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

Diagnosis: Chronic Atrial Fibrillation
Treatment: Formulary exception for Eliquis
The insurer denied the Formulary exception for Eliquis
The denial is overturned

The patient is a male with history of atrial fibrillation, PCI (percutaneous coronary intervention), hyperlipidemia, and hypertension. He has history of CABG (coronary artery bypass graft) and stenting. He has been treated with optimal medical therapy for CAD (coronary artery disease). He has recurrent paroxysmal atrial fibrillation, and was placed on Eliquis.

The health plan's Formulary anti-coagulation agents for atrial fibrillation are Xarelto and warfarin. An exception is requested for Eliquis.

Yes, the health plan should cover the Formulary exception for Eliquis.
Recent published studies in respected journals, including New England Journal of Medicine and JAMA (Journal of the American Medical Association) have concluded that Eliquis is the preferred anticoagulant for this patient's condition. Large population studies have shown that Eliquis is safer, with less bleeding, fewer strokes, and fewer complications than either Xarelto (Rivaroxaban) or warfarin.

Eliquis was found to be more effective than warfarin in lowering the risk of stroke and systemic embolism. People who took Eliquis also had significantly fewer bleeding episodes than those who took warfarin.

Eliquis is the only NOAC (non-vitamin K oral anticoagulant) that is better than warfarin in the prevention of stroke and results in fewer bleeding complications. Overall, all-cause mortality from DOACs (directly acting oral anticoagulants) is evidenced to be lower than that from warfarin, driven primarily by a decrease in fatal intracranial bleeding risks.

Among Medicare beneficiaries 65 years or older with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events.

In conclusion, in patients with atrial fibrillation, apixaban is superior to warfarin and Xarelto in preventing stroke or systemic embolism, caused less bleeding, and results in lower mortality.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a female who was admitted after a tonsillectomy and adenoidectomy procedure for obstructive sleep apnea (OSA). She had an apnea hypoxia index of 2.8 and was considered to have severe tonsil and adenoid hypertrophy.
She underwent the surgical procedure without complications and was subsequently admitted for overnight airway monitoring with continuous pulse oximetry, intravenous fluids at maintenance, and pain medications around the clock as needed. She was also treated with amoxicillin. By the following day she had remained stable and was felt ready for discharge to home with follow-up as an outpatient. The inpatient hospitalization is under review.

The requested health service/treatment of inpatient hospital stay was medically necessary for this patient.
This is a patient who presented for a tonsillectomy and adenoidectomy procedure for obstructive sleep apnea. She required inpatient admission for airway monitoring and intravenous fluid following the procedure.
Postoperative respiratory complications in the immediate postoperative period after a tonsillectomy and adenoidectomy are common and range in severity from mild desaturation to life-threatening airway obstruction. The risk of respiratory complications is greatest among children with obstructive sleep apnea, and can include airway edema, central apnea/hypoventilation, bronchospasm, and post obstructive pulmonary edema.
Importantly, risk factors for postoperative respiratory complications include age less than 3 years and obstructive sleep apnea. Age less than (<) 3 years and severe OSA are considered indications for inpatient admission.
This patient was at increased risk of respiratory complications following the procedure based on her age and the presence of obstructive sleep apnea. Hospital admission was appropriate for close monitoring of the airway in addition to the administration of intravenous fluids.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder/Incontinence/Urinary/Bladder Control
Treatment: Surgical Services (InterStim procedure)
The health plan denied the requested InterStim procedure as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a diagnosis of lower urinary tract symptoms (LUTS) including hesitancy, frequency, nocturia, and urgency. Cystoscopy and urodynamics were normal. He had tried anticholinergics and beta 3 agonists. He had percutaneous tibial nerve stimulation (PTNS). The medical necessity for an InterStim procedure is under review.

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

No, the requested service would not be considered a clinically appropriate and generally accepted standard for management of the patients' medical condition. As such, it would not be considered medically necessary.

Based on the information, the patient has LUTS presumed to be from an overactive bladder. Benign prostatic hyperplasia (BPH) is the most likely cause of irritative LUTS and overactive bladder in men over 50. The documentation does not support a prior trial of BPH treatments. In addition, the role of sacral neuromodulation in men with bladder outlet obstruction (BOO) and overactive bladder (OAB) is largely unknown. Most studies evaluating efficacy of sacral neuromodulation are done on women with refractory OAB. Current scientific evidence does not support the routine use of sacral neuromodulation in men with LUTS refractory to medical therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis.
Treatment: Acute inpatient admission.

The insurer denied coverage for acute inpatient admission.
The denial is upheld.

This is the case of a female with history of an appendectomy, cholelithiasis and asthma who presented emergency department (ED) with RUQ (right upper quadrant) tenderness, nausea, several episodes of emesis and a positive Murphy's sign. As per the ED triage note, the patient had stable vital signs and was afebrile and presented with pain in her RUQ since four in the morning. As per the ED provider note, she admitted to a history of gallstones however she had not had an attack in several years. She denied fever, chills. Exam revealed RUQ and epigastric tenderness without guarding. She was admitted to surgery with the principal diagnosis of cholecystitis. The patient was admitted.

The acute inpatient admission was not justified as this patient could have been managed as noted by the insurer in an ambulatory/observation setting as she had an uneventful lap cholecystectomy. 

According to MCG (Milliman Care Guidelines), Inpatient and Surgical Care 26th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory. Thus, this patient should have been managed without an inpatient acute admission for this procedure. MCG also noted "that analysis of a cohort of 95,523 adult patients who underwent laparoscopic cholecystectomy within 10 days of presentation with acute cholecystitis found that 65% (percent) of the laparoscopic cholecystectomies were performed either the day of presentation (day 0) or the following day (day 1)."  Thus, ambulatory status would have been appropriate.

The recommended health care services provided that the admission was not justified at the inpatient admission level as the patient should have been managed in an ambulatory/observation setting. 

The health care plan did act reasonably and with sound medical judgment. Denial is UPHELD.

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

The insurer's denial of coverage for an acute inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The case involves an adult male who was self-referred with admission to inpatient rehabilitation and substance use disorder treatment to address substance use disorder with alcohol and cocaine use, as well as tobacco dependence at one pack per day. The patient has no history of blackouts or withdrawal seizures or delirium tremens. He had been using one to one-half pints of liquor and beer together with daily use of up to $200 worth of crack cocaine. He had multiple past treatment experience with at least 26 detoxification treatment episodes and at least 8 rehabilitation treatment episodes. His drug screen was positive for cocaine and his blood alcohol level was zero with no significant withdrawal symptoms. The patient has no psychiatric disorders, and he denied history of psychiatric hospitalization or suicidal behavior. 

Inpatient Hospitalization was not medically necessary for this patient. 

The proposed inpatient substance use disorder treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care in a less restrictive treatment setting. The clinical features and indicated treatment dimensions of this patient's alcohol and cocaine use disorders did not require or warrant the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cocaine. Moreover, the patient had been evaluated and cleared with regard to safety concerns, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment. 

Thus, the inpatient admission for substance-related rehabilitation treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario. Any indicated treatment for alcohol or cocaine use disorder in this case could have been provided, as clinically appropriate, at a lower level of care as the health plan asserts in the denial determination in keeping with New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Pharmacy/Prescription Drugs/Nexlizet. 
The insurer denied Nexlizet. 
The denial is upheld.

This case involves a male with a history of atherosclerotic cardiovascular disease, and angina, who has reported intolerances to statin therapy including Crestor, Lipitor, Zocor as well as ezetimibe. The patient has been treated with Nexlizet for treatment of hyperlipidemia. The patient's health plan has denied coverage for Nexlizet on the grounds it does not meet prescription benefit exception criteria as there has been no documentation provided regarding intolerance, failure, or contraindications to Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors Repatha and Praluent. The use of Nexlizet in this case is the subject under review.

The health plan's determination is upheld.

Based on the records provided for review of this case, there is no documentation indicating that the formulary medications, Repatha or Praluent, will be less effective, have adverse effects, on would be contraindicated for the treatment of this patient's cardiovascular disease and hyperlipidemia. In addition, based on results of the FOURIER trial published in the New England Journal of Medicine in 2017, patients treated with evolocumab in addition to statin therapy with baseline low density lipoprotein (LDL) cholesterol 70 milligrams per deciliter (mg/dL) or greater demonstrated significant reduction in LDL cholesterol as well as in the composite primary endpoint of cardiovascular death, myocardial infarction, stroke, hospitalization for angina, or coronary vascularization (1). Therefore, the formulary PCSK9 inhibitors appear to be a very good medical option for this patient given his statin intolerances.
There has been no documentation that the formulary medications, Repatha or Praluent, would be less effective or contraindicated for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis, Lower Extremity

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient is a female with past medical history significant for diabetes mellitus and congestive heart failure, who was referred to the emergency department with complaints of fever, chills, and left lower extremity pain. Vitals on presentation included: Temperature-99.0 Fahrenheit, Blood Pressure-90/46, Pulse-98, Respiration Rate-20, O2 (oxygen) saturation-98% (percent) on Room Air. Laboratory results included the following: WBC (white blood cells)-15.0, HGB (hemoglobin)-9.2, Hct (hematocrit)-30.7, creatinine-0.65, glucose-133, CRP (C-Reactive Protein)-10.99. CXR (chest x-ray) showed right perihilar increased markings.

The patient was started empirically on intravenous antibiotics (vancomycin and cefepime) for possible re-infection of lower extremity cellulitis. Ultrasound of bilateral lower extremity was negative for DVT (deep vein thrombosis). MRI (Magnetic Resonance Imaging) of the legs showed no evidence of osteomyelitis. The patient was treated for congestive heart failure with diuretics. Echocardiogram was performed. Cultures remained negative. She remained afebrile, and clinically and hemodynamically stable. The patient was discharged to continue outpatient management.
 
According to documentation, the patient presented with possible lower extremity cellulitis. She was hypotensive in the emergency department with low-grade fever. Laboratory results were notable for elevated WBC (15). Based on these findings in a high-risk patient with co-morbid conditions including extensive debridement of lower extremity previously, inpatient hospital admission was medically necessary for administration of intravenous antibiotics and further evaluation.

Prior determination of denial of coverage for inpatient hospital admission is overturned.

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

Diagnosis: Difficulty Breathing.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with a diagnosis of moderate to severe persistent asthma. He was admitted to the hospital.

The health plan denied coverage for the inpatient admission on the basis that it lacked medical necessity. This denial is being appealed.

No, the Inpatient admission was not medically necessary.
The patient presented to the ED (emergency department) with 4 day onset of rhinorrhea, nasal congestion, dry cough, and poor appetite. For the two hours prior, the patient had been having trouble breathing and "air hunger." Physical exam noted that the patient was ill-appearing and had moderate respiratory distress with low-grade fever and borderline tachycardia. Diffuse wheezing, tachypnea, retractions, and decreased breath sounds were also noted. The patient was diagnosed with bronchiolitis associated with moderate bronchospasm and signs of moderate respiratory distress. He was given 3 Duo Nebs and Solumedrol. He responded to the treatments and IV (intravenous) fluids. Mild breathing effort remained but the patient's breathing and retractions improved. He was noted to be speaking to his parents. Oxygen saturation was 100%. It is not clear why the patient was transferred and admitted, given his improvement in the ED (emergency department).

In an appeals letter, it was noted that the patient "was admitted immediately and started on albuterol every 2 hours. This asthma pathway regimen continued with continuous reassessing for the need for nebulizer treatment.  As the plan of care continued, there were no noted acute events overnight. With noted clinical improvement, he was discharged to home on albuterol nebulizer treatments every four hours as needed for any shortness of breath or wheezing." However, the provided clinic notes do not corroborate the veracity of these statements.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The documentation provided does not justify the hospitalization, given the patient's improvement in the ED (emergency department).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Iron Deficiency Anemia 

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This case involves a female diagnosed with iron deficiency anemia and vertigo.

The patient was seen in the emergency department (ED) with a past medical history of iron deficiency anemia. There were reports of waking up with dizziness, headache, and nausea. There was nausea with small amounts of vomiting associated. In the ED, Valium, Benadryl, Ativan, meclizine, Reglan, and normal saline were administered. Symptoms remained. Computed tomography (CT) of the head was negative for acute changes. The examination documented horizontal nystagmus. The patient was admitted ruling out posterior stroke. Neurological consultation revealed nystagmus consistent with benign positional vertigo (BPV) and the patient gradually improved over 3 days. The patient was stable and cleared for discharge.  

The patient presented with headache with nausea and dizziness to the ED along with vomiting and vertigo with horizontal nystagmus. CT of the head was negative for acute stroke/hemorrhage. She was admitted to the hospital and was seen by neurology who diagnosed symptoms with BPV. Care provided, including diagnostic imaging, specialty consultation and medical management could have been performed in the ED and at an observation level of care. 

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

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

Diagnosis: Plantar flexion contracture. 
Treatment: Brace and the additional parts to be used with it. 

The insurer denied the brace and the additional parts to be used with it. 
The determination is overturned. 

The patient has been toe walking since early childhood. He presented to the orthopaedic surgeon with a fixed plantar flexion contracture. This was treated with stretching exercises, physical therapy, night-time bracing, and serial casting, with some improvement in the contracture. The orthopaedic surgeon has recommended a hinged ankle-foot orthosis with plantar flexion stop at neutral, in order to try to maintain the foot in a plantegrade position. At issue is whether this brace and the additional parts to be used with it are considered medically necessary. 

Yes, the ankle-foot orthoses and the additional parts to be used with this are medically necessary. The patient has idiopathic toe walking, possibly associated with autism, and bilateral equinus contractures. He has had extensive non-surgical treatment with some improvement, and the brace is designed to help maintain the foot in the corrected position. Without the brace, it is likely that the contracture would recur or worsen, possibly necessitating surgery. A prefabricated brace would not meet the standard of care for this patient. A brace that is applying a corrective force (holding the foot in a neutral position and preventing it from going back into equinus) must be well molded to the foot; if not, the foot is able to slip up within the brace and excessive pressure will be applied to prominent areas of the foot, resulting in skin breakdown. 

The requested ankle-foot orthosis and additional parts would be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurative
Treatment: Cosentyx
The insurer denied the Cosentyx
The denial is overturned

The patient is a male with hidradenitis, treated with antibiotics, Humira, isotretinoin, and systemic, intralesional and topical steroids. His provider is requesting Cosentyx. The health plan denied coverage of Cosentyx for this diagnosis as not medically necessary. This is being appealed.

Yes, the requested Cosentyx is medically necessary.
This patient has already failed Humira. Infliximab can also be tried, but this requires an infusion center. Other biologics have also shown promise for hidradenitis and after Humira, but no therapeutic alternative has been definitively shown to be superior.

Secukinumab is a human monoclonal antibody that inhibits IL (interleukin)-17A. Data from small, open-label studies suggest secukinumab may be a beneficial therapy.

In an open-label study (Casseres et al) in which 20 patients with moderate to severe HS (hidradenitis suppurativa) received secukinumab (weekly 300 milligram doses followed by repeat does either every four weeks or every two weeks), 14 patients achieved the HiSCR (Hidradenitis Suppurativa Clinical Response) endpoint (at least 50 percent reduction in the number of abscesses and inflammatory nodules and no increase in draining fistula or abscess count relative to baseline) after 24 weeks.

Another open-label study (Prussick et al) that included nine patients with moderate to severe HS (hidradenitis suppurativa) given subcutaneous secukinumab 300 mg (milligrams) weekly for 5 weeks and then every 4 weeks for a total of 24 weeks found six of the nine patients achieved the HiSCR (Hidradenitis Suppurativa Clinical Response) endpoint.

There were no serious adverse events in either study.

Therefore, given the above, the Cosentyx is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.