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

Diagnosis: Multiple Sclerosis. 
Treatment: Formulary exception for Vumerity. 

The insurer denied the Formulary exception for Vumerity. 
The denial is upheld. 

The patient is a female with multiple sclerosis (MS). She has been treated with Vumerity for approximately one year and has been clinically stable. The provider is requesting continuation of treatment with Vumerity. The requested medication was denied coverage by the health plan, as the patient has not tried and failed generic dimethyl fumarate and two other preferred medications. 

No, the health plan should not cover the Formulary exception for Vumerity. 

There is no documented reason the patient cannot be treated with generic dimethyl fumarate or the other formulary agents for her condition. All of the preferred agents are FDA (United States Food and Drug Administration) approved for her condition based on high quality clinical trials published in the peer reviewed medical literature (McGinley et al.). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Vumerity relative to the preferred agents (Naismith et al.). There is no evidence that switching to a preferred agent would jeopardize her clinical stability. There is no evidence that she would have an adverse effect from using any of the preferred medications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's Disease. 
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) to 12 Hours per Day/7 Days a Week, 12 Hours per Day/7 Days a Week (Split-Shift), for a Total of 168 Hours per Week. 

The insurer denied the increase in CDPAP to 12 hours per day/7 days a week, 12 hours per day/7 days a week (split-shift), for a total of 168 hours per week. 
The denial is upheld. 

The patient is a male with a diagnosis of Alzheimer's disease. The patient has multiple comorbidities which include coronary artery disease, diabetes mellitus type 2, BPH (benign prostatic hypertrophy), hyperlipidemia, pacemaker placement, and hypertension. The patient is being evaluated for hospice. Documentation noted that the patient is eating less than 50% (percent) of his meals, has progressive weakness, and has complete dependence for his activities of daily living (ADLs). Subsequent recertification for hospice noted that the patient had progressive generalized weakness, requires total assistance for ADLs, as well as the instrumental activities of daily living (IADLs). 

No, the requested increase in Consumer Directed Personal Assistance Program (CDPAP) to 12 hours per day/7 days a week, 12 hours per day/7 days a week (split-shift), for a total of 168 hours per week is not medically necessary. 

This is a male with terminal diagnosis of Alzheimer's disease. The disease has progressed gradually to the point where the patient has been hospice homebound. The patient has poor oral tolerance with noted less than 50% intake of his food. The patient was noted to have progressive weakness and has total dependence for ADLs as well as IADLs. The patient has a catheter placement. It was noted that an assessment noted that his dependence for ADLs as well as the IADLs had not changed. Furthermore, the patient has strong family support in the form of his son and other family members. The patient is already receiving personal assistance at home. There was no clear documentation which showed that the services that are already being provided, as well as the fact that the patient has strong family caregivers/support is inadequate for his daily needs. Time is specifically allocated for meal preparation, laundry, and housework. The patient is already receiving a total of 77 hours weekly for the management of the above. Assistance is already provided for his ADLs and IADLs. At the present time, with the current assessment in place, the additional hours are not medically necessary. 

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

Services are normally provided when there is objective documentation that the severity of illness would be appropriate for the intensity of services and vice versa. In this instance, the current objective documentation did not demonstrate that the additional services were medically necessary. There is no documentation to suggest otherwise. At the present time, the health plan acted reasonably and with sound medical judgment.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Idiopathic Constipation. 
Treatment: Motegrity (prucalopride). 

The insurer denied coverage for Motegrity (prucalopride). 

The denial is upheld. 

The patient has a long history of constipation and bloating. The medical record states that she had previous improvement on Linzess. She was taking Motegrity and Dulcolax at the time of that office visit. The insurance company has now denied the Motegrity since the formulary alternatives of Amitiza and Linzess have not failed. 

UpToDate article titled "Management of Chronic Constipation in Adults" discusses pharmacologic therapy. There are several recommended medications. Lubiprostone is an approved medication based on studies that have shown that significantly more patients receiving this medication had an increase in spontaneous bowel movements. There was also improvement in bloating, discomfort and stool straining. Linaclotide has also been approved by the FDA (Food and Drug Administration) for the treatment of chronic idiopathic constipation. It has also shown an improvement in spontaneous bowel movements. Prucalopride is another medication that is advised for chronic constipation. 

This patient has chronic constipation. The submitted medical record states that the bowel movements did improve on Linzess. There is no record that she had a side effect from the Linzess. There is also no record that she has tried and failed lubiprostone. The insurance company has offered formulary alternatives that have been shown to be effective, as supported in the UpToDate article. 

The formulary drugs have not been shown to have an adverse reaction. The clinical records that were submitted for review did not show that the formulary alternatives were ineffective. It is not known that the Motegrity will be more effective than the formulary alternatives.  Since there is no record that the patient has failed Linzess and Amitiza, formulary exception for Motegrity is not likely to be more effective than the formulary alternatives. 

The insurer's denial of coverage for Formulary Exception for Motegrity (prucalopride) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Taltz.
The insurer denied the Taltz.
The denial is overturned.

The patient is a male with psoriasis to the abdomen and extremities, 15% BSA (body surface area), treated with topicals and Taltz.

The patient's provider is requesting continuation of Taltz.  The health plan denied the request as the patient must try and fail methotrexate as well as preferred biologics Humira, Stelara, Tremfya, Skyrizi, or Cimzia.

Yes, the requested Taltz is medically necessary.
Taltz, an IL-17 (interleukin 17) inhibitor, is an appropriate medication for this patient. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. Taltz is an effective, safe and approved medication for psoriasis and has shown greater efficacy than other biologics with a favorable side effect profile in studies. IL-17 (interleukin 17) inhibitors are also among the most effective therapies according to current peer-reviewed literature.

According to the meta-analysis by Sbidian et al, compared to placebo, the biologics infliximab, ixekizumab (Taltz), risankizumab (Skyrizi), bimekizumab, secukinumab (Cosentyx), guselkumab (Tremfya) and brodalumab were the most effective treatments for achieving PASI (Psoriasis Area and Severity Index) 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence. Therefore given this support for Taltz, medical necessity is met.

It is generally considered medically necessary to continue a patient on a therapy to which they have favorably responded given the risk of cessation and changing to a different agent, which has no evidence-based medical basis.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent. 

The insurer denied Dupixent. 

The health plan's determination is upheld. 

The patient is a male with moderate to severe atopic dermatitis (over 50% [percent]body surface area involvement, IGA (immunoglobulin A) of 4) and Netherton's Syndrome. The patient has previously tried and failed topical cyclosporine cream and oral prednisone (5 milligrams (mg) /day). 

Dupixent is not medically necessary for this patient. 

The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, medium- to high-potency topical steroids, phototherapy, standard, first-line oral medications used for Netherton's Syndrome (such as oral retinoids), or more time-tested injected biologic agents such as Tumor Necrosis Factor inhibitors (Humira or Remicade) or Interleukin-17 inhibitors (Cosentyx or Taltz). Dupixent is not proven to be superior to formulary alternatives as per comparative, controlled studies. Therefore, as per current medical literature, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Skin Disease
Pharmacy/prescription drugs

Diagnosis: atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent. The health plan's determination is upheld.

The patient is a male with atopic dermatitis (AD). He has tried and failed triamcinolone ointment, halobetasol ointment, and hydrocortisone cream. 

Dupixent Syn 300 is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the generic medicines such as methotrexate are effective treatments for the management of atopic dermatitis. There are no unique clinical circumstances to this particular individual that would make Dupixent medically necessary. The patient has no true contraindications to the use of the preferred generic medications. The preferred agents, such as methotrexate, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Degenerative disc disease, Cervical and Thoracic

Treatment: magnetic resonance imaging of the cervical spine without contrast (code 72141)

The insurer denied coverage for magnetic resonance imaging of the cervical spine without contrast (code 72141)

The denial is overturned

This is the case of a female with a history of upper back pain across her shoulders. Per an office visit, the patient has been experiencing pain for 10 weeks. She had physical therapy without any relief.  She also had chiropractic care but now complained of left arm soreness. The patient described her pain as a stabbing feeling in the mid-back. Treatment history includes heat application, Tylenol, CBD (Cannabidiol) salve, gabapentin and ibuprofen for the pain. The doctor assessed the patient has degenerative disc disease in the cervical and thoracic area. Imaging studies indicated the patient has multi-level degenerative and lower cervical spondylosis. At this visit, the doctor discussed with the patient having a magnetic resonance imaging test for further evaluation of her condition.

An MRI(magnetic resonance imaging) is necessary in circumstances where additional information can aid in diagnosis and treatment plan. There should be sufficient conservative treatment prior to MRI. (Plan requires 6 weeks). 

The records show the patient had attempted a course of PT (physical therapy) which was not beneficial. The letter of appeal from treating physician reports this fact. She had attempted chiropractic and taken several medications all without benefit. Her physician (in letter of appeal) clarifies several issues. The physician specifically recommends the study as she had not improved, and other treatment options could be considered. 

As she had unremitting radicular symptomatology for several months with poor response to conservative treatment, the next step should be the cervical spine MRI. 

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

A magnetic resonance imaging of the cervical spine without contrast (code 72141) is considered medically necessary for this patient.

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 a magnetic resonance imaging of the cervical spine without contrast (code 72141) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea (OSA)
Treatment: Implantation of Hypoglossal Nerve Stimulator 
The insurer denied Implantation of Hypoglossal Nerve Stimulator. The health plan's determination is overturned. 

The patient is a male with a history of obstructive sleep apnea. A most recent study confirmed obstructive sleep apnea (OSA) with a sleep study. This showed an apnea hypopnea index (AHI) of 21. The minimum oxygen desaturation was 86%. Other pertinent vitals include a body mass index (BMI) of 31.8. Past medical history was significant for chronic fatigue. The patient has been on PAP (positive airway pressure). In addition the patient underwent a multiple sleep latency test which found that the patient had pathologic sleepiness. 

Implantation of Hypoglossal Nerve Stimulator is medically necessary for this patient.
This treatment (Inspire) is considered by the general otolaryngology community to be an accepted surgical treatment in select patients. This is based on clinical evidence. The patient has failed a continuous positive airway pressure trial (using only 4 hours per night on average) and has failed an oral appliance. The appropriate work up for a hypoglossal stimulator was done with a sleep endoscopy which showed lack of concentric collapse of the upper airway, and significant prolapse of the tongue during sleep. Finally, the patient is at risk for developing severe medical co-morbidities if the OSA continues to go untreated.
This patient is an appropriate candidate for the device. The Food and Drug Administration (FDA) approval of the device is for obstructive sleep apnea, and the current research shows strong evidence that upper airway stimulation is an effective treatment in certain patients who meet a certain inclusion criteria. A hypoglossal stimulator is the most viable option for this patient for treatment for OSA.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypokalemia, Chronic Kidney Disease
Treatment: Veltassa
The insurer denied Veltassa.
The determination is upheld.

The patient has diabetes and stage III chronic kidney disease. Veltassa was prescribed for hyperkalemia. The potassium was 5.7. Veltassa was denied because the medication is a nonformulary medication and the member had not failed sodium polystyrene sulfonate. Veltassa is under review for medical necessity.

No. Veltassa is not medically necessary for this patient. He has not failed or been intolerant to and has no contraindication to the formulary agent sodium polystyrene sulfonate. In summary, Veltassa is not medically necessary. A review of published literature demonstrates that both Veltassa and polystyrene sulfonate are efficacious for treatment of hyperkalemia.  In addition, sodium polystyrene sulfonate has Food and Drug Administration (FDA) approval for treatment of hyperkalemia. There is no nephrologic societal or practice guideline recommending the use of Veltassa over sodium polystyrene sulfonate. The provider stated that the patient has chronic hyperkalemia due to chronic kidney disease and cannot take kayexalate actually due to the risk of intestinal necrosis.  However, this is a very rare side effect of sodium polystyrene sulfonate, which is not contraindicated, in the absence of obstructive bowel disease, based on the package label for the medication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission

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

The patient presented to the hospital for elective cardiac catheterization following symptoms of chest pain and a positive perfusion stress test. Diagnostic cardiac catheterization revealed a 70% (percent) lesion of the distal left anterior descending coronary artery and a 100% occlusion of the left circumflex and obtuse marginal arteries. A stent was successfully placed in the obtuse marginal artery.  No perioperative complications were noted. The patient was monitored overnight and released the following day.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented for elective percutaneous revascularization.  She underwent an uncomplicated procedure, and a drug eluting stent was placed in the obtuse marginal artery. She was subsequently discharged the following day.  Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care.

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: Chronic Pelvic Pain/Complex Regional Pain Syndrome.
Treatment: Ketamine (CPT code 3600, J3490).
The insurer denied the Ketamine (CPT code 3600, J3490).
The denial is upheld.

The patient is a with chronic pelvic pain and right leg pain secondary to complex regional pain syndrome (CRPS).  The patient's pelvic pain began several decades ago after right genitofemoral nerve was severed during inguinal hernia surgery.  She has tried medications (Lyrica, gabapentin, Cymbalta, Duragesic), Medronic, St. Jude (DRG), and Boston Scientific spinal cord stimulators, nerve reconstruction and neuroma decompression, and ketamine infusions previously.  Per report, the patient had excellent relief with ketamine infusions previously.  Five day infusions provided good (greater than [>] 80%) for eight weeks and then, one day infusion provided "good relief."  Magnetic resonance image (MRI) of the lumbar spine shows nonspecific asymmetric increased signal within the right femoral nerve and unchanged piriformis asymmetry versus imaging.  

The request for repeat ketamine infusion for chronic pelvic pain and complex regional pain syndrome was denied based on the UnitedHealthcare policy for off-label/unproven specialty drug treatment policy number 282.11 as having not been shown to be safe and/or effective in medical studies for this patients illness.

No, the proposed treatment, ketamine, is not medically necessary.
The use of ketamine for chronic pain including complex regional pain syndrome (CRPS) is considered experimental/investigational based on the current published literature.  In a systemic review and meta-analysis which reviewed publications regarding efficacy of ketamine infusion for treatment of complex regional pain syndrome (CRPS), the authors suggested that ketamine infusion can provide clinically effective pain relief in short term for less than three months. However, because of the high heterogeneity of the included studies and publication bias, additional random controlled trials and standardized multicenter studies are needed to confirm this conclusion. Furthermore, studies are needed to prove long-term efficacy of ketamine infusion in the treatment of complex regional pain syndrome (CRPS).  The level of evidence for the use of ketamine varies by condition and dose range. Most studies evaluating the efficacy of ketamine are small and uncontrolled and either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of non-intravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.  As such, the proposed treatment is unproven and not medially necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet; crossbite.
Treatment: Braces, Monthly Visits.

The insurer denied the Braces, Monthly Visits.
The denial is overturned.

Patient is a male with Class I skeletal and soft tissue profiles. The patient has permanent dentition with mild maxillary and moderate mandibular crowding.  The patient has overjet of approximately 2-3mm, a deep bite, unilateral posterior crossbite on the right side, and crossbite at the left lateral incisors.  The patient also has multiple rotated teeth, a small upper right lateral incisor, and a lower left lateral incisor with clinical attachment loss.  Additionally, the patient has poor oral hygiene.

The requested treatment was denied coverage by the health plan, because the patient did not meet the clinical criteria for comprehensive orthodontics. The treating provider appealed this decision stating, "The Reviewer did not consider Anterior crossbite with gingival attachment loss (mandibular left lateral incisor)."

Yes, the braces and monthly visits are medically necessary.
The patient has rotation of his lower left lateral incisor, which caused a crossbite with the opposing tooth, gingival recession, and clinical attachment loss. This is considered an 'Auto-Qualifier' for orthodontic treatment per HLD (Handicapping Labio-Lingual Deviation) Index Instructions.  Given the patient's severe handicapping malocclusion, the comprehensive orthodontic treatment is thus medically necessary for this patient.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient has rotation of his lower left lateral incisor which caused a crossbite with the opposing tooth, gingival recession, and clinical attachment loss.  This meets criteria for severe handicapping malocclusion per NYS (New York State) Medicaid Program Dental Policy and Procedure Code Manual and HLD (Handicapping Labio-Lingual Deviation) Index Scoring Instructions.  This alignment problem will cause continued soft tissue damage by way of worsening attachment loss which can lead to severe periodontal infection and bone loss.  The health plan's denial should be overturned for this reason.  Comprehensive Orthodontics is in the best interest of this patient.