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

Diagnosis: Psoriatic Arthritis.  
Treatment: Otezla 30 mg (milligrams) OR (oral) tabs (tablets).	

The insurer denied coverage for Otezla 30 mg OR tabs. 

The denial is upheld. 

This case involves a patient with a history of cervical degenerative disc disease in addition to cervical stenosis and psoriatic arthritis.  The documentation indicated he was seen to establish care.  He has axial symptoms of pain with swelling over the metacarpophalangeal joint (MCP) and proximal Interphalangeal (PIP)s.  There was mild stiffness to the hands.  Medications to include amlodipine and metoprolol.  He did have limited range of motion to cervical spine with diffuse muscle spasm.  There was also crepitus to the shoulders with pain.  Elbows and wrists are not tender or swollen.  MCPs are mildly tender with synovial thickening.  The physician indicated the patient should undergo laboratory studies to rule out inflammatory arthritis.  Was also recommended he begin Celebrex.  He was seen to undergo an arthrocentesis to the left shoulder.  It was noted that there was no symptom difference with the utilization of Celebrex.  He complained of increasing pain and swelling to the hands with plaque psoriasis to the elbows.  The C-reactive protein (CRP) was 7.2 and sed rate was 6.  He did have an elevated cyclic citrullinated peptide (CCP) at 26 and a negative rheumatoid factor.  His hand imaging did show mild diffuse degenerative joint disease.  The physician indicated it is difficult to determine if some of the axial symptoms are related to inflammatory disease.  He was recommended to begin disease-modifying antirheumatic drug (DMARD) therapy.  The physician indicated alternative agents such as methotrexate or leflunomide or biologic would not have an effect on axial symptoms and will carry an increasing risk of infection.  Additionally, the physician detailed cyclosporine causes high risk for nephrotoxicity and is not recommended in sulfasalazine may be reasonable alternative however there was a national shortage.  The request was submitted for Otezla. 

In psoriatic arthritis a conventional DMARD such as methotrexate (MTX), leflunomide and sulphasalazine should be tried before biologic therapies are initiated except when there is a contraindication. There is no absolute contraindication listed in this member's records which would prevent him from using a conventional DMARD first. 

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

Based on the above, the medical necessity for Otezla 30 milligrams (mg) OR tabs is not substantiated. The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Thyroid nodule
Treatment: Radio Frequency Ablation (60699)
The insurer denied the Radio Frequency Ablation (60699)
The denial is overturned

The patient is a female with a large left multinodular goiter and an enlarging dominant thyroid nodule requesting thermal ablation. She is status post an alcohol ablation and a thermal ablation. Four biopsies of the nodules were benign.

Yes, the health plan should cover the Radio Frequency Ablation (60699).
A search on PubMed.com finds many articles regarding the use of thermal ablation to treat thyroid nodules. A systematic review by Muhammad, found that ablative therapy was an effective and safe alternative to surgical resection for benign thyroid nodules. A systematic review by Chung, found that "RFA [radiofrequency ablation] was found to be safe for the treatment of benign thyroid nodules and recurrent thyroid cancers."

A systematic review, by Trimboli, found that "both RFA [radiofrequency ablation] and laser ablation are able to obtain a significant volume reduction in BNFSTNs [benign non-functioning solid thryoid nodules]. A significant volume reduction is already evident at 6 months after thermal ablation and results are stable over the time."

A randomized controlled trial by Jin, found that "Thyroid thermal ablation is superior to conventional thyroidectomy in terms of patients satisfaction, post-operative quality of life, and shorter hospital stay but takes longer to achieve BTNs [benign thyroid nodules] volume reduction. The complication rates between the two groups were similar."

A review by Jasim, for the American Association of Clinical Endocrinology, found that "Surgery and radioiodine treatment remain the conventional and established treatments for nodular goiters. However, the new image-guided minimally invasive approaches appear safe and effective alternatives."

Thermal ablation of thyroid nodules has been proven to be efficacious and could be useful in this patient. It is in accordance with generally accepted standards of medical care, clinically appropriate, not for convenience, and not more intensive than alternatives. The requested thermal ablation would be considered medically appropriate for this patient.

Yes, the requested therapy is likely to be more beneficial for the enrollee than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Thyroid nodule
Treatment: Radio Frequency Ablation (60699)
The insurer denied the Radio Frequency Ablation (60699)
The denial is overturned

The patient is a female with a left large multinodular goiter with ongoing enlargement complicated by neck compressive symptoms. Request for radio frequency ablation of the thyroid (60699) is under review. The prior request was denied as experimental/investigational. The physician is appealing this determination.

Yes, the health plan should cover the requested radio frequency ablation of the thyroid (60699).
A recent meta-analysis of radiofrequency ablation of benign thyroid nodules showed a statistically significant improvement with the use of radiofrequency ablation, including reduction in nodule size and improvement of both symptoms and cosmetic scores.

In a randomized clinical trial, radiofrequency ablation was superior to laser ablation in nodule volume reduction [1]. The AACE (American Association of Clinical Endocrinologists)/ACE (American College of Endocrinology)/AME (Associazione Medici Endocrinologi) Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules support that radiofrequency ablation is a less expensive and less invasive alternative to thyroid surgery, without the risks of subsequent cutaneous scar or hypothyroidism, and support the use of radiofrequency ablation in patients with benign thyroid nodules who warrant treatment such as for cosmetic reasons or local symptoms.

This patient has a large multinodular goiter which was causing compressive symptoms. The use of radiofrequency ablation in this clinical situation is supported by the peer-reviewed literature and is in accordance with generally accepted standards of medical practice, clinically appropriate, not for convenience, and was the most appropriate level of care. Therefore, the health plan should cover the proposed radio frequency ablation of the thyroid (60699).

Yes, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.
The alternative treatment would be thyroidectomy. The AACE (American Association of Clinical Endocrinologists)/ACE (American College of Endocrinology)/AME (Associazione Medici Endocrinologi) Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules support that radiofrequency ablation is a less expensive and less invasive alternative to thyroid surgery, without the risks of subsequent cutaneous scar or hypothyroidism. Therefore, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Thyroid nodule.
Treatment: Radio Frequency Ablation (60699).
The insurer denied the Radio Frequency Ablation (60699).
The denial is overturned.

The patient is a female diagnosed with left thyroid nodule. This request is for Radio Frequency Ablation CPT (Current Procedural Terminology) 60699. As reported; she is status post retreatment ablation for a left large Mutlinodular goiter. She is doing well in post-procedure. She is without N/V (nausea/vomiting), uncontrolled pain or difficulty speaking or swallowing void and walking. She has a past medical history for Large Mutlinodular goiter status post alcohol ablation and RFA (radiofrequency ablation). Approximately several years prior, she was discovered to have left thyroid mass. Since then she has had four FNAs (fine needle aspirations), all of which were benign. Her thyroid function has remained normal. She returns for retreatment of the mass which is enlarged from even baseline. She reports compression symptoms in the neck.

The patient's FT4 (free thyroxin) was 1.6 (0.9-1.7); TSH (thyroid stimulating hormone) was 0.7 (0.3-4.2).

Yes, the health plan should cover the Radio Frequency Ablation (60699), as it was medically appropriate, as described below.

Yes, the Radio Frequency Ablation (60699) is more beneficial.
The standard of care for large or enlarging thyroid nodules that are causing symptoms is resection or radiofrequency ablation, assuming they are shown to be benign. Radiofrequency ablation carries less morbidity and mortality and is equally effective when compared to surgical resection [1-3].

The patient has large thyroid nodules that are causing symptoms. The patient's nodules have been determined to be benign. Radiofrequency ablation is consistent with generally accepted standards of medical practice. It is more beneficial than the alternative, which is surgical resection, and carries less morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperlipidemia. 
Treatment: Vascepa. 

The insurer denied Vascepa. The health plan's determination is upheld. 

The patient is a male with past medical history of hypertriglyceridemia who had been prescribed Vascepa 2 tablets orally twice daily. The patient's triglyceride level was 183. Recently, the patient's triglyceride level was 702. The patient has tried atorvastatin in the past with noted myalgias. The patient has tried fenofibrate in the past with gastrointestinal (GI) upset. An office visit documents the patient's diagnosis of hyperlipidemia, statin intolerance and hypertriglyceridemia. The note also documents the patient is taking Livalo and Vascepa daily. The patient's health plan denied coverage for Vascepa. 

Vascepa is not medically necessary. 

Although the patient has moderate to severe hypertriglyceridemia, he does not have documented increased risk of heart disease, documented heart disease, or diabetes mellitus type 2. He is being treated with omega-3 fatty acid, Vascepa, 2 tablets p.o. (by mouth) twice daily and there is a generic equivalent that should be tried and failed prior to coverage with Vascepa. The patient has not tried and failed generic Lovaza. The patient is taking a statin medication. In summary, the treatment of hypertriglyceridemia with Vascepa is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent Syn 300.
The insurer denied the Dupixent Syn 300.
The denial is overturned.

The patient is a female with atopic dermatitis. She has been treated with triamcinolone, Clobetasol, mometasone, and Tacrolimus with only partial control of the condition per the documentation. She was given Dupixent samples with some improvement. She also has allergies. Eczema is affecting more than 10% body surface area including eyelids and groin.

The health plan denied coverage for Dupixent due to requirement for use of at least 2 topical steroids, Tacrolimus and Eucrisa for the last 180 days.

Yes, the requested Dupixent is medically necessary.
There is no support in current literature and guidelines that Eucrisa is a required agent. This is only approved for mild atopic dermatitis. This patient has severe disease. She has failed appropriate topicals and has noticed some improvement with Dupixent samples.

Dupilumab is United States Food and Drug Administration indicated for treatment of recalcitrant atopic dermatitis, approved several years ago. Two trials, SOLO-1 and SOLO-2, demonstrated that patients treated with Dupilumab experienced significant, clinically meaningful improvements in their atopic dermatitis at week 16 as measured by the EASI score (Eczema Area and Severity Index). Dupilumab was well tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis. Dupilumab is a novel interleukin-4 and interleukin-13 blocker, which inhibits the arm of the immune system responsible for atopic dermatitis. In clinical trials, after 12 weeks of monotherapy with dupilumab, 85% of patients had a greater than 50% reduction in eczema severity and pruritus scores decreased by 57.1%. In phase III clinical trials, dupilumab led to a 75% improvement in eczema severity, when compared to placebo, and decreased symptoms of anxiety and depression. It also led to a significantly decreased use of topical corticosteroids. The safety and efficacy were supported in a recent meta-analysis of all published dupilumab paper.

The patient cannot do phototherapy due to facial and groin involvement, and systemic immunosuppressants are not appropriate for a female of childbearing potential and in the current pandemic.

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

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: Hereditary angioedema (HAE)

Treatment: Haegarda 3000 units subcutaneous (SC) solution reconstituted (SOLR)

The insurer denied coverage for Haegarda 3000 units SC SOLR.

The denial is upheld.

The patient is a male recently diagnosed to have hereditary angioedema (HAE). He was diagnosed initially when he presented with abdominal pain and intussusception. Subsequently the patient had 2 more attacks - first with bilateral hand swelling and then had presented with abdominal pain and vomiting.

The patient's physician now wanted to put him on long term prophylaxis due to 3 attacks in the past year. The patient's physician prescribed Haegarda. 

There are 3 first line products approved for the long-term prophylaxis of HAE.
1) Cinryze a C1 esterase inhibitor (C1-INH) which is given intravenous (IV) 2) Haegarda a C1 INH which is given subcutaneous (SC) 3) Lanadelumab which is a monoclonal antibody (AB) to plasma Kallikrein given SC but approved for people over 12.

As per the insurance company, Cinryze is the agent from this class of medications which is on their preferred list and that is the one to be used unless the patient has ineffectiveness to the medication or intolerance to it. There is no documentation in the medical records to show that this was the case. Note that Cinryze and Haegarda are different brand names of the same product. 

Both Cinryze and Haegarda are effective and approved for the prophylaxis of HAE in patients like him. Haegarda can only be approved if the patient did not have benefit from Cinryze or did not tolerate it. That was not the case. The physician prescribed Haegarda as the patient did not want to take IV.

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

The insurer's denial of coverage for Haegarda 3000 units subcutaneous (SC) solution reconstituted (SOLR) is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Constipation.
Treatment: Formulary exception for Motegrity (prucalopride).
The insurer denied the Formulary exception for Motegrity (prucalopride).
The denial is upheld.

The patient is a female with chronic idiopathic constipation. She has failed Linzess and has been doing well on Motegrity for approximately two years. Her provider is requesting continuation of Motegrity.

No, the health plan should not cover the Formulary exception for Motegrity (prucalopride).
The patient has chronic idiopathic consipation, and has failed the plan preferred Linzess but not the plan preferred Amitiza. There is no medical literature to support that Motegrity is more effective than the plan preferred Amitiza to treat chronic idiopathic constipation, or that Amitiza is more likely to cause side effects. Therefore, the health plan should not cover the formulary exception for Motegrity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal fusion
Treatment: epidural steroid injection
The insurer denied coverage for epidural steroid injection
The denial is overturned

This patient with a history of hypercholesterolemia, diabetes, and spinal fusion. He presented to the Pain Management physician's office for a follow up visit for lower back pain. He takes Norco with tolerable relief. The patient previously had an epidural steroid injection left L(lumbar)4 and L5. He reported an 80% improvement in pain for more than 12 weeks.

B. Chen (Medscape August 6, 2018) answered the question: What is the frequency of Epidural Steroid Injections (ESI)?

"The interval between injections varies with the steroid preparation used. Because injected methylprednisolone has been reported to remain in situ for approximately 2 weeks, the clinician should consider waiting approximately 2 weeks after the injection to assess the patient's response and to determine if it would likely be beneficial to administer a repeat injection. However, this 2-week interval may be reduced if a different (short-acting) steroid is used or if the clinical scenario warrants an earlier performance of the repeat epidural. In general, however, routine performance of a predetermined fixed number of epidural injections without a clinical reevaluation in between injection procedures should be discouraged."

Similarly, CMS (centers for Medicare and Medicaid services) LCD (local coverage determinations) L36920 states:

"Repeat ESI when the first injection directly and significantly provided improvement of the condition being treated may be considered medically reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline for at least three months. 

A second Epidural Steroid Injection is medically reasonable and necessary.

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 64483 x 1 and 64484 x 1, pain injections is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: osteoarthritis and neuropathy
Treatment: Increase Consumer Direct, 1 Client 30 Hours/Week
The insurer denied the Increase Consumer Direct, 1 Client 30 Hours/Week
The denial is upheld.

The patient is a female with osteoarthritis and neuropathy. The request is for increased consumer hours of 30 hours/week from 17.5 hours/week.

The health plan denied coverage of the request as not medically necessary. The denial is being appealed.

No, the requested increase in service hours to 30 hours/week is not medically necessary.
The patient has OA (osteoarthritis) and neuropathy.  The patient needs help with cooking, shopping. She has a home aide at this time. The patient has no cognitive deficits. The patient has no frequent needs at night time. She has no incontinence.

Per UAS (Uniform Assessment System) assessment done, the patient has unsteady gait, but can walk with a rollator. She can manage her own phone, medications and finances. She denied any falls in the prior 90 days.

According to above information the patient does not have any frequent needs at night time. She has no cognitive deficits. The requested increase in services is not medically necessary at this time.

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: Respiratory Problems 
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

The patient is a male with benign prostatic hyperplasia (BPH) who presented with one week of cough productive of purulent, blood-tinged sputum, pleuritic pain, chills, exertional dyspnea.

In the emergency department (ED), the patient's vitals were temperature 101, blood pressure (BP) 109/72, heart rate (HR) 96, respiratory rate (RR) 20, peripheral capillary oxygen saturation (SpO2) 95% (percent) room air (RA). He was in no distress, breathing comfortably, clear lungs, alert and oriented. Test results showed white blood cell (WBC) count 3.8, sodium (Na) 136, bicarb 24, blood urea nitrogen (BUN)/creatinine (Cr) 15/1.07, albumin 3.9. Chest x-ray (CXR) showed band-like opacities at left base. Computed tomography (CT) of the thorax showed patchy, bilateral ground-glass opacities, sub-segmental left lower lobe (LLL) consolidation. The patient was COVID (Coronavirus disease) positive.

He was diagnosed with COVID-19 pneumonia and possible community acquired pneumonia (CAP), started on ceftriaxone and azithromycin, changed to ceftriaxone and doxycycline.

The patient had a fever of 102, and bacteremia was noted on blood cultures. Patient decided to leave against medical advice (AMA).

The health plan's determination is overturned.

An inpatient hospital admission was medically necessary.

The patient presented with pain, dyspnea, and hemoptysis and was diagnosed with COVID and likely super-imposed CAP. While his initial presentation did not include severe disease (encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, or acute kidney injury or marked electrolyte abnormality), and his scoring systems suggested low risk of worsening, meaning that admission at a lower level of care may have been reasonable admission initially, he eventually developed bacteremia. With this development, an inpatient hospital admission became necessary. Bacteremia requires close monitoring to ensure the patient does not worsen, as well as ongoing intravenous (IV) antibiotics until there is an identification of the bacteria and sensitivities are determined. These cannot be performed as an outpatient. As such, for close monitoring and ongoing IV antibiotics, an inpatient hospital admission was needed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: failing dentition and endodontically treated teeth in the left maxilla

Treatment: D6750, retainer crown on teeth 12 and 14 and pontic D6240 on tooth 13

The insurer denied coverage for D6750, retainer crown on teeth 12 and 14 and pontic D6240 on tooth 13

The denial is overturned

Upon review of the submitted documentation which includes copies of periapical radiographs, narrative letter from the patient and insurer correspondence, it appears that this patient presented for dental care with a failing dentition and endodontically treated teeth in the left maxilla. Recommended treatment was to place a fixed bridge prosthesis spanning teeth #12-14 with pontic at #13 site. The insurer has denied this service stating that medical necessity criteria are not met. The patient is appealing.

Upon review of the documentation, on radiograph radiographs it is evident that the teeth have had endodontic therapy and there is an edentulous space. To restore function to the maxillary dentition, placement of a fixed prosthesis spanning #12-14 site as recommended is the standard of care dental treatment in general dental practice especially on endodontically treated abutment teeth. There is adequate coronal structure to maintain a bridge and there does not seem to be biologic width issues.

Coverage for D6750 retainer crown on teeth 12 and 14 and pontic D6240 on tooth 13 is medically necessary as this would be the standard of care dental treatment in clinical practice.

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 D6750, retainer crown on teeth 12 and 14 and pontic D6240 on tooth 13 is overturned. Medical Necessity is substantiated.