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

Diagnosis: Spinal Muscular Atrophy (SMA) Type 2., Asthma, Reflux, Polycystic Ovary Syndrome (PCOS), Scoliosis, Irritable Bowel Syndrome (IBS). 
Treatment: PDN (Private Duty Nursing) services 20 hours a day 5 days a week and 16 hours a day 2 days a week; procedure codes S9123 and S9124. 

The insurer denied coverage for PDN services 20 hours a day 5 days a week and 16 hours a day 2 days a week; procedure codes S9123 and S9124. 

The denial is overturned. 

The patient is a female with history of Spinal Muscular Atrophy (SMA) Type 2. 
She has other co morbidities including Asthma, Reflux, Polycystic Ovary Syndrome (PCOS), Scoliosis, Irritable Bowel Syndrome (IBS). The patient has been receiving private duty nursing (PDN) for many years for her progressive degenerative motor neuron disease. The patient has hypotonia and is wheelchair bound. 

The patient is on an oral diet and uses bilevel positive airway pressure (BIPAP) machine at night. She is at a high risk for aspiration and mucus plugging so is receiving Vest therapy for 25 min twice daily and as needed. The patient requires assistance for all activities of daily living (ADL's).  The patient needs monitoring of her vital signs closely to detect any deterioration which may indicate sepsis/pneumonia (PNA). She is also on bronchodilators and other medications which have to be administered as necessary and require frequent monitoring.  The patient has done well with continuous PDN for all these years and graduated college and is now working full time. Additional hours were added due to her commute. 

This patient is wheelchair bound, extremely hypotonic and other than minimal movement of her hands totally dependent. She was given this employment contingent upon a skilled person who was available to monitor her while she was at work as her work facility does not have anyone capable of doing that. 

This patient has done well, graduated college and is now gainfully employed. This all has been possible due to excellent care that she has been receiving from PDN. SMA is a genetic progressively degenerative condition and these patients do not get better. These patients are extremely fragile and have multiple medical co morbidities which need continuous monitoring to keep them safe and avid complications which would lead to hospitalizations. It is imperative that she continue with her PDN which she has been receiving for the past 16 years to remain in her best medical state. 

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 private duty nursing 20 hours a day five (5) days a week and 16 hours a day two (2) days a week is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Irritable Bowel Syndrome (IBS) with Constipation. 
Treatment: Formulary exception for Zelnorm. 

The insurer denied the Formulary exception for Zelnorm. 
The denial is overturned. 

The patient is a female with irritable bowel syndrome with constipation (IBS-C). She has failed Amitiza, Linzess, Miralax, Senna, Dulcolax, Motegrity, Trulance and Zelnorm; however, the patient has done well on a combination of Trulance and Zelnorm for the past two years. The attending physician (AP) is requesting continuation of Trulance with Zelnorm. 

Yes, the health plan should cover the proposed treatment with Zelnorm. 

The patient has failed two preferred formulary alternatives, Amitiza and Linzess. Zelnorm is a pro-kinetic agent. Trualnce is a pro-secretory agent.  The patient is doing well on the combination of the two medications.  There are no contraindications to using Trualnce and Zelnorm together as they have different mechanisms of action.  As the patient has failed the preferred formulary agents, and as the patient is doing well on the two medications combined, the health plan should cover Trulance in combination with Zelnorm.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent Syn 300mg/2mL Pen Injector.

The insurer denied the Formulary exception for Dupixent Syn 300mg/2mL Pen Injector.
The denial is upheld.

The patient is a female with moderate to severe atopic dermatitis affecting 15% body surface area, namely the arms, hands, neck, and trunk.  The rash is flaking, itchy, and painful.  It has been present for years.  She has had an inadequate treatment response to at least two medium or high potency topical steroids in the past 180 days.  She has not had an inadequate treatment response to topical tacrolimus in the past 180 days.  The medical record indicates the patient has tried Dupixent in the past.

No, the health plan should not cover the formulary exception for Dupixent Syn 300 milligrams (mg) per two milliliters (mL) pen injector.
Dupilumab is a monoclonal antibody that inhibits interleukin (IL)-4 and interleukin (IL)-13 signaling by blocking the shared interleukin (IL)-4Ra and originally demonstrated efficacy in phase II clinical trials. It was approved by the United States Food and Drug Administration (FDA) for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It is a subcutaneous injection administered initially at a dose of 600 milligrams and then every two weeks thereafter. 

This patient has moderately severe disease and has only used topical steroids in the past. She is currently prescribed triamcinolone.  There is no documentation of her response to that treatment nor any explanation of prior Dupixent use. Therefore, it is not clear whether the patient responded to topical steroids, or has had to use Dupixent in the past, and what her response to that treatment was. There is no documentation of use of other topical therapies, such as calcineurin inhibitors or crisaborole.  In view of that, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Saxenda 3mg/0.5ml Pen Injector, Pre-service. 

The insurer denied the Saxenda 3mg/0.5ml Pen Injector, Pre-service. 
The denial is overturned. 

The patient is a female with obesity with body mass index of 35.3. The request for Saxenda is under review. 

The prior request for Saxenda was denied coverage by the health plan, as the prior request did not include documentation of current enrollment into a qualified comprehensive weight management program for at least 3 months in addition to counseling in a physician's office. The physician is appealing this determination, because this patient has been enrolled in a weight loss program. 

Yes, the requested Saxenda is medically necessary. 

The prior request for Saxenda was denied as the prior request did not include documentation of current enrollment into a qualified comprehensive weight management program for at least 3 months in addition to counseling in a physician's office. The Endocrine Society guidelines on obesity management recommend the use of Food and Drug administration approved weight loss medications (over no pharmacological therapy) to ameliorate comorbidities and amplify adherence to behavior changes, which may improve physical functioning and allow for greater physical activity in individuals with a BMI (body mass index) 30 or in individuals with a BMI (body mass index) of  27 and at least one associated comorbid medical condition such as hypertension, dyslipidemia, T2DM (type 2 diabetes mellitus), and obstructive sleep apnea. 

This patient has a BMI (body mass index) of 35.3. This patient has participated in a weight loss program. In addition, the patient saw her provider recently where diet and activity were discussed. The Endocrine Society guidelines support the use of Saxenda in this clinical situation of a BMI (body mass index) over 30. Without Saxenda, this patient will be at increased risk of the complications of untreated obesity, including type 2 diabetes. Therefore, yes, the proposed Saxenda is medically necessary. 

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

The requested Saxenda was medically necessary and was denied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient hospital admission. 

The health plan denied the inpatient hospital admission as not medically necessary. The reviewer has upheld in whole the health plan's determination. 

At the time of service this patient with a medical history of chronic pain from endometriosis, sleep apnea, hypothyroidism and morbid obesity was admitted for a viral pneumonia due to COVID-19 with symptoms of shortness of breath, generalized weakness, nausea, vomiting and loose stools. Her chest x-ray did not demonstrate pleural effusions/empyema or necrotizing pneumonia. She was treated with supplemental oxygen, and dexamethasone, Remdesivir and Doxycycline. Although in the emergency room she had an oxygen saturation of 88% on exertion, the following day she had an oxygen saturation of greater than (>) 90% both at rest and ambulation. 

Based upon the severity of illness and intensity of required therapy, the inpatient level of care was not medically necessary. This patient with a medical history of chronic pain from endometriosis, sleep apnea, hypothyroidism and morbid obesity was admitted for a viral pneumonia due to COVID-19 with symptoms of shortness of breath, generalized weakness, nausea, vomiting and loose stools. As per the clinical documentation, in the emergency room the patient was afebrile, hemodynamically stable, with a respiratory rate of 17 breath per minute, she was not in any respiratory distress but had an oxygen saturation of 88% on exertion and 96% at rest on room air. She was started on supplemental oxygen, dexamethasone, Remdesivir and antibiotics (Doxycycline). The patient continued to be afebrile, hemodynamically stable, was in no apparent distress. Her chest x-ray did not demonstrate evidence of a pleural effusion/empyema/abscess/necrotizing pneumonia. She was alert, awake and oriented throughout her stay, she did not have documented immunosuppressed state, she did not have documented bacteremia or dehydration and she was able to take oral medications/feeds. Although the patient was placed on supplemental oxygen, she had an oxygen saturation >90% both at rest and ambulation. Based on the available records, it was not medically necessary for this member to be treated at the inpatient level of care and the treatment and care could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Fibroids

Treatment: Inpatient pre-planned hospital admission

The insurer denied coverage for inpatient pre-planned hospital admission.

The denial is overturned.

The patient is an adult female with a history of symptomatic fibroids. She underwent a laparotomy with supracervical hysterectomy, bilateral salpingectomy, and a cystoscopy. Blood loss was 900 cc (cubic centimeters), necessitating transfusion with 1-unit PRBCs (packed red blood cells). The hospital course was uneventful. The patient was discharged after a period of medical stability. 

This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in the hospital for 48 hours. On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. On postoperative day 2, if the patient is passing flatus, and tolerating regular diet she is discharged home. This patient was managed according to the guidelines and the standard of care. 

The health care plan did not act reasonably and with sound medical judgement or in the best interest of the patient.

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

Diagnosis: Hypertensive Emergency

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient presented to the hospital complaining of shortness of breath that awoke him from sleep and resolved once he sat up.  Upon arrival, blood pressure (BP) was 211/124 and pulse was 94.  Past medical history was relevant for hypertension and diabetes.  The patient had not taken any medication for a three-week period. Physical examination revealed mild wheezing over both lung fields. A 12-lead electrocardiogram revealed normal sinus rhythm with nonspecific T (interval on EKG [electrocardiogram] wave changes. Chest x-ray revealed interstitial marking consistent with congestive heart failure.  Serum blood testing revealed acute renal insufficiency with a creatinine (CR) of 2.0, elevated (BNP) B type natriuretic peptide (2171), and hyperglycemia (Glucose 303). Serum troponin levels were not elevated.   The patient was treated with lisinopril, intravenous hydralazine, intravenous Lasix and admitted to the hospital for management of a hypertensive emergency.

Hypertensive emergency is defined as BP>180/120 with target organ damage (Reference 1). In this patient, BNP was elevated consistent with left ventricular dysfunction and target organ damage. Acute renal insufficiency was also noted. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction (Reference 2). Blood pressure remained elevated following initial medical therapy and admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the intensive care unit (ICU) for management of hypertensive emergencies (Reference 1). In conclusion this patient could have been managed at a higher level of care. 

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

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

Diagnosis: Fever, COVID (Coronavirus disease)-19
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with sickle cell trait, who presented to the emergency room with chest pain, fevers and chills for ten days. The patient was febrile, tachycardic, and hypertensive in the emergency room. The chest x-ray (CXR) revealed bilateral infiltrates. The blood work revealed anemia and elevated lactate dehydrogenase (LDH). The patient was also tested for COVID-19 and was positive. 

The patient was admitted to acute in hospital level of care for the management of acute chest syndrome from sickle cell crisis as well as COVID-19 pneumonia. The patient was started on intravenous (IV) antibiotics, intravenous remdesivir, intravenous pain medications, and intravenous fluids. The patient also had positive blood cultures. The patient continued to received intravenous antibiotics, intravenous remdesivir, intravenous fluids, and supplemental oxygen. The patient was in the hospital. This admission was denied due to lack of medical necessity. This denial is being appealed.

Yes, the proposed treatment, inpatient admission, was medically necessary.
The patient was admitted to the hospital for the management of COVID-19 pneumonia as well as possible sickle cell crisis causing acute chest syndrome, anemia due to sickle cell disease and bacteremia. During this admission, the patient required closer monitoring of her cardio respiratory system. The patient was on intravenous antibiotics and intravenous remdesivir for COVID-19 infection. The patient could not have been safely and effectively treated at a lower level of care due to multiple active medical problems. The current standard of clinical practice is to admit to acute hospital level of care. The treatment is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient was admitted to the hospital for the management of COVID-19 pneumonia as well as possible sickle cell crisis causing acute chest syndrome, anemia due to sickle cell disease and bacteremia. During this admission, the patient required closer monitoring of her cardio respiratory system. The patient was on intravenous antibiotics and intravenous remdesivir for COVID-19 infection. The patient could not have been safely and effectively treated at a lower level of care due to multiple active medical problems. The current standard of clinical practice is to admit to acute hospital level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is the case of a female with benign past medical history who presented to the Emergency Department (ED) with complaints of left lower extremity pain and swelling. 
Vitals on presentation were normal with a temperature of 98.5 Fahrenheit, blood pressure 153/80, pulse 65, respiratory rate 18, and oxygen (O2) saturation 100% (percent) on room air. Laboratory results included white blood cell (WBC) count 12.9, hemoglobin 13.5, hematocrit 40.9, creatinine 0.7, and glucose 100.

The patient was started empirically on intravenous (IV) antibiotics (Unasyn and clindamycin) for possible lower extremity cellulitis. Ultrasound of bilateral lower extremity was negative for deep vein thrombosis (DVT). Computed tomography (CT) scan showed subcutaneous edema with no discrete collection. Cultures remained negative. She remained afebrile, clinically, and hemodynamically stable. The patient was discharged to continue outpatient management on oral antibiotics.

According to documentation, patient presented with possible lower extremity cellulitis. Otherwise, the patient remained afebrile, and hemodynamically stable. Laboratory results were unremarkable except for mildly elevated WBC. All cultures remained negative. The patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on above findings, the patient did meet criteria for observation level of management. He did not fulfill criteria for acute hospital admission. 

The health plan acted reasonably with sound medical judgment 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: Upheld

Diagnosis: Hypertension. 
Treatment: Azor (amlodipine-olmesartan) 10-40MG OR TABS. 

The insurer denied the  Azor (amlodipine-olmesartan) 10-40MG OR TABS, pre-service. 
The denial is upheld. 

The patient is a female with hypertension, angina, depression and anxiety. She was prescribed Azor, a combination medication. Coverage for this was denied by the health plan, as they note that the patient has not taken or had a poor response to medications on the health plan's preferred drug list. The patient's treating physician noted that formulary medications may not be tolerated, as it caused nausea, vomiting and GI (gastrointestinal) upset in the past. 

No, the requested Azor is not medically necessary. 

Azor is a combination of two generic drugs, amlodipine and benicar. No clinical evidence is provided, nor references cited that would suggest that the combination drug is better-tolerated that generic drugs from those classes. 

There is no evidence provided or clinical information that would suggest that the formulary medications would cause GI (gastrointestinal) issues or not be tolerated, or that Azor has superior tolerance in this case. Also, the patient's medical conditions were reviewed and are not known to cause any issues with formulary drugs as compared to Azor. 

The health plan's denial reason, that there is no reason why the patient could not take each drug individually rather than a combination, is reasonable. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

Treating the patient with separate prescriptions for Amlodipine and Olmersartan would be consistent with the standard of care. It would not reasonably be expected to jeopardize the patient's health, and it would reasonably be expected to be at least as efficacious as the requested Azor.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plantar Fasciitis. 
Treatment: Custom Orthotics. 

The insurer denied custom orthotics. 
The health plan's determination is overturned. 

The patient is a male who has a history of foot pain caused by plantar fasciitis and tendonitis. The medical records report that the patient is in a great deal of pain when he plays basketball. The physician states "cannot play sports due to pain in his feet". The patient is a student and very active. The history reveals the patient has tried soaking his feet. He also has used store bought over the counter orthotics. The treating doctor states the treatments used have not helped the pain. The treating doctor recommended custom molded orthotics. 

The custom shoe inserts are medically necessary for this patient. The treatments for plantar fasciitis recommended are, rest, ice, elevation, shoe modification, non-steroidal anti-inflammatory medication, cortisone injection therapy, physical therapy, and biomechanical support consisting of strapping, over the counter orthotics, and custom molded orthotics. When conservative treatments have failed surgical intervention may be recommended. This patient record's demonstrate pain associated with plantar fasciitis. The records state that the patient cannot play sports due to pain in his feet. The treating doctor recommends custom molded orthotics. The custom molded orthotics are medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Taltz. 
The denial is upheld. 

The patient is a male with plaque psoriasis of the nails, and also has psoriatic joint pain of the hands and fingers. Minimal skin involvement is reported, and concerns about the appearance of the nails with softening and pitting are reported, but systemic inflammation and fatigue have been reported and noted. The patient has tried and failed topical clobetasol, oral Otezla, Celecoxib, and Prednisone. The patient has a history of Basal Cell Carcinoma, so systemic therapies such as Methotrexate, Humira, Cimzia, Simponi, and Stelara have been avoided. Taltz is preferred because the provider maintains it is superior to other biologics.
At issue is the medical necessity of Taltz.

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

The requested health service/treatment of Taltz is not medically necessary for this patient.
The patient has tried Otezla, but otherwise has no other treatment history with standard systemic treatments for psoriasis of the nails and joints. Alternative treatments with as much time-tested clinical experience, evidence-based literature, and specialty consensus-based opinion as the requested Taltz exist that have not been tried by the patient. There are alternative treatments that are medically appropriate to treat this patient's condition. The patient has no documented treatment failure with, or true medical contraindication to, either methotrexate, Humira, Cimzia, Tremfya, Simponi, or Stelara, or Cosentyx. Taltz is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. With the exception of Otezla, no systemic therapies have been utilized to date.
Therefore, as consistent with current medical literature, [1-4] the requested Taltz is not medically necessary.