lesser degree at the L4-S1 disc.  The request for L2-L3 and L5-S1 Intracept was denied as experimental/investigational.

The health plan should not cover the proposed treatment.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.   

At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable.  There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such the health plan should not cover the proposed treatment.

Additional studies/trials are necessary to determine efficacy as compared to other conventional therapies. The requested health service or treatment has not been proven to be more beneficial than any standard treatment for the patient's condition or disease.  

Other standard treatment options may include nonopioid medications (i.e., non-steroidal anti-inflammatory drugs [NSAIDs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., physical therapy, home exercise program, chiropractor treatments), interventions (i.e., epidural steroid injections, medial branch blocks/radiofrequency ablation), spinal cord stimulation, and/or surgical interventions.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain.
Treatment: Radiofrequency Ablation of the Basivertebral Nerve (64628 and 64629).

The insurer denied: Radiofrequency Ablation of the Basivertebral Nerve (64628 and 64629).  The denial is overturned.

The patient is an adult male with chronic low back pain not responsive to conservative management, including at least six weeks of physical therapy, medication management (non-steroidal anti-inflammatory drugs [NSAIDs] and opioids), and injections (lumbar epidural steroid injections).  His treating provider diagnosed him with vertebrogenic low back pain (confirmed by magnetic resonance image [MRI] of the lumbar spine - modic changes at the L [lumbar] 2 and L3 vertebral bodies) and recommended the Intracept procedure; however, the procedure was denied due to it being considered experimental/investigational.

The health plan should cover the proposed treatment.

The Intracept procedure is Food and Drug Administration (FDA) approved and there is enough data in the medical literature to show it is safe and effective in the treatment of vertebrogenic low back pain.  A prospective, randomized, multi-center study by Khalil et al. in 2019 and another prospective, randomized, multi-center study done by Fischgrund also in 2019 both presented high quality evidence of efficacy and safety of the procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Alcohol withdrawal.
Treatment:  Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.  
The denial is upheld.

This patient is an adult male with a history of alcohol use, who presented with tremors, headaches, nausea, and feeling unwell.  The patient reported to be withdrawing from alcohol.  He has a past history of seizures.  He had been discharged earlier but did not enter alcohol rehab.  

The patient's vital signs included: temperature 97.5, pulse 90, respiratory rate 18, blood pressure 153/84, and oxygenation saturation 99%.  Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 16. The patient's exam was remarkable for tremulous.  The patient's labs revealed: white blood cells (WBC) 7.1, hemoglobin/hematocrit (H/H) 14/39.5, platelet (Plt) 205, sodium (Na) 139, potassium (K) 3.6, and blood urea nitrogen/creatinine (BUN/Cr) 6/0.77. 

The patient was admitted.  Plan of care included Clinical Institute Withdrawal Assessment for Alcohol (CIWA).  The next day, intravenous fluids and intravenous Ativan were discontinued; the patient was continued on home medications.  Plan for discharge was for the following day.

The proposed inpatient hospital admission was not medically necessary.

This patient with a history of alcohol abuse and withdrawal was admitted with alcohol withdrawal.  He was not acutely intoxicated.  The patient was hemodynamically stable and afebrile.  He did not tachycardic.  He was tremulous but did not have signs of severe alcohol withdrawal.  He did not have severe electrolyte abnormalities.  He did not have comorbid conditions.  The patient was admitted with a plan for Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.  On day #2, the patient remained clinically stable.   Intravenous fluids and Ativan were discontinued.  During the hospital stay, the patient did not have findings of acute alcohol withdrawal.  The patient was clinically stable and did not have findings of severe alcohol withdrawal.  He did not have symptoms that required an acute inpatient level of care and had not failed a lesser level of care.  The acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal/Stomach Pain
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a male with a history of prediabetes, hypertension, and sleep apnea, who presented with right lower quadrant abdominal pain. He was found to have acute appendicitis. He was admitted, started on antibiotics, and underwent an uncomplicated laparoscopic appendectomy on the day of presentation. Surgery findings were significant for non-ruptured acute appendicitis. His postoperative course was routine, and he was discharged to home the next day.

At issue is the medical necessity of the inpatient admission.

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

The requested health service/treatment of inpatient admission was not medically necessary for this patient. For many years, it has been well established that appropriate patients who have undergone a laparoscopic appendectomy for uncomplicated acute appendicitis may go home even from the recovery room. Same day appendectomy is well-studied and safe with no worse outcomes than for patients who were admitted following surgery. The referenced literature is a sampling of this data. Frazee et al states, "Outpatient laparoscopic appendectomy can be performed with a high rate of success, low morbidity, and low readmission rate. This protocol has withstood the test of time." The title of one of the articles referenced is even titled, "Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis." Complications that might have necessitated an inpatient stay, such as appendiceal perforation with abscess, hemodynamic instability, or sepsis were absent in this case. In addition, the patient was young and without significant comorbidities that would require an inpatient level of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic pain.
Treatment: Oxycontin [oxycodone ER (extended release)].
The insurer denied the Oxycontin (oxycodone ER).
The denial is overturned.

The patient is an adult male with chronic pain. He has been prescribed Oxycontin 30 mg (milligrams). This is a continuation of therapy. He was previously stable on this medication. The medication was denied coverage by the health plan, as three formulary alternatives had not been tried and failed.

The health plan should cover the formulary exception for Oxycontin.
The patient is an adult male with chronic pain. He has been prescribed Oxycontin 30 mg (milligrams). This is a continuation of therapy. He was previously stable on this medication. He is following up with a pain management provider. No red flags are evidenced in the records. He has failed three formulary alternatives. Trying additional formulary alternatives are not likely to be of benefit, and can lead to increased pain and potentially adverse effect. He has tried three alternatives that were not effective for him. Given the above, the requested Formulary exception for Oxycontin should be covered by the health plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis and psoriatic arthritis.
Treatment: Taltz 80MG/ML SC SOAJ, pre-service.
The insurer denied Taltz.  The denial has been overturned.

The requested Taltz is medically necessary.

The patient is a female with psoriasis and psoriatic arthritis, treated with numerous topicals, Xeljanz and Cosentyx. The provider is requesting Taltz. The health plan requires a trial and failure with an anti-TNF (tumor necrosis factor) agent.
The health plan requires a trial and failure with an anti-TNF (tumor necrosis factor) agent. Taltz, an IL (interleukin)-17 inhibitor, is an appropriate medication for this patient and is not known to be more intensive. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. Taltz is an effective, safe, and approved medication for psoriasis and has shown greater efficacy than other biologics with a favorable side effect profile in studies. IL (interleukin)-17 inhibitors are also among the most effective therapies according to current peer-reviewed literature.