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

Skin disorders
Pharmacy/prescription drugs

This is a patient with amyopathic dermatomyositis (DM). The patient has failed intravenous immunoglobulin (IVIG), CellCept, methotrexate, Rituxan, Tremfya, and Otezla. The provider is requesting Xeljanz XR. The health plan's determination of medical necessity is upheld in whole. 
No, the treatment of Xeljanz XR is not medically necessary for this patient. The patient has failed many conventional immunosuppressive medications. There are no specific Food and Drug Administration (FDA) approved medications for this patient's condition. The medication has only been used in case reports in case series. Further trials are warranted to assess the safety and efficacy of Xeljanz in treating this population of patients. While Xeljanz may hold promise in managing this patient's condition, further studies are warranted as there are no clinical guidelines with regards to optimal dosing and duration of therapy. A medical exception for the use of Xeljanz has not been established, and therefore, Xeljanz XR for this patient is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Eczematous dermatitis and scalp psoriasis

Treatment: Clobetasol foam

The insurer denied coverage for Clobetasol foam. The denial is upheld. 

This patient is a male with eczematous dermatitis and scalp psoriasis. For his scalp psoriasis he was given samples of blue foam and loprox shampoo and he was given nizoral shampoo and Clobetasol foam. Formulary exception for Clobetasol has been requested.

Per Schlager, J. G., et al. (2016), "The two-compound combination as well as corticosteroid monotherapy were more effective and safer than vitamin D monotherapy. Given the similar safety profile and only slim benefit of the two-compound combination over the steroid alone, monotherapy with generic topical steroids may be fully acceptable for short-term therapy."

Per Wang, T. S., & Tsai, T. F. (2017), "Topical corticosteroids provide good effects and are usually recommended as first-line treatment. Calcipotriol-betamethasone dipropionate is well tolerated and more effective than either of its individual components. Localized phototherapy is better than generalized phototherapy on hair-bearing areas. Methotrexate, cyclosporine, fumaric acid esters, and acitretin are well-recognized agents in the treatment of psoriasis."

Per Svendsen, M. T., Feldman, S. R., Tiedemann, S. N., Srensen, A., Rivas, C., & Andersen, K. E. (2019), "Four surveys, six randomized controlled trials, and two prospective studies of mainly good quality were included. Seven of the studies investigated patient preferences for topical drug formulations, while five studies investigated their preferences for different topical drugs. Overall, patients preferred drugs that are easy to apply, less messy, and have a pleasant scent."
                                                       
There is no documentation that the patient has attempted therapy with any of the formulary medications.  There is no documentation of an allergy or contraindication to the formulary drugs listed.   The requested medication is not more effective than the formulary drug.
  
The patient has involvement of his scalp, making creams and ointments impractical, but the formulary medications fluocinolone and fluocinonide come in solutions which are practical and effective for treatment of the hair bearing scalp. Thus formulary exception is not necessary.

The insurer's denial of Formulary exception for Clobetasol foam is upheld.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems / Other 
Dental  Procedure 

The patient who presented to the office of his dental provider for evaluation and treatment of tooth #13. The patient suffered a fracture of the lingual cusp of tooth #13 as a result of decay. The proximity of the fracture to the pulp was documented to necessitate the endodontic treatment.  The health plans determination of medical necessity is overturned in whole .
Yes, the requested service of root canal therapy on tooth #13 is medically necessary. The tooth can be restored which is the best indicator if efforts to retain the tooth should be attempted. There is no evidence to suggest that the tooth will get worse based on the provided documentation. Hence, the treatment is medically necessary due to the fracture proximity to the pulp and the restorability of the tooth. Any proximity issues the tooth may have to the bone and need for surgical interventions have been proven to prolong the lifespan of the tooth and the prognosis as it allows for cleansability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic transverse myelitis secondary to neuromyelitis optica

Treatment: Soliris

The insurer denied coverage for Soliris. The denial is reversed. 

This patient is a female who was AQP4 ab positive and seen regarding treatment of chronic transverse myelitis secondary to neuromyelitis optica.   Prior to this visit, the patient had received two intravenous immunoglobulin (IVIG) infusions and was on a maintenance dose.  The patient stated that this treatment regimen was too time-consuming, and that she was experiencing significant fatigue and headaches after the infusion. The patient also noted that she was not experiencing much improvement in terms of her neck pain and numbness to the upper extremities. The patient had also trialed on trigger point injections as well as Botox treatments in the past for her pain.  The patient's neurological examination revealed that the patient had 5/5 strength in all of her extremities, no presence of involuntary movements, normal and bilaterally equal deep tendon reflexes, and a normal gait.  The physician indicated the patient would likely benefit more from the requested Soliris infusion which is FDA approved for the treatment of neuromyelitis optica.  The infusion schedule was preferred.

Soliris is FDA approved for neuromyelitis optica spectrum disorder in adults. Based on the literature review, studies including double-blinded, placebo controlled study showed that the use of Soliris reduced the level of relapse rate and improved overall neurological functionality in patients with neuromyelitis optica. This patient has trialed multiple treatment modalities including trigger point injections, Botox and IVIG infusions with little relief. The patient's latter treatment with IVIG infusions was associated with significant fatigue and headache that made compliance intolerable and ineffective since the benefit to its treatment was minimal to none in relieving her symptoms.  
Since the patient has failed on alternative treatments and there is literature support for the use of Soliris for the treatment of neuromyelitis optica, Soliris is considered medically necessary to treat this patient's medical condition.

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

The carrier's denial of coverage for Soliris is reversed.  The medical necessity is substantiated
Appeal type: Medical necessity
Decision: Overturned

Blood Disorder
Inpatient hospital

The patient is a male child who presented to the emergency department (ED) with a rash and fever for 5 days. He had recently been treated with Bactrim and cefdinir for a urinary tract infection, as well as amoxicillin for otitis media for two days, and had been seen in an ED at the onset of rash. Vital signs included temperature 100.4 to 102.4, heart rate 120-150, and respiratory rate 18-28. Examination was significant for generalized macular rash on the chest and extremities, sparing palms and soles. Laboratory evaluation revealed concentrated urine with 5-10 white blood cells (WBC), mild metabolic acidosis (CO2 21), transaminitis (alanine aminotransferase (ALT) 136, aspartate aminotransferase (AST) 213), elevated C-reactive protein (CRP) 7.777, leukopenia with WBC 3.0K (34% neutrophils, 27% bands, 29% lymphocytes), and mild thrombocytopenia (platelets 141K). He was admitted to the hospital. 

The health plan's determination is overturned. The inpatient stay was medically necessary.
Kawasaki disease (KD) is an acute vasculitic process, typically affecting children under the age of five years, the exact etiology of which is unclear but may be related to an exaggerated immune response to a pathogen. It is typically characterized by prolonged fever, mucosal erythema, rash, and lymphadenopathy. If left untreated, coronary artery aneurysms may develop, leading to significant cardiovascular sequelae. The American Heart Association published criteria in 2004 for classic and incomplete or atypical Kawasaki disease. These criteria are still in use today. The diagnosis of typical or classic Kawasaki disease has been based on presence of 5 or more days of fever, and four or more of the following features: changes in extremities (erythema of palms and soles, edema of hands and feet, peeling of fingers and toes), polymorphous exanthem, bilateral bulbar conjunctival injections without exudate, changes in the lips and oral cavity (erythema, cracked lips, strawberry tongue, diffuse injection of the mucosa), and cervical lymphadenopathy. There are a number of other associated clinical findings, including extreme irritability, desquamating rash in the groin, arthritis and arthralgia.
This young child presented after completing and initiating treatment with several antibiotics because of fever and rash. The initial concern was for Kawasaki disease, prompting consultation with Cardiology and Infectious Disease. Following evaluation and additional testing, it was determined that his clinical presentation was most consistent with an acute viral infection. Once his rash began to resolve and he was able to eat/drink, he was discharged home, with close follow-up. The care that he received during his hospital stay was most consistent with acute inpatient management. He could not have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Postural Orthostatic Tachycardia Syndrome

Treatment: Corlanor 5 mg OR TABS

The insurer denied Corlanor 5 mg OR TABS. The denial was upheld. 

This is a female patient with a diagnosis of postural orthostatic tachycardia syndrome (POTS). She presented to a pediatric cardiologist with complaints of dizziness, light headedness, fatigue, and visual changes. She reported that she had near syncopal episodes with change in her body position. An electrophysiology study was performed and orthostatic vital signs monitored. It was determined that the diagnostic results were consistent with the diagnosis of POTS.  Ivabradine (Corlanor) was recommended for treatment of the patient's medical condition.

After careful review of the clinical information provided and review of the current literature:

1) The current initial treatment for POTS, as is noted in the medical summary is non-pharmacologic interventions (Heart Rhythm Society) including increase in water and salt intake. It does not appear that this patient was given that initial therapy. 2) When the above therapy fails pharmacologic intervention can be considered. The drugs used include fludrocortisone, Beta blockers, (propranolol) and midodrine and others. Ivabradine is not to date a standard first line drug. 3) The 2 articles presented in the electrophysiology summary do not support the suggestion that Ivabradine is the initial drug of choice in this child. In the article by Gee et.al., "Ivabradine for the treatment of Postural Orthostatic Tachycardia Syndrome: A systematic Review" in the American Journal of Cardiovascular Drugs (2018), the authors found 13 articles involving a total of 132 pts and concluded "Based on this small sample, ivabradine appears to be a reasonable option for patients with POTS who have failed or unable to tolerate other treatment options, however, but a randomized controlled trial in this population is needed." There is such an ongoing trial in adults (Clinical Trials.gov.IdentifierNCT03182725). Wells et.al state "Current available therapies for this condition are mainly focused on symptom control. Further research is needed to help clarify the optimal approach to diagnosis, evaluate novel therapeutics and inform long-term prognosis of this debilitating condition." Lastly Up to Date in their section on management of POTS do not mention the use of ivabradine. They note that "the optimal therapy of POTS is not established. Patients should avoid precipitating factors, and physical activity should be encouraged. We suggest volume repletion and fludrocortisone (0.05 to 0.2 mg per day) as the first line of therapy (Grade 2C). Some patients may benefit from midodrine or beta blocking agents. Other therapies remain under investigation, and further confirmation of benefit is needed before they can be recommended."

Based on the above, the medical necessity for Corlanor 5 mg OR TABS is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lower extremity claudication.
Treatment:  Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.  The denial is upheld 

This patient is a male with a past medical history of chronic kidney disease, asthma, hypertension, and hyperlipidemia.  The patient was at the hospital for a scheduled peripheral angiogram.  The patient had lower extremity claudication.  The patient underwent a computed tomography (CT) angiogram of the right lower extremity, which revealed a complete occlusion of the proximal femoral artery with mid-distal reconstitution.  The patient's Rutherford classification was a class III.  The patient underwent a successful peripheral angiogram with the placement of three drug-eluting stents.  After the procedure, the patient was admitted to the Telemetry unit for postoperative monitoring.  The patient was treated with Plavix, Xarelto, and was hydrated overnight.  The patient was monitored for his vital signs, neurovascular status, and the access site.  There were no abnormal events noted overnight.  The patient was discharged in stable condition.

Based on the review of the medical record provided, this case involved a routine procedure, which was right lower extremity angiogram and peripheral endovascular arterial intervention in the right superficial femoral artery (SFA).  The indication for this procedure was due to this patient's severe, lifestyle-limiting claudication where conservative management with medications and a walking exercise program failed to improve the patient's symptoms.  While this procedure was within the standard of care, literature review support that this was clearly an outpatient procedure that did not require inpatient care or observation.  The procedure report stated the placement of a vascular closure device and that there were no complications associated with the procedure, such as femoral artery injury or closure site complications that warranted inpatient monitoring.  Thus, the inpatient hospital admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is upheld. The inpatient admission was not medically necessary. 

The patient is a woman. Her medical history included hypertension, type-II diabetes mellitus, and obesity. Her surgical history included hysterectomy and tubal ligation. The patient presented to an emergency department with abdominal pain and constipation. 

The patient's vitals were temperature 97.6, pulse 60, blood pressure 198/88, respirations 17, and oxygenation 100%. Physical examination demonstrated tenderness to palpation in the right upper and lower quadrants of the abdomen. Serum laboratories demonstrated a normal white-blood-cell count of 6.83. Ultrasound demonstrated hepatic steatosis. Computed tomography demonstrated a mildly dilated appendix, though no evidence of acute pathology. MRI demonstrated no acute pathology. X-rays demonstrated "mild degenerative changes of her right hip." 

The patient was admitted with a diagnosis of abdominal pain of unknown etiology. She was provided with intravenous fluids, analgesics, and anti-emetics. She underwent serial abdominal examinations. Though she had normal appetite, normal bowel habits, normal examinations, and normal laboratories, she reported continued abdominal and musculoskeletal pain, requiring Neurosurgical and Orthopedic consultations, imaging, and titration of analgesics. Ultimately, it was concluded she had pain due to "mild degenerative changes of her right hip." 

Having returned to her baseline function and health, the patient was discharged home in good and stable condition with home care. 

Because the patient's symptoms and signs were not entirely consistent with an acute abdominal process, and because the patient did not have significant co-morbidities, and because the patient did not significant anatomic or physiologic derangements, she could have been treated with intravenous hydration and serial abdominal examinations at a lower level of care; admission at an acute inpatient level of care was not medically necessary. Admission at a lower level of care would have provided ample time for an acute abdominal process to be ruled-in or ruled-out [Jaffe and Berger]. 

Because the patient's history and physical were not entirely consistent with an acute abdominal process, she could have been admitted at a lower level of care, providing ample time for an acute abdominal process to be ruled-in or ruled-out. Admission at an acute inpatient level of care was not medically necessary. None of the treatments or consultations that were provided required an acute inpatient level of care. The entire scope of the patient's treatment and followup could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems
Nursing Services (including Private Duty Nursing)

Diagnosis: Cardiac Arrhythmia
Treatment: PCA Services. The insurer denied the PCA services. The health plan's determination is overturned. 

The patient is a female with past medical history of cardiac arrhythmia, bilateral knee osteoarthritis, morbid obesity, gout, transient ischemic attack (TIA), difficulty walking, osteoporosis, varicose veins, dizziness, edema and a history of lower extremity cellulitis who had been assigned personal care aide services of 3 hours/day, 3 days/week to total 9 hours/week. These hours were approved based on an assessment tool performed. There was a request for an increase in patient controlled analgesia (PCA) service hours to 4 hours/day, 5 days/week to total 20 hours/per week. 

The Increase in Personal Care Aide (PCA) Services: Total of 20 Hours per Week - 4 Hours per Day/5 Days per Week is medically necessary for this patient.
The patient's PCP noted on two occasions that the patient has had worsening of her chronic medical conditions requiring an increase need for help with activities of daily living (ADL) and Instrumental activities of daily living (IADL) at her home. She had an assessment with an increase in need for assistance with tasks of bed mobility, toilet use and use of stairs compared to her previous assessment. The patient's physician noted the patient required more assistance ambulating with the need for physical guidance as well as hep with personal hygiene. These are both unscheduled tasks requiring the need for a personal care assistant. The patient does not have an informal helper during the additional time requested for personal care assistance. The assessment tool underestimated the patient's personal care needs. Therefore, the requested services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia 
Treatment: Inpatient mental health admission 

The insurer denied coverage for continued inpatient mental health admission. The denial is reversed. 

This was then a female who was admitted to the inpatient mental health treatment due to suicidal ideation and plans to jump out of a train or take pills, paranoid delusions, disorganized and illogical thinking, poor insight, substance use, and self-harm. The patient had a diagnosis of schizophrenia. The patient's history was significant for multiple past psychiatric hospitalizations. The patient took Risperidone and Trazodone. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization. 

In this case, this patient continued to have exhibit psychotic symptoms, including disorganized and paranoid thinking. Notes reported that the patient had disorganized thoughts, thought blocking, circumstantial thinking, and internal preoccupation. Notes reported that the patient was oddly related, guarded, delusional, and had illogical thoughts, internal preoccupation, and had impaired insight. Notes reported that the patient had disorganized and paranoid thinking. Based on this review of the medical chart, this patient was noted to have psychotic symptoms, and was at high risk for self harm given that this patient had thought of suicidal ideations and plans on admission. The patient's history of multiple past psychiatric hospitalizations in the past as well as this persistent psychotic symptoms status post trauma put this patient at high risk for self-harm if discharged prematurely from inpatient level of care and monitoring. It was not until the date of this patient's discharge, that this patient had no reported overt delusions or disorganization. Thus, continued inpatient mental health admission was medical necessary for this patient's care. 

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

The carrier's denial of coverage for the continued inpatient mental health admission should be reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Disorder.
Treatment:   Braces. 
The insurer denied braces.  The health plan's determination is upheld.

This is a patient with a Skeletal Class I occlusion, mild maxillary crowding and mild mandibular crowding, crossbite on tooth number (#) 6 and #27 and mild overjet and mild overbite.  At issue is the medical necessity for braces.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 9 with no auto qualifiers.  Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 mm or greater and underbite 3.5 millimeters (mm) or greater.  The case requires a score of 26 or more for treatment to be considered medically necessary.  The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary.  Thus, braces are not medically necessary for this case.