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

Diagnosis: Immunologic Disorders.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Xeljanz. 
The denial is upheld.

The patient is a female with severe alopecia areata (over 40% hair loss on her scalp). The patient has tried and failed topical, intralesional, and oral steroids. The patient's condition has severely impacted her personal life, and she feels embarrassed in public and has become increasingly isolated and depressed due to her appearance. The condition has come to affect her livelihood and overall mental well-being.
At issue is whether the proposed health service Xeljanz is likely to be more beneficial than any standard treatment for the patient.

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

The proposed health service or treatment Xeljanz is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
While understandable to consider Xeljanz for this patient's condition, the requested medication is investigational at this time, and merits further study before being presumed acceptable for widespread clinical use. At this time, the long-term safety of this medication is not confirmed. Alopecia areata is notoriously difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, contact allergen treatment and related therapies have all resulted in variable and unsatisfactory outcomes, and self-resolution is often the only choice a patient has (along with hairpieces) for severe cases. However, while Xeljanz has some promising preliminary results in open-label studies (5, 6) the overall literature and reviews on alopecia areata (1-4) mention Xeljanz only as investigational. Xeljanz was denied United States Food and Drug Administration (FDA) approval for use in psoriasis, in large part for safety reasons, and is not without a significant risk of side effects that preclude an acceptable risk for use outside of the investigational setting for the condition of alopecia areata.
The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of alopecia areata, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with a specific dosing of Xeljanz. Therefore, as per the evidence-based literature, Xeljanz is acceptable only within the investigational setting and not medically necessary for less-monitored outpatient clinical use.
Therefore, the proposed health service or treatment Xeljanz is not likely to be more beneficial than any standard treatment or treatments for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Relapsing remitting multiple sclerosis

Treatment: Vumerity

The insurer denied coverage for Vumerity

The denial is upheld.

The patient was seen by her Neurologist to discuss disease modifying therapies (DMTs). It was noted that magnetic resonance imaging (MRI) and symptoms were consistent with multiple sclerosis (MS). The plan was to start the patient on Vumerity. An appeal letter submitted by the provider noted that the patient was recently diagnosed with relapsing remitting MS.

"Disease-modifying therapies are the mainstay of treatment of relapsing-remitting MS. Glatiramer acetate, dimethyl fumarate, fingolimod, interferon-beta preparations, natalizumab, and mitoxantrone are some of the primary disease-modifying therapies available. Early treatment should commence upon establishing a diagnosis of MS. Short term goal includes a reduction in MRI lesion activity. Long term goals include prevention of secondary progressive MS. The primary issues after initiating therapy include patient compliance and monitoring for drug toxicity.

Patients with secondary progressive MS, progressive-relapsing MS, and primary progressive MS appear to represent primarily neurodegenerative processes. Disease-modifying therapies are, therefore, less effective, and treatment with these therapies has ranged from possible benefit to little effect on disease progression. Young patients with a short duration of progression seem to derive the most benefit." (Tafti, D., et al. 2022)

"Corticosteroids, such as methylprednisolone, given in high doses can decrease the duration of relapses of MS but do not affect the degree of eventual recovery after relapses. A number of different medications are useful for treating various symptoms of MS, such as fatigue, bladder dysfunction, and spasticity, but these medications do not reverse the damage that has already occurred or decrease disease activity" (Lane, M., & Yadav, V., 2020)

The requested drug would not be more effective than the formulary drugs. The formulary drugs have all proven to be effective for the treatment of relapsing remitting multiple sclerosis, which the patient is diagnosed with. The patient has yet to try any medication for his diagnosis. 

The formulary drugs are not likely to cause the patient an adverse reaction any more than Vumerity would also be expected to.  

The formulary drugs have not been ineffective based on the patient's clinical history.

The insurer's denial of coverage for Formulary Exception for Vumerity is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dizziness
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns for dizziness and inability to ambulate. Pertinent history included migraine headaches. Review of symptoms was notable for shortness of breath while lying down, neck pain, and bilateral leg swelling of one month duration.

The inpatient hospital admission was not medically necessary. In this particular situation, the patient presented with dizziness. An extensive evaluation was performed which was essentially unremarkable. Treatment plan essentially included close observation, Epley maneuver, oral meclizine, and diagnostic testing. Follow observation care, no other issues or complications were documented. Clinical indications for admission to inpatient care were not met. The patient did not have acute bacterial labyrinthitis, cerebellar, brainstem, cerebral ischemia or hemorrhage, suspected etiology that requires admission for treatment (e.g. vertebral artery dissection), hemodynamic instability, signs of symptoms that are severe and persistent (e.g., inability to ambulate after observation care treatment), persistent vomiting, cardiac arrhythmias of immediate concern, severe (new) neurologic findings requiring inpatient care (papilledema, cerebral edema, mass effect, cerebral bleeding, ischemic, or vasospasm, increased intracranial pressure or hydrocephalus), continuous intravenous infusion of anticoagulation, platelet inhibitor, vasoactive, or antiarrhythmic medication, or other condition, treatment, or monitoring requiring inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Home Health Care.  
The insurer denied personal care aide 25 hours/week, consumer direct 1 client.
The health plan is overturned.

The patient is a female with medical history significant for end stage renal disease. She has chronic weakness and requires assistance for all activities of daily above and beyond a typical child her age. She is unable to raise her arms above her head and she has difficulty with personal hygiene tasks such as brushing her teeth. She is able to ambulate with a cane but moves more slowly than other children her age. She sips liquids and takes limited solid food.

Her father works outside of the home full-time. Her mother also works outside of the home full-time. Her uncle assists her at home. Father's work schedule included starting in the afternoon. There is no information about the mother's work schedule. She can read and write and make her needs known. She wears glasses. She currently receives 14 hours/week of consumer direct personal care aide assistance.

Personal care aide needs include assistance with eating including meal preparation and feeding, bathing, dressing upper and lower body, personal hygiene including brushing teeth, and supervision taking medications. She requires assistance with ambulation, including stairs and transferring on and off the toilet.

The subject under review is the medical necessity for the Personal Care Aide 25 hours/week, consumer direct, 1 client.

Personal care aide services 25 hours/week consumer direct 1 client are medically necessary. According to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents With Chronic Disease, "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." (1) Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." (1)
This female has multiple disabilities as a result of and in addition to her end stage renal disease. She has significant weakness and fatigue that limit her activities and ability to perform age-appropriate activities of daily living. She currently does not attend school because of the pandemic, but both parents work outside of the home and are unable to assist her during the day. She is cognitively able to function but is limited physically and requires assistance while her parents are at work. The care and assistance that she requires are outside the scope of a typical babysitter situation. She requires the assistance of a personal aide to meet her needs while her parents are outside of the home at work. The requested 25 hours per week are medically necessary and reasonable. Less hours would leave her without the ability to successfully meet her needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease; septic arthritis.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is overturned.

Patient is a male with a past medical history significant for end stage renal disease on hemodialysis, peripheral neuropathy, hypertension, hyperlipidemia, diabetes, anemia, and venous stasis ulcers who presented to the emergency room with complaints of loss of consciousness while at dialysis. 

Vitals on presentation included: T (temperature) of 36.3 C (Celsius), BP (blood pressure) -166/80, P (pulse) -80, RR (respiratory rate) 17, O2 (oxygen) sat (saturation)-100% on RA (room air). Laboratory results included the following: WBC (white blood cell count) 16.5, HGB (hemoglobin)-8.0, HCT (hematocrit)-28.6, creatinine-6.93, glucose-162, BNP (brain natriuretic peptide)-942.1. CXR (chest x-ray) showed no focal consolidation. Head CT (computed tomography) scan showed no acute findings. 

A head CT scan showed no evidence of acute intracranial hemorrhage or acute territorial infarction. CXR was negative. Abdominal ultrasound was negative for cholelithiasis. Podiatry evaluated the patient for a chronic foot ulcer. Renal was consulted for a continuation of hemodialysis. Infectious disease was consulted for empiric antibiotic coverage (vancomycin and cefepime). Imaging of his ankle and foot revealed neuropathic osteoarthropathy with superimposed septic arthritis. The patient refused debridement initially, but later accepted incision and drainage with a bone culture and biopsy. Cultures were positive for step and Candida parapsilosis. The patient was placed on a four-week course of Diflucan.

According to documentation, the patient presented with loss of consciousness during hemodialysis of unclear etiology. The patient was afebrile, but hypertensive. Laboratory results were notable for leukocytosis (WBC-16.5) and an elevated BNP (942.1), in addition to other abnormalities due to underlying medical issues. The patient had numerous potential sources of infection including his ankle and foot. Due to his numerous co-morbid conditions, the patient remained at high-risk for infectious complications. Outpatient evaluation/management was not feasible due to his end stage renal disease requiring hemodialysis. Based on the above findings, the patient met criteria for acute hospitalization.    

Prior determination of denial of coverage for inpatient hospital services 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 full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lesion of the right lower lid. 
Treatment: Procedure code 67911 repair retraction of the right upper lid. 

The insurer denied coverage for procedure code 67911 repair retraction of the right upper lid. 

The denial is overturned. 

The healthcare plan did not act reasonably and with sound medical judgement and in the best interest of the patient. The patient has bilateral lower lid retraction, s/p (status post) repair on the left, and now needs surgery on the right side. The procedure is medically necessary because retraction is causing tearing and discomfort and interfering with daily activities. 

The procedure 67911 is medically necessary for this patient. The patient has visually significant and symptomatic right lower lid retraction after blepharoplasty procedure. 

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 outpatient procedure (67911 x 1) Professional Services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Parkinson's disease, stroke, multiple system atrophy, unsteady gait, orthostatic hypotension, bilateral sciatica, incontinence, and sacral ulcers.
Treatment:  Personal care aide (PCA) hours 7 days a week two 12-hour shifts a day (split shift).

The insurer denied coverage for personal care aide (PCA) hours 7 days a week two 12-hour shifts a day (split shift).  The denial is upheld.

This is a patient with chronic medical problems including Parkinson's disease, stroke and orthostatic hypotension. She lives in a 3-bedroom home with her son. The insurer approved 7 days/week, 24 hours/day (live-in). Under review is the request for PCA hours 7 days a week, two 12 hour shifts a day (split shift).

According to the Uniform Assessment System (UAS) report, the patient's cognitive skills are "minimally impaired" and according to the clinical note from her treating physician, her mental status was described as "alert, oriented to person, place and time." She is totally dependent for activities of daily living tasks, including bathing, dressing, hygiene and toilet transfers/use. She is incontinent of bowel and bladder. The patient is wheelchair dependent. There have been no reported falls over the prior 90 days. Routine skin care has been provided by the live-in PCA and the sacral wound (according to the treating physician) "has been healing well." The patient lives with her son and a live in who requires only 5 hours of continuous uninterrupted sleep during a 24-hour period, which does not need to be at night. Her care has been managed appropriately with the current services, rendering the PCA hours 7 days a week, two 12-hour shifts a day (split shift) not medically necessary. 

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

From a physical medicine and rehabilitation perspective, (PCA) hours 7 days a week, two 12-hour shifts a day (split shift) is not medically necessary.

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

The insurer's denial of coverage for personal care aide (PCA) hours 7 days a week two 12-hour shifts a day (split shift) is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atrophic vaginitis.

Treatment: Estring 2 milligram (mg) VA (vaginal) RING.

The insurer denied coverage for Estring 2 milligram (mg) VA RING.

The denial is upheld.

The patient is diagnosed with atrophic vaginitis. According to the provider, the patient was prescribed Vagifem. According to progress notes, the patient had some trouble inserting it and saw some blood. She took a few days off and was able to insert it without problems. However, she kept complaining about the inability to insert it. She is requesting coverage for Estring because it is inserted every 90 days and she can have it inserted in her provider's office.

Estrogen is the most effective treatment for moderate to severe symptoms of vaginal atrophy. Use of estrogen therapy is appropriate for women with symptoms of vaginal atrophy in the setting of low estrogen levels, provided that there are no contraindications to this therapy (e.g., certain women with estrogen-dependent tumors). 

Adequate estrogen therapy leads to restoration of the normal vaginal acidic potential hydrogen (pH) and microflora, thickening of the epithelium, increased vaginal secretions, and decreased vaginal dryness. The agents for vaginal estrogen therapy that are commercially available in the United States are conjugated estrogens (cream) and estradiol (cream, tablet, and ring). 

A systematic review of 19 randomized trials including over 4000 women that investigated local estrogen treatment found that creams, tablets, and rings were all similarly effective in relieving symptoms of vaginal atrophy. In other words, Estring is no more beneficial than the formulary products.

The need for formulary exception is not supported by current medical literature for the requested medication, Estring.

Note that all the formulary alternatives contain the same ingredients as Estring which is estradiol (except for Premarin that contains conjugated estrogens).

Based on the above, Estring is not likely to be more effective than the formulary agents; the patient should be able to use the formulary products.

The formulary drug(s) are unlikely to cause the patient an adverse reaction. 

The formulary drug(s) have not been ineffective based on the patient's clinical history. The patient stated that she had difficulty inserting it.

The requested drug will not be more effective than the formulary drug. They all provide the same needed estrogen to the vaginal tissue.

The insurer's denial of coverage for Formulary Exception for Estring 2 milligram (mg) VA RING is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Anorexia/lab abnormalities.
Treatment:  Inpatient stay.

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

The patient is a female, who initially was directed to the emergency department by her primary care physician for concerns of laboratory abnormalities. Pertinent history included anorexia/bulimia, vanishing bile duct syndrome, and history of C. diff (clostridium difficile) colitis. 

In this particular situation, the patient had a history of an eating disorder and weakness for months to a year and was directed to the emergency department after her primary care physician discovered electrolyte abnormalities. Initial evaluation found the patient to be afebrile, hemodynamically stable, alert, and oriented. Initial laboratory testing revealed hyponatremia, hypokalemia, hypomagnesemia, and hypochloremia. There were no significant conduction abnormalities noted on the EKG (electrocardiogram). Treatment plan included intravenous fluids and electrolyte replacement. Prior to electrolyte recheck, the patient requested to leave against medical advice and ambulated out of the hospital without assistance.

The patient's hyponatremia would not be classified as severe and thus did not warrant urgent intervention to prevent permanent disability or death. Moreover, clinical indications for admission to inpatient care were not met. The patient did not have a serum sodium less than 135 with severe finding requiring inpatient management (e.g., altered mental status, seizures). The patient also did not have a serum sodium less than 130 not corrected to near normal or near chronic baseline despite observation care treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD (chronic obstructive pulmonary disease).
Treatment: Inpatient admission. 

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

The patient has a history of chronic obstructive pulmonary disease (COPD), asthma, diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD) and obesity.

The patient presented to the emergency department (ED) with complaints of shortness of breath. Oxygen saturation was 98% on 4 liters. The patient was in no acute distress. There were bilateral wheezes heard on the lung exam. The patient was awake and alert with a non-focal neurological exam.

The patient was treated with intravenous (IV) steroids, bronchodilators, and magnesium. The patient was also given Azithromycin.

The patient showed improvement with treatment, but he was still wheezing and became short of breath (SOB) upon ambulating to the bathroom. He was admitted for a COPD exacerbation.

As per the History & Physical (H&P), the patient was in no acute distress (NAD) and oxygen saturations were at 98% on room air (RA). The lung exam revealed a bilateral wheeze. Cardiovascular systems were normal. The abdomen was soft. The neurological exam was non-focal.

There were no acute infiltrates on the chest x-ray and the Troponin level was normal.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. By the next day, the patient was already at baseline and was discharged home.

The patient could have been discharged home on oral medications after a period in observation status.

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.