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

Diagnosis: Community-acquired pneumonia.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented to the hospital with complaints of fever, cough, and back pain for 2days.  Vital signs at presentation were temperature 101.2 degrees Fahrenheit, heart rate 116, respirations 18, blood pressure 124/67, oxygen (O2) saturation 98%.  The patient was in no acute distress. Lungs were clear, heart sounds normal, abdomen soft, non-focal neurologic exam and alert and oriented x 3.

The White Blood Cell (WBC) count was 25.4. Blood urea nitrogen (BUN) was 13, creatinine 1.34, sodium 137, and venous blood gas 7.41/39/51. The patient's chest x-ray (CXR) revealed a possible left retrocardiac infiltrate. The patient was admitted to the hospital with a diagnosis of community-acquired pneumonia. The patient was treated with intravenous (IV) antibiotics.

The patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. The observation could have been for up to 48 hours. The patient remained stable after admission. The patient improved after treatment with IV antibiotics. The patient could have been placed in observation and treatment initiated. After the patient improved with treatment the patient was stable to have been discharged home on oral (PO) antibiotics.  The patient remained afebrile and hemodynamically stable. The patient was discharged home on PO Levaquin.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pleural Effusion
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with a history of breast cancer, gastric adenocarcinoma, and malignant pleural effusion. She was admitted for the placement of PleurX catheter. After the placement of the catheter, the patient was monitored for pneumothorax and was subsequently discharged home. The acute in-hospitalization is denied due to lack of medical necessity. This denial is being appealed.

The requested health service was not medically necessary.

The patient had a known history of malignant pleural effusion. The patient was admitted to the hospital for the placement of PleurX catheter, which was placed on the day of admission, and 
patient was subsequently discharged home. The patient was not on any intravenous treatment. The patient was not on supplemental oxygen. The patient was able to tolerate the procedure without any complications. The patient did not receive any treatment that could not have been safely and effectively provided at a lower level of care. The acute hospitalization is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits.
The determination is upheld.

This is a female patient with a Class II malocclusion, moderate maxillary crowding and moderate mandibular crowding, and severe overjet and moderate open bite. At issue is the medical necessity of braces and monthly visits.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 22 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deeply impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment of braces and monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Refractory Relapsing Granulomatosis with Polyangiitis
Treatment: Tavneos
The insurer denied Tavneos.
The determination is overturned.

This is a female patient with refractory granulomatosis with polyangiitis (GPA), requiring long term prednisone with Rituxan and methotrexate (MTX). She is also on Avacopan 30 milligrams (mg) twice daily (BID) (Tavneos) with an excellent response, enabling her to successfully taper off of prednisone and achieve remission. At issue is the medical necessity of Tavneos.

Tavneos is medically necessary for this patient.
Long term steroid use is associated with many adverse effects, including diabetes, hypertension (HTN), osteoporosis, infection, avascular necrosis, and weight gain. It is imperative that the patient remain on Tavneos and there is ample data supporting its use in GPA. As published in the J Am Soc Nephrol in 2017, 'C5a receptor inhibition with avacopan was effective in replacing high-dose glucocorticoids in treating vasculitis'. Moreover, a study in the American College of Rheumatology (ACR) Open Rheumatol published in 2020 concluded that 'avacopan in addition to standard of care (SOC) for antineutrophil cytoplasmic antibody (ANCA) -associated vasculitis was well tolerated, and at the higher study dose, it appeared to improve time to remission'. Lastly, as published in the New England Journal of Medicine in 2021, 'in this trial involving patients with ANCA-associated vasculitis, avacopan was noninferior but not superior to prednisone taper with respect to remission at week 26 and was superior to prednisone taper with respect to sustained remission at week 52. All of the patients received cyclophosphamide or rituximab'.
The patient has a life-threatening illness (GPA) and was steroid dependent in addition to being on Rituxan and MTX. Tavneos was added to her regimen, enabling the patient to taper off of steroids and achieve remission. It is imperative that she continue Tavneos to remain off of steroids, which have myriad unacceptable long term side effects (e.g. diabetes, HTN, osteoporosis, infection, avascular necrosis, weight gain), thus Tavneos is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary Histoplasmosis

Treatment: Itraconazole Solution 10 milligram/milliliter (mg/mL)

The insurer denied coverage for Itraconazole Solution 10 milligram/milliliter (mg/mL).

The denial is overturned.

This is an adult with a past medical history of significant for immunodeficiency, pneumocystis jirovecii pneumonia (PJP), cryptococcal pneumonia, and pulmonary histoplasmosis. The patient was initially treated with amphotericin-B and flucytosine and was later switched to itraconazole to cover histoplasmosis.  

Itraconazole is highly active against histoplasmosis. Oral therapy with itraconazole is appropriate for patients with mild to moderate histoplasmosis and for continuation of outpatient therapy in those initially treated with amphotericin-B.

There are important pharmacokinetic differences between the capsules and liquid preparations of itraconazole. Liquid formulation is often preferred because of its improved absorption compared with the original capsule formulation. The absorption of the original itraconazole capsule formulation is highly variable and requires gastric acidity. In contrast, the liquid formulation has better bioavailability, does not require an acidic environment, and is taken on an empty stomach.

Itraconazole Solution 10 milligram/milliliter (mg/mL) is medically necessary for this patient's clinical condition.

Based on the above, the insurer's denial must be reversed. 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 Itraconazole Solution 10 milligram/milliliter (mg/mL) is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes
Treatment: Rybelsus 7 mg Tablet
The insurer denied Rybelsus 7 mg Tablet
The health plan's determination is upheld.

This is a male patient diagnosed with T2DM (type II diabetes mellitus). This request is for Rybelsus 7 milligrams (mg). As reported, he has not tried and failed Ozempic, Trulicity, and Victoza. At issue is whether the formulary drugs will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The formulary alternatives have not been and will not be as ineffective as the requested medication.
Rybelsus is a GLP1R (glucagon-like peptide-1 receptor) agonist that is Food and Drug Administration (FDA) approved in the treatment of adults with type II diabetes. There are no studies demonstrating the superiority of the requested medication over the formulary alternatives.
The patient is reported to have failed the formulary alternatives. However, there is no documentation for this claim. The patient can try the preferred formulary alternatives. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I Occlusion
Treatment: braces
The insurer denied braces
The health plan's determination is upheld. 

The patient in question is a male with a Class I occlusion with 4 millimeter (mm) overjet and 3 mm overbite. He has moderate maxillary and mandibular crowding. He is treatment planned for braces to correct his malocclusion.

Braces are not medically necessary for this patient.
The patient has crowding. His overbite is appropriate and there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient.
There is no medical reason to correct his malocclusion with braces. While the patient has crowded teeth, there is no posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but his overjet would not affect oral health related quality of life unless it was greater than 6mm. If his teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Rheumatoid arthritis
Treatment: Simponi aria
The insurer denied Simponi aria
The health plan's determination is upheld. 

The patient is a female with rheumatoid arthritis (RA). Prior treatments have included over-the-counter (OTC) Tylenol and nonsteroidal anti-inflammatory drugs (NSAIDs). Simponi aria is being requested and is under review. Per the health plan's, the patient must try a traditional disease modifying anti-rheumatic drug (DMARD) (e.g. methotrexate (MTX), Arava, SSz (Sulfasalazine) or Plaquenil) x (times) 3 months. The patient also has a history of cirrhosis, thus MTX and Arava are contraindicated.

Simponi aria is not medically necessary at this time as the patient has not tried a traditional DMARD x 3 months. Although traditional DMARDs, such as MTX or Arava, are contraindicated due to the patient's history of cirrhosis, Plaquenil or SSz are not contraindicated in patient's with liver disease.

As per UpToDate, "In patients unable or unwilling to take MTX, we use leflunomide, sulfasalazine, hydroxychloroquine, or a tumor necrosis factor (TNF) inhibitor (eg, etanercept or adalimumab)'. Moreover, an older study published in Ann Rheum Dis in 1989 looked as plaquenil monotherapy in RA and concluded that 'a significant reduction of disease activity was observed after one year's treatment'.

The health plan's determination of medical necessity is upheld.
Appeal type: Formulary Exception
Decision: Overturned



Diagnosis: hyperlipidemia
Treatment: Livalo
The insurer denied Livalo.
The health plan's determination is overturned. 

The patient is a woman with a history of hyperlipidemia and coronary artery disease. She has been intolerant to atorvastatin 20 milligrams (mg) daily, rosuvastatin 10 mg daily, pravastatin 10 mg daily and ezetimibe 10 mg daily. She developed myalgias on each of these medications and, in addition, her low density lipoprotein (LDL) cholesterol level (LDL-C) was not reduced to goal. She is currently on Livalo (pitavastatin) 2 mg daily which she tolerates well and has been effective in reducing her LDL-C. 

A formulary exception is indicated in this case.
The formulary drugs are fluvastatin, lovastatin, atorvastatin, simvastatin, pravastatin and rosuvastatin. The patient has been intolerant to atorvastatin, pravastatin and rosuvastatin. She has not had a trial of fluvastatin, lovastatin or simvastatin.
Due to its unique metabolic properties, pitavastatin has been associated with significantly less muscle toxicity than other statins and has been shown to be tolerated by patients previously intolerant to other statins. Pitavastatin is also the most potent statin on a milligram by milligram basis, with significant reductions in low density lipoprotein (LDL) cholesterol levels seen with doses as low as 1 milligrams (mg) daily. The ability to treat with such low doses further minimizes the risk for adverse effects. Thus, pitavastatin offers the advantage of reducing the risk for myotoxicity in patients, such as this woman, who have been intolerant to other statins.
This woman has not had a trial of fluvastatin, lovastatin or simvastatin. However, all three of these agents are considerably more lipophilic than pitavastatin and therefore more likely to result in muscle toxicity. Moreover, they are among the least potent of all available statins. Accordingly, it is highly likely that this woman would not tolerate doses of these medications that were high enough to reduce her LDL-C to goal.
This woman has tried/failed atorvastatin, pravastatin and rosuvastatin. Therefore, a formulary exception is indicated in this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Insomnia
Treatment: Belsomra
The insurer denied coverage for Belsomra.
The denial is overturned.

This is the case of a patient with chronic insomnia and has failed all of the health plan's approved sedative medications. These included Zaleplon, Zolpidem, and Triazolam. The denial letter listed formulary alternatives including Ramelteon, Zolpidem, and Zolpidem extended release.   

Reviewed were the medical records as well as the letter of denial from the health plan. The letter from the provider stated clearly that this patient was followed by her office for over two years and experiences frequent sleep disturbance. The patient is an adult and has tried Zaleplon, Zolpidem, and Triazolam. The main complaint of the patient is not having uninterrupted sleep and not getting enough sleep. This is causing the patient significantly decreased quality of health. The provider also correctly points out that the medication Belsomra is FDA (United States Food and Drug Administration) approved for the management of this condition. 

This medication works by adopting a newer mechanism of action that is not seen with other sleep medications. It works with the interaction of Orexin. Orexin-A and -B (also known as hypocretin-1 [OX1] and hypocretin-2 [OX2]) are neuropeptides produced in the lateral hypothalamus that promote many aspects of arousal through the OX1 and OX2 receptors. Thus, by blocking Orexin the mechanism of arousal is being blocked, hence improving sleep. 

The formulary drugs are not expected to cause adverse effects. However, the formulary drugs were tried and were ineffective.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a formulary exception for Belsomra (suvorexant) to treat insomnia is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: right-sided headache 
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male with a history of osteoporosis who presented with a five-day history of right-sided headache and monocular right-eye diplopia. The headache began as a dull pounding on the right side and progressed throughout the day, leading to nausea and photophobia. Despite using Advil and Tylenol, the headache persisted in terms of location and character. The patient noticed double vision that improved when covering his right eye, along with right facial sensory changes and possible subtle hearing loss in the right ear. There were no other neurologic symptoms reported.

The inpatient hospital admission was not medically necessary due to the fact that the patient had no evidence of severe central nervous system (CNS) infection, vasculitis, persistent altered mental status, or any other neurologic findings that would require an acute inpatient level of care including aphasia, progressive or severe weakness, paralysis, spasticity, ataxia, amnesia, involuntary movements, severe or persistent vertigo, new onset or progressive visual loss, or some other abnormalities. The patient had unremarkable imaging studies and a stable neurologic exam. During the hospital stay, the patient did not need any interventions that would justify admission at the acute inpatient level of care.
Therefore, after a period of observation, the patient could have been transitioned to outpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cerebral palsy

Treatment: 12 visits of occupational therapy (OT)

The insurer denied coverage for 12 visits of occupational therapy (OT)

The denial is upheld

 
The patient is a young adult with a reported diagnosis of cerebral palsy.  The patient has reportedly been receiving physical and occupational therapy for several years.  Currently under review is the medical necessity of 12 occupational therapy (OT) visits.  

A lack of consistent improvement after several months of therapy is consistent with maintenance treatment.
After several months (and years) of occupational therapy, the treatment notes do not document significant functional improvement.  For example, the occupational therapy notes  do not demonstrate evidence of significant and consistent improvement regarding wrist range of motion (ROM), grip/pinch strength or manual muscle testing.  The lack of consistent improvement after several months (and years) of therapy is consistent with maintenance treatment and is not medically necessary.  
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 12 visits of occupational therapy is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine headaches

Treatment: Nurtec oral disintegrating tablet (ODT)

The insurer denied coverage for Nurtec oral disintegrating tablet (ODT)

The denial is overturned

 
This is an adult with a history of migraine, unspecified, not intractable, without status migrainosus. A Formulary Exception for Nurtec oral disintegrating tablet (ODT) is requested. 

According to the insurer's denial letter, if the prescriber provides evidence of trial and failure of 3 formulary alternatives (generics and/or formulary brands) in a class with 3 or more alternatives available, the prior authorization will be approved. The patient is reported to have tried and failed Amitriptyline, Atogepant (Qulipta), Eletriptan hydrobromide, Aimovig, Ajovy, Naratriptan hydrochloride (HCl), Propranolol HCl, Maxalt and Topiramate. 

The formulary drugs are unlikely to cause the patient adverse reaction (other than reported grogginess) and the patient does not have a contraindication to them. However, formulary medications were tried and the patient failed to improve with these medications.

The formulary drugs are expected to be ineffective, based on the patient's clinical history. The patient has tried Amitriptyline, Atogepant (Qulipta), Eletriptan, Erenumab, fremanezumab, Naratriptan, Propranolol up to 40 milligram (mg) tablets, Rizatriptan 10 mg and Topiramate.
The requested drug (Nurtec ODT) may be more effective than the formulary drugs. It can be used as an abortive therapy to stop acute migraines and also as a preventative migraine medication.  
The non formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Nurtec oral disintegrating tablet (ODT) to treat migraine, unspecified, not intractable, without status migrainosus is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation with rapid ventricular rate (RVR)
Treatment: Inpatient admission 
The insurer denied coverage for Inpatient admission.
The denial is Upheld.

This is an adult patient that presented to the hospital complaining of palpitations and chest pain. Score for stroke risk due to atrial fibrillation (CHADSVASC) score was zero. The patient had no past medical history. On arrival to the hospital, the patient was hemodynamically stable and tachycardic: Blood pressure was 116/82 millimeters of Mercury (mmHg), pulse was 159 beats per minute (bpm). Physical examination was significant only for an irregularly irregular pulse. A 12-lead electrocardiogram (EKG) demonstrated atrial fibrillation with rapid ventricular rate (RVR). The patient was treated with intravenous (IV) Metoprolol to control heart rate. Serum blood testing revealed normal thyroid function and a mildly elevated creatinine (1.3 milligrams per deciliter [mg/dl]). The patient was admitted to the telemetry ward and rhythm reverted to normal sinus overnight. Echocardiogram demonstrated a left ventricular (LV) ejection fraction of 65-70% (percent) without valvular abnormalities. The patient was discharged home the following day with follow-up. 

Bellew et al. studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department. In this study of almost 600 patients, there was no difference in outcome. American Heart Association (AHA) guidelines note that admission to the hospital for management of atrial fibrillation is not necessary in patients that achieve rate control.

This patient presented with symptomatic atrial fibrillation and was effectively treated with atrial ventricular (AV) nodal blocking agents. Following evaluation and additional testing, the patient reverted to normal sinus rhythm and was released from the hospital. In conclusion, admission to the hospital for treatment of paroxysmal atrial fibrillation was not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the full hospital admission is not substantiated.