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

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Otezla for medical necessity.
The denial is upheld.

The patient is a male with a diagnosis of psoriasis. He has tried and failed hydrocortisone cream. He is undergoing treatment for Hepatitis B.
At issue is the medical necessity of Otezla.

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

The requested health treatment Otezla is not medically necessary for this patient.
Based on the evidence-based literature, Otezla is not medically necessary. There are no comparative, controlled studies showing that Otezla has a superior efficacy and safety profile to all the standard of care alternatives such as phototherapy. According to the national physician specialty society recommendations for psoriasis, the American Academy of Dermatology Psoriasis Guidelines, and dermatology literature, phototherapy is an effective treatment for the management of psoriasis. (1, 2)
Within the peer-reviewed literature, Racz et al writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks." (3) Mehta et al writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with greater than (>)10 % affected body surface area who have not responded to topical treatments...narrowband (NB)-UVB....effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile." (4)
There is no documentation provided that the patient has an intolerance to, contraindication to, or has tried and failed the conventional therapy phototherapy. Acitretin is a contraindication for this patient, as the patient is undergoing treatment for active hepatitis B. Any immunosuppressive, or any medication which has a risk of causing liver injury, such as acitretin, would be contraindicated in this patient. Prescribing a patient with hepatitis B acitretin would not be consistent with the standard of care. Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not necessary. It is noted that the patient has failed the topical steroid hydrocortisone. However, there is no documentation provided that the patient has tried and/or failed phototherapy. The patient also has no true contraindications listed to a conventional treatment modality that would make the use of Otezla medically more appropriate than the other options.
Therefore, the administration of Otezla is not strongly supported for this patient, and Otezla is not medically necessary for this patient based on the current evidence-based medical literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: SLE (systemic lupus erythematosus)

Treatment: sildenafil

The insurer denied coverage for sildenafil.

The denial is overturned.

The patient is a female with a history of PSS (progressive systemic sclerosis), SLE (systemic lupus erythematosus), G6PD (glucose 6 phosphate dehydrogenase) deficiency, Raynaud's syndrome, gangrene of digits and multiple positive antibodies. She is followed by Rheumatology specialist. Nifedipine alone did not help. The patient was taking sildenafil 20 milligrams (mg) daily for systemic sclerosis-related Raynaud phenomenon.  Continuation is requested.

The insurer has denied coverage for sildenafil as not medically necessary. In their Final Adverse Determination letter, they write that current plan criteria only allow coverage of sildenafil for a diagnosis of pulmonary arterial hypertension.

Rheumatology specialist is appealing. In an appeal letter , she writes that there are no Food and Drug Administration (FDA)-approved therapies for scleroderma-associated Raynaud's and digital ulcerations, but sildenafil is widely used for this condition. Given the patient's poor response to alternative oral therapies and that she is currently on sildenafil 20 mg three times per day, continuation is medically necessary and appropriate.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. They did not take into account the unusual circumstances here. 

There are no FDA-approved treatments for severe PSS-associated digital ulcers. As noted in the www.uptodate.com chapter "Treatment of Raynaud phenomenon: Refractory or progressive ischemia" sildenafil is a well-established treatment in this situation. She failed nifedipine alone. Sildenafil is appropriate here. 

Based on the above, the medical necessity for the Sildenafil is substantiated. The insurer's denial is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine.
Treatment: Ubrelvy.
The insurer denied the Ubrelvy.
The determination is upheld.

The patient, with acute and chronic migraine. The patient is treated with Botox for prevention of migraine. For treatment of an acute migraine, the patient has tried and failed Imitrex. Treatment with Ubrelvy is the subject of this review. There is no documentation that the patient has failed other triptan drugs. The patient was prescribed Zomig (zolmitriptan) nasal spray at the same time as Ubrlevy.

There is only documentation that the patient has tried and failed Imitrex (sumatriptan).
There is no documentation that the patient has tried and failed the formulary alternatives aimotriptan, eletriptan (generic for Relpax), frovatriptan, naratriptan, rizatriptan, sumatriptan injection, sumatriptan nasal spray, zomitriptan, Nurtec orally disintegrating tablet (ODT), or Zembrace Symtouch.
All of these medications are considered safe and effective for the treatment of acute migraine. While there is documentation that the patient has tried and failed Imitrex, failure to one triptan does not guarantee failure to all other triptans. The formulary alternatives include tablets, disintegrating tablets, nasal sprays, and injections. The formulary alternatives also include Nortec ODT, which is an oral calcitonin gene related peptide (CGRP) inhibitor similar to Ubrelvy. There is no evidence in the medical literature to show that Ubrelvy is superior to triptans or Nutrec ODT.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a man with alcoholism who complained of polyuria, polydipsia, and polyphagia. The symptoms are present for about 2 months and progressive. In addition, the patient has weight loss. There is a family history of diabetes. The patient drinks up to a pint of vodka every day.
Vital signs in the emergency department (ED) included a temperature of 98.3, a heart rate of 103, and blood pressure of 140/98. On exam, this is a thin man with no acute distress. Lungs are clear; the cardiovascular exam is unremarkable, and there is no leg edema.
Laboratory studies in the ED show a lactic acid level four, the glucose of 400, an elevated anion gap of 21, and positive urine ketones and beta-hydroxybutyrate. Renal function is normal, white blood cell count is normal, and hemoglobin is 16.9. Serial lactate levels decreased to 3 and 2.7 after the patient was given 2 L (liters) of bolus fluid and 5 units of neutral protamine Hagedorn insulin. The bicarbonate improved from 18-21, and the anion gap decreased. Chest x-ray done in the ED showed no focal consolidations.
Principal admitting diagnosis is mild diabetic ketoacidosis (DKA) versus uncontrolled diabetes with alcoholic ketosis.

The inpatient hospital admission is not medically necessary for this patient. The patient presented with signs and symptoms of diabetes and was confirmed to have type 1 diabetes, based on age, A1c in the 13 range. He also showed signs of mild diabetic ketoacidosis. The venous potential hydrogen (pH) was 7.33, and the bicarb was 18. Beta-hydroxybutyrate was positive, and the blood glucose values were elevated to greater than 200. The patient did not satisfy inpatient criteria due to lack of hemodynamic instability, pH greater than 7.2, bicarb greater than 10. The acidosis improved within the observation timeframe with intravenous (IV) fluids and a small dose of subcutaneous insulin. The patient did not exhibit an inability to maintain oral hydration. Blood glucose levels significantly decreased by the time of discharge with appropriate therapy. As a result, this condition can be managed under a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Agitation/paranoid behavior
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with a past medical history significant for hypertension, diabetes mellitus type 2, and alcohol abuse. He was admitted through the emergency room secondary to agitation and paranoid behavior. Previously within the last week, the patient had an emergency room (ER) visit for alcohol intoxication. The patient was agitated in the emergency room requiring parental administration of anxiolytics along with treatment for possible alcohol withdrawal. He was admitted to the hospital.

The acute inpatient hospital admission is not medically necessary for this patient.
The patient is a male with a past medical history significant for hypertension diabetes and alcohol abuse. He was admitted through the emergency room secondary to agitation and paranoid behavior. Previously, he had an ER visit for alcohol intoxication. The patient was agitated in the emergency room requiring parental administration of anxiolytics along with treatment for possible alcohol withdrawal. A neurological exam showed that the patient was alert and oriented times person and place but not specifically to time. There is no evidence of seizure-like activity. His mental status did improve. A progress note  states that the patient's symptoms such as hallucinations have completely resolved. He was evaluated by psychiatry and it was recommended either to go to an outpatient clinic or to be admitted to the hospital inpatient clinic for substance use. Vital signs were stable with no evidence of significant hypertension or tachycardia. There is a notation in chart that the patient may have taken some sort of other substance, possibly Ambien which cause his erratic behavior on admission. It was not felt that the patient had an underlying psychiatric illness, and that his symptoms were more likely secondary to alcohol. There were no other specific other underlying medical conditions that were being treated for during the hospitalization.
Therefore, the patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma, index finger

Treatment: upper extremity prosthesis (L7499)

The insurer denied coverage for upper extremity prosthesis (L7499)

The denial is overturned.

The patient sustained a traumatic amputation of the right thumb and index finger. His provider has requested an MCP (prosthesis) driver index and thumb driver with code L7499, upper extremity prosthesis (functional prosthetic fingers), not otherwise specified, which is currently under review. 

From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, based on the clinical information available for review, the requested MCP driver index and thumb driver are appropriate finger prostheses for this patient. In this case, the patient is an engineer, mechanic and volunteer firefighter. The requested functional prostheses are specifically designed to restore the middle and distal phalanges of the fingers, to allow him to perform grasping activities to include pinch, key, cylindrical and power, as well as assist with grip stability. The grip is powered by the residual finger stump at the MCP joint. Providing the requested prostheses to the patient will result in significant upper extremity functional improvement and should be considered medically necessary. 

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

Based on the above, the medical necessity for the upper extremity prosthesis (L7499) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peg laterals
Treatment: Composite Restoration For Teeth 7,8,9 and 10
The insurer denied the Composite Restoration For Teeth 7,8,9 and 10
The denial is upheld

The patient is a male in braces. Has spacing on both sides of the upper lateral incisors (teeth #'s 7 and 10). The lateral incisors are "peg laterals", meaning they are narrower than normal.

No, the proposed Composite Restoration For Teeth #s 7, 8, 9 and 10 is not medically necessary.
Teeth #s 7, 8, 9 and 10 are virgin teeth without any existing restorations or decay in them. There are also no fractures. The proposed treatment is solely for esthetic reasons, to make the upper front teeth look wider. The treatment is not medically necessary.

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

Diagnosis: age-related physical debility, diabetes, hypertension, osteoarthritis, BPH (benign prostatic hyperplasia) and GERD (gastroesophageal reflux disease).
Treatment: Reduction of Consumer Directed Personal Assistance Services from 40 Hours per week to 24 Hours per week as a shared/mutual case with spouse.
The insurer denied the Reduction of Consumer Directed Personal Assistance Services from 40 Hours per week to 24 Hours per week as a shared/mutual case with spouse.
The denial is upheld.

The patient is a male. He has conditions including age-related physical debility, diabetes, hypertension, osteoarthritis, BPH (benign prostatic hyperplasia) and GERD (gastroesophageal reflux disease). He lives with his spouse. Reduction of Consumer Directed Personal Assistance Services from 40 hours per week to 24 hours per week as a shared/mutual case with his spouse is being appealed. The hours were reduced because the patient agreed to attend Social Adult Day Care.

UAS (Uniform Assessment System) evaluation was completed. The patient was approved for 40 hours per week CDPAS (consumer directed personal assistance) for specific dates of service. However, the patient attends Social Adult Day Care several days per week and receives meals during those days.

No, the Consumer Directed Personal Assistance Services 40 Hours per week is not medically necessary.
Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic medical conditions. Reduction of Consumer Directed Personal Assistance Services from 40 hours per week to 24 hours per week as a shared/mutual case with his spouse is being appealed. The approved hours were reduced after the patient requited to attend Social Adult Day Care.

The patient attends day care several days per week. There is no evidence of additional needs. CDPAS (Consumer Directed Personal Assistance Service) is not indicated when no tasks are being performed. The proposed Consumer Directed Personal Assistance Services 40 hours per week is not medically necessary.

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

Diagnosis: Migraines

Treatment Emgality 120 mg/mL (milligrams per milliliter) pen injector

The insurer denied coverage for Emgality 120 mg/mL pen injector

The denial is overturned

This patient has a past medical history of migraines.  The documentation indicated she has been recommended to utilize Emgality for her headaches.  The submitted documentation indicated she was seen for a follow-up.  The documentation detailed she was having approximately 10 headache days a month.  She has trialed Imitrex, Fioricet, magnesium, and feverfew.  Objectively there was no significant findings.  The physician indicated she had recently utilized Emgality and noticed improvement.  She indicated she only had headaches around her menstrual cycle.  She was seen for a follow-up where it was noted Emgality continued to work, and it was recommended she continue with medication and added utilization of Fioricet.  The submitted documentation indicated this medication has previously been denied as there is no documentation of average headache duration and average pain score in addition to the adequate trial and failure of at least 2 different types of oral medications to prevent migraines.

The patient's headaches persisted despite treatments with first-line drugs. In contrast, headaches were suppressed by Emgality. This provides empiric evidence that Emgality is an adequate pharmacotherapy for this individual. 

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 Emgality 120 mg/mL pen injector is overturned. Medical is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: prematurity, hydrocephalus, ventriculoperitoneal (VP) shunt, gastroesophageal reflux disease (GERD), subglottic stenosis, persistent stridor, and tracheomalacia.

Treatment: private duty nursing (PDN) services 8 hours per day, 7 days per week

The insurer is denied coverage for private duty nursing (PDN) services 8 hours per day, 7 days per week

The denial is upheld. 

This male patient has a history of prematurity, hydrocephalus, ventriculoperitoneal (VP) shunt, gastroesophageal reflux disease (GERD), subglottic stenosis, persistent stridor, and tracheomalacia.

Given the factors this patient's medical condition and care needs do not meet standards for medically necessity for 8 hours of private duty nursing per day. His chronic medical conditions and chronic care needs appear stable and within the family's ability to perform independently meriting the proposed reduction and termination in hours of skilled nursing coverage. The child has oppositional behaviors and hyperactivity. His needs are custodial in nature and do not require skilled nursing. Periodic adjustments in this patient's treatment plan will continue to occur guided by his chronic multidisciplinary treatment team. This decision was rendered based on review of the medical record, the NY criteria for private duty nursing and from UptoDate reviewing the assessment and management of aspiration due to swallowing dysfunction in children.

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

The carrier's denial of coverage for private duty nursing (PDN) services 8 hours per day, 7 days per week is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: PsA (psoriatic arthritis)
Treatment: Humira 40 milligrams (mg)/0.8 milliliter (ml) subcutaneous (SC) pen kit. 

The insurer denied coverage for Humira 40 milligrams (mg)/0.8 milliliter (ml) subcutaneous (SC) pen kit. 

The denial is overturned. 

The patient has a history of psoriasis and PsA (psoriatic arthritis).  Symptoms of psoriasis include morning stiffness, bilateral plantar fasciitis, knee pain, and tenderness in the proximal interphalangeal (PIP) joints and metacarpophalangeal (MCP) joints. She has been treated with non-steroidal anti-inflammatory agents (NSAID), Methotrexate, and Humira. She had a history of elevated liver function tests (LFT) and Methotrexate was discontinued. The patient has been on Humira and it was increased to weekly due to breakthrough of symptoms days after her former every other week regimen. The physician has recommended Humira 40 milligrams (mg)/ 0.8 milliliter (ml) subcutaneous (SC) pen kit weekly to treat psoriatic arthritis. 
	
The use of Humira in PsA and psoriasis is well-established and Food and Drug Administration (FDA) approved. The approved regimen is every other week. It can also be used every week with Rheumatoid Arthritis (RA). Its use in PsA so closely mimics that of RA that it is common to use it weekly if needed. This use is addressed by Gordon et al. 

The treating physician has supplied sufficient information to support the use of weekly Humira. There has been sustained improvement in skin and joint since the dose was increased to weekly months ago, and the regimen should be continued. 

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

Based on the above, the medical necessity for the Humira 40 milligrams (mg)/ 0.8 milliliter (ml) subcutaneous (SC) pen kit to treat psoriatic arthritis is substantiated. The insurer's denial is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara 90mg/ml Syringe 1 For 28 Days
The insurer denied the Stelara 90mg/ml Syringe 1 For 28 Days.
The denial is overturned.

The patient is a male with Crohn's disease who is on Stelara. His Stelara levels were 7.1 without antibodies.  While on standard dosing, the patient continues to have abdominal pain, joint aches, diarrhea.

Yes, the health plan should cover the Stelara every 4 weeks.
Dose escalation of Stelara may be required in some patients. In a retrospective multicenter cohort study performed on patients with CD (Crohn's disease), dose escalation was required in 17 patients (16.3%); response was recaptured in 9/17 (52.9%) (Ma C et al, Inflamm Bowel Dis.). In another multicenter open-label study, dose escalation was effective in 8 of 11 (73%) patients (Khorrami S et al. Inflamm Bowel Dis.).  In a single center retrospective open-label observational study, dose escalation was required in 47.7% of the patients and was successful in 61.1% of them (Kapylov et al.  J Crohns Colitis.).

In a retrospective study to determine the effectiveness of ustekinumab dose interval shortening, 506 patients with CD (Crohn's disease) who received subcutaneous ustekinumab 90 mg (milligrams) every 8 weeks at a single center was reviewed.  Data from 110 patients who initially received subcutaneous ustekinumab 90 mg (milligrams) every 8 weeks and then had their interval shortened to every 4 weeks was studied.  Harvey Bradshaw Index (HBI) scores before and after the dose interval shortening was available for 78 patients in the cohort (71%), levels of C-reactive protein (CRP) for 60 patients (55%), and levels of fecal calprotectin for 8 patients (7%). Following dose interval shortening, the patients' median HBI (Harvey Bradshaw Index) decreased from 4.5 to 3, the median level of CRP (C-reactive protein) decreased from 8 mg/L (milligrams per liter) to 3 mg/L (milligrams per liter), and median level of fecal calprotectin decreased from 378 g/g (micrograms per gram) to 157 g/g (micrograms per gram). Among patients who had an HBI (Harvey Bradshaw Index) > (greater than) 4, a level of CRP (C-reactive protein) 5mg/dL (milligrams per deciliter), a level of fecal calprotectin > (greater than) 250g/g (micrograms per gram), or endoscopic evidence for disease activity before dose interval shortening, after the dose interval was shortened, 28% achieved clinical remission (an HBI [Harvey Bradshaw Index] score 4), 22% had a normal level of CRP (C-reactive protein) (<5 mg/dL [milligrams per deciliter]), 50% had reduced levels of fecal calprotectin, and 36% achieved endoscopic remission (Ollech JE et al, Clin Gastroenterol Hepatol.).

Yes, Stelara every 4 weeks is more beneficial.
Fully utilizing the benefit of Stelara would be indicated prior to changing to another biologic agent, since there are few biologic agents that may be used in the treatment of Crohn's disease.