Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Incontinence/Urinary/Bladder Control. 
Treatment: Injection of periurethral bulking agents (procedure code 51715). 
The health plan denied injection of periurethral bulking agents (procedure code 51715). 
The determination is overturned. 

The patient is a female who had stress incontinence treated with surgery. Initially, she experienced relief of symptoms but subsequently developed worsening leakage. She was re-evaluated and underwent a Bulkamid placement for intrinsic sphincter deficiency per attestation of the attending physician. 
At issue is whether or not the proposed health service or treatment, injection of periurethral bulking agents, is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The health plan's determination regarding the proposed health service or treatment is overturned, in whole. 

The proposed health service or treatment, injection of periurethral bulking agents, is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Bulkamid is an endorsed procedure for this specific medical problem per guidelines of the American Urological Association (AUA). It is not an experimental procedure. 
The AUA states, "Clinicians should counsel index patients considering surgery for stress urinary incontinence (SUI) regarding the efficacy and safety of each of their options, which may include the following: (Strong Recommendation; Evidence Level: Grade A) Mid-urethral sling (retropubic, transobturator, or single-incision sling), autologous fascia pubovaginal sling, Burch colposuspension, and bulking agents. The role for bulking agents may best be considered in patients who wish to avoid more invasive surgical management, who are concerned with the lengthier recovery time after surgery or who experience insufficient improvement following a previous anti-incontinence procedure."
Literature endorses the safety and efficacy of the therapy for SUI management. Authors state, "Available data support the use of Bulkamid and Macroplastique, which has shown a short-term efficacy of 30 percent (%)-90% and 40%-85% respectively, and long-term efficacy of 42%-70%, and 21%-80%, respectively. Bulkamid appears to have a more favorable safety profile, with no cases of erosion or migration of product associated with its use."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal Cord Injury
Treatment: Air ambulance services and ground transport advanced life support
The health plan denied: Air ambulance services and ground transport advanced life support
The determination is: Overturned

The patient is a male who sustained a fall from around 25 feet. Upon presentation, he had complete paralysis of the lower extremities, loss of rectal tone, priapism, and decreased upper extremity strength. He was found to have cervical spine 7 (C7) subluxation and bilateral jumped facets with a left cervical spine 6 (C6) fracture, thoracic spine 1 (T1) fracture, and vertebral spine 2 (V2) dissection. He was admitted to the neurological intensive care unit (ICU) and underwent emergent operative stabilization of his spine. After an initial period of hemodynamic instability related to his spinal cord injury, he was transferred out of the neurological ICU. Ultimately, he was deemed appropriate for an inpatient rehabilitation facility. He was transported by advanced life support (ALS) ground transport and air ambulance transport.
At issue is the medical necessity of air ambulance services and ground transport advanced life support.
The health plan's determination of medical necessity is overturned in whole.
The physicians caring for the patient at both facilities have documented what was in the best interest of the patient. They have both stated that the length of time for ground transport is not in the best interest of the patient and that the patient should be transported by air ambulance. While technically possible to drive the patient in a ground ambulance for the nearly 1,000-mile trip, it is impossible to argue that keeping a spinal cord injury patient on an ambulance stretcher for the duration of that trip, approximately 15 hours, is in the best interest of the patient. This is a patient who cannot move his lower body. He would need turning every 2 hours for prevention of further skin breakdown and pressure ulcers. Even just the turning of the patient would require a wider bed than an ambulance gurney. The patient also had some dysautonomia symptoms which could have resulted in hemodynamic alterations for which one would not want to add any extra time to the transport. These are medically necessary services for this patient who required an approximate 1,000-mile trip to get to the necessary facility to care for his injuries. Basic ground level transportation without ALS services when the patient had never been transported over any distance and thus not knowing how he would do hemodynamically was sound and medically appropriate. As mentioned, the air ambulance and ALS ground transport was the safest and most medically appropriate means to get this patient to the appropriate facility.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: thyroid eye disease
Treatment: Tepezza
The insurer denied Tepezza. The health plan's determination is overturned.

The patient is a female with chronic thyroid eye disease (TED) for whom coverage of Tepezza is the subject of review. She has intermittent eye pain, eyelid edema and significant proptosis of 26 mm (millimeter) right eye (oculus dexter) (OD) and 22 millimeter (mm) left eye (OS). Ocular history is complicated by congenital ptosis (masking eyelid retraction) and lazy eye (which may limit potential for diplopia). Extraocular muscles are enlarged on computed tomography (CT). The provider notes that steroids only produce minimal and transient benefit with numerous side effects. A clinic note documents follow up for monitoring of Graves' disease. She complains of tearing, intermittent pain and diplopia affecting reading. 

Tepezza is medically necessary for this patient. Most recently, Ugradar et al investigated the impact of teprotumumab on patients with non-inflammatory TED (thyroid eye disease). Consecutive patients with non-inflammatory TED (clinical activity score (CAS) 1), for at least 4 months, were treated with teprotumumab. They received a complete course (total eight infusions) of teprotumumab (10 mg/kg [milligrams/kilogram] for the first infusion and 20mg/kg for subsequent infusions every 3 weeks). The primary outcome was a proptosis response at week 24. Four patients met eligibility criteria for the clinical study, with a mean (standard deviation (SD)) CAS of 0 (0). Following teprotumumab treatment, there was a mean (SD) reduction in proptosis of 2.6 mm (millimeter) (1.2). Five patients were included for each group of the histological study: inflammatory TED (thyroid eye disease), non-inflammatory TED and controls. The authors concluded that their findings demonstrated that teprotumumab reduces proptosis in a series of patients with non-inflammatory TED.

Therefore, as there is a growing body of evidence for the efficacy of treatment with Tepezza in patients with chronic TED with low CAS (clinical activity score), and as this patient would have likely otherwise met medical necessity criteria based on documentation of Grave's disease, complaints of diplopia, and congenital ptosis masking eyelid refraction, Tepezza is medically necessary and standard of care in this case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional/Other/Hyperkalemia
Treatment: Pharmacy/Prescription Drugs/Veltassa 8.4gm powder
The health plan has denied the proposed treatment as they consider it to be a formulary exception. 
The health plan's determination is upheld.

The patient has a history of a lung and liver transplant. The patient has developed hyperkalemia. The patient's potassium was 5.1. Veltassa was prescribed. The provider stated that due to the patient having chronic kidney disease, sodium polystyrene sulfonate could not be used due to an increased risk of gastrointestinal perforation.

At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

I uphold, in whole, the health plan's determination.

the formulary drug will not be and has not been ineffective, would be as effective as the nonformulary drug, and would not have adverse effects.

The patient has not failed or been intolerant to and has no contraindication to sodium polystyrene sulfonate. The patient's history of chronic kidney disease does not place the patient at risk for gastrointestinal perforation if sodium polystyrene sulfonate is used. The formulary drug will not be and have not been ineffective, would be as effective as the nonformulary drug, and would not have adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Braces and Office Visits.

The insurer denied Braces and Office Visits.  The determination is overturned.

The patient has an anterior crossbite on teeth 7, 8, and 9. He presented with a Class III malocclusion with moderate crowding in the maxilla and minor crowding in the mandible. He is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity. At issue is the medical necessity of an inpatient stay.

The patient presented with an anterior crossbite on teeth 7, 8, and 9. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3)
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, the treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Abdominal Pain.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is overturned.

This is a male patient with a past medical history of a motor vehicle accident complicated with a splenectomy, rib fracture, and epidural bleed, who presented with abdominal pain associated with vomiting and exacerbated by food in the setting of tetrahydrocannabinol (THC) use. Abnormal lab results on admission revealed leukocytosis. The patient was admitted to the inpatient floor for intractable abdominal pain and nausea concerning for peptic ulcer disease/acute gastritis versus THC-induced gastroparesis. The patient completed an infectious work-up and received intravenous (IV) analgesic, IV antiemetics, IV antibiotics, and IV fluid. At issue is the medical necessity of an inpatient stay.

Inpatient care was medically necessary.

This is patient with immunosuppression from a splenectomy presenting with acute gastrointestinal (GI) symptoms complicated with dehydration secondary to decrease oral intake. His clinical presentation required a detailed inpatient workup, aggressive infectious workup, empiric intravenous (IV) antibiotics and intravenous fluids (IVF) to prevent dehydration.

The patient was at high risk for an occult infection, due to his history of immunosuppression secondary to the splenectomy. The patient was at risk for dehydration from decreased oral intake due to intractable nausea and vomiting, likely secondary to THC. This detailed inpatient care cannot be prudently provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebral vascular accident
Treatment: home health care
The insurer denied Personal Care Services (PCS): 12 Hours per Day, 7 Days per Week (Total of 84 Hours).
The health plan's determination is overturned. 

The patient is a female with medical history notable for incontinence, wheelchair bound status, prior stroke, and pain. The patient's primary care physician provided a letter of support for this appeal. The letter states that the patient has diabetes, hypertension, chronic obstructive pulmonary disease (COPD) on home oxygen, and a prior cerebrovascular accident (CVA) with resulting right sided weakness and difficulty ambulating. She requires assistance with all activities of daily living including toileting, bathing, and dressing.

The requested health service of Personal Care Services (PCS): 12 Hours per Day, 7 Days per Week (Total of 84 Hours) is medically necessary for this patient.
The patient requires hands-on assistance for all activities of daily living. She is wheelchair bound. She has incontinence of urine and stool. She is not able to toilet or manage her own incontinence care independently. She will require personal care assistance throughout the day. A task tool cannot be relied on to accurately reflect her true need, given that her care needs are expected to be continuous and unscheduled throughout the day. Therefore, the requested services are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incontinence
Treatment: Ambulatory Surgery
The insurer denied the Ambulatory Surgery.
The determination is upheld.

This is a female patient evaluated for incontinence. She had 10 loose bowel movements per day and had been worked up by 2 gastroenterology (GI) doctors. The patient improved with Questran. On exam, a slightly diminished squeeze was noted. The patient was prescribed Imodium.  The patient was scheduled for peripheral nerve evaluation. Permanent interstim was also discussed. The patient underwent temporary lead placement connected to an external nerve stimulator.  Successful peripheral nerve evaluation was noted as the patient had no accidents. The patient wanted to proceed with permanent placement. She was scheduled for interstim. She had implantation of a sacral nerve stimulator with radiologic guidance into the sacral nerve (S) 3 foramen. At issue is the medical necessity of ambulatory surgery.
The patient does not meet criteria for the requested health service/treatment of Ambulatory Surgery (Interstim placement). The patient did not meet criteria of having fecal incontinence for 6 months. The patient did not attempt medical management with dietary management and strengthening exercises and has continued failure (1). The patient did a sacral nerve stimulation test, but the documentation does not demonstrate that improvement lasted longer than 1 week; the ASCRS Textbook recommends 1-2 week assessment. The patient did meet the rest of the criteria. However, all criteria were required to be met.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.
 

Patient is an adult male with a benign past medical history significant for anxiety, depression, pilonidal cyst, status post recent excision, and a recent Invega injection who presented to the emergency room with complaints of fevers, chills, and right gluteal pain.

Vitals on presentation included: Temperature 36.4 degrees C, Blood Pressure 139/83, Pulse 83, Respiratory Rate 17, oxygen (O2) saturation 100% on Room Air. Laboratory values were notable for the following: White Blood Cells (WBC)-20.2, Hemoglobin (Hgb)-13.2, Hematocrit (Hct)-37.4, creatinine-0.7, glucose-101.

Patient was empirically started on intravenous antibiotics (vancomycin and Zosyn). Computed tomography (CT) scan of the pelvis showed sizable right buttock subcutaneous collection compatible with abscess. Patient underwent an incision and drainage procedure by surgery. Wound culture grew Staphylococcus aureus, oxacillin susceptible. Patient remained afebrile, hemodynamically stable and clinically improved. Patient eloped from the hospital.

According to documentation, patient presented with a large gluteal abscess following an injection. Patient was afebrile and hemodynamically stable. Laboratory results were notable for significantly elevated WBC (20.2). He required an incision and drainage procedure. Based on the above findings, hospital admission was medically necessary for administration of intravenous antibiotics and surgical intervention. 

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 the hospital admission is substantiated.
Appeal type: Formulary Exception
Decision: Upheld



Diagnosis: Polycystic Ovarian Syndrome.
Treatment: Metformin.
The insurer denied Metformin.
The health plan's determination is upheld.

The patient is a female with an abnormal insulin tolerance test. She also has polycystic ovarian syndrome. She was prescribed Metformin and has gagging and vomiting with the pills. Her physician has prescribed Metformin HCL 500mg (milligrams)/5ml (milliliter) oral solution and this medication is under review.

The formulary drug would be as effective as the non-formulary drug and would not be expected to have adverse effects.
The patient has abnormal glucose levels and a history of polycystic ovarian syndrome. Metformin was prescribed and there is a letter indicating that the patient is gagging on the medication. However, there is no documentation to support these complaints in the medical documentation provided and the patient has taken these medications for just under a year. In addition, there is no documentation that the patient has cut or crushed the immediate-release tablets to make them easier to swallow which is supported by this medication. There is some confusion that she may be intolerant to the extended-release; however, the documentation is not clear. Therefore, the formulary medications would be reasonable, and the non-formulary liquid medication is not indicated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity

Treatment: Mounjaro 10 milligrams (mg) / 0.5 milliliter (ml) pre-filled pen solution for injection

The insurer denied coverage for Mounjaro 10 milligrams (mg) / 0.5 milliliter (ml) pre-filled pen solution for injection

The denial is overturned
 

The patient has a long history of obesity. She had previous gastric sleeve surgery 
but gained weight back. She had been on Rybelsus using sample medications and was able to lose weight. She was then switched to Mounjaro and lost 50 pounds. A letter from the patient states that she has insulin resistance. The most recent hemoglobin A 1 C (glycated hemoglobin) was 5.8. 

An article from The New England Journal of Medicine July 21,2022 Vol 387 titled "Tirzepatide Once Weekly for the Treatment of Obesity " has been submitted by the patient. The conclusion of this study was that tirzepatide provided substantial and sustained reductions in weight. 

UpToDate has an article titled "Obesity in Adults: Drug Therapy." The article 
discusses the choice of pharmacologic agents. Options include glucagon like peptide 1 (GLP-1) agonists such as semaglutide and liraglutide. Semaglutide has demonstrated efficacy in weight loss as well as improvement in glycemia and lipids. There is also another category of drugs which are the dual acting GLP-1 and Glucose-Dependent Insulinotropic Polypeptide (GIP) receptor agonists and Mounjaro falls into this category. 

The insurance company has offered other formulary GLP-1 receptor agonists. These include Victoza and Trulicity. These are drugs that are primarily used for diabetes but also result in weight loss. Tirzepatide is a novel GLP-1 and GIP receptor agonist that is effective in the treatment of obesity in patients with or without diabetes. In an open-label trial including over 1800 patients comparing semaglutide with tirzapedine, reduction in body weight with all doses of tirzapedine was greater compared with semaglutide. 

This patient requires medical therapy for weight loss. The formulary drugs offered to the patient are approved for diabetes but are not as good as Mounjaro for weight loss. Although they will likely not cause an adverse reaction, they have not been shown to be as effective as Mounjaro when being used for weight loss. Since the insurance company has already offered this patient the diabetes medications of Trulicity and Victoza which are approved primarily for diabetes, it would be more appropriate to give Mounjaro which is better for weight loss. Note also that, given a Hgb A1c of 5.8, she is no longer classified as having diabetes. The denial is reversed. 

The carrier's denial of a request for a Formulary Exception for Mounjaro 10 milligrams (mg) / 0.5 milliliter (ml) pre-filled pen solution for injection is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory distress. 
Treatment: Inpatient admission.
The insurer denied coverage for the inpatient admission. 
The health plan's determination is overturned. 

The patient is a female with a medical history of polysubstance abuse including heroin, alcohol and tobacco, chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) with a preserved ejection fraction. She was admitted for an acute exacerbation of CHF and acute exacerbation of COPD with symptoms of shortness of breath, lower extremity edema, and chest tightness. 

Inpatient Hospital Admission was medically necessary for this patient. 
This patient was admitted for an acute exacerbation of CHF and acute exacerbation of COPD with symptoms of shortness of breath, lower extremity edema, and chest tightness. On admission, the patient was in respiratory distress with tachypnea, accessory muscle use and bilateral wheezing requiring bilevel positive airway pressure support (BiPAP). She was hemodynamically unstable with a blood pressure 182/98. She had evidence of acute cardiac ischemia with positive troponins, lower extremity edema, an elevated BNP (B-type natriuretic peptide) and hyponatremia. She required treatment with diuresis with intravenous diuretics, while monitoring her renal function and electrolytes, respiratory support with BiPAP, supplemental oxygen, nebulizers, and steroids. Therefore, due to the new onset supplemental oxygen along with BiPAP support, elevated BNP with an acute myocardial ischemia evident by a positive cardiac biomarkers (elevated troponin levels) requiring treatment with diuresis, and monitoring of her renal function along with electrolytes, the Inpatient Hospital Admission was medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Kidney transplant.
Treatment:  Envarsus XR.

The insurer denied Envarsus XR.  The health plan's determination is overturned. 

The patient is a male with end-stage renal disease from polycystic kidney disease, status post living related renal transplant. The patient has stage IV chronic kidney disease. The patient has been treated with Prograf, which was discontinued due to tremor. The patient was initiated on Envarsus XR (extended release) at this time and has had an improvement in tremor. 

A formulary exception is indicated in this case. The documentation indicates that the patient had a tremor because of tacrolimus, which has improved with Envarsus XR. Gengraf (cyclosporine) has been shown in published literature to be less efficacious at preventing renal transplant rejection than tacrolimus formulations and to have a higher incidence of calcineurin inhibitor toxicity. In summary, the formulary drug tacrolimus capsule has been ineffective and caused adverse effects. The formulary drug would not be as effective as the nonformulary drug and would have adverse effects.