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

Diagnosis: vomiting
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is an infant who presented to the emergency department (ED) with 1 week of vomiting and weight loss. She had been seen several times, most recently as an outpatient and an abdominal ultrasound indicated pyloric stenosis.

Based on medical guidelines for care of infants with pyloric stenosis and accompanying dehydration and/or electrolyte disturbance, inpatient hospital admission is medically necessary for this patient.
This infant presented with progressive emesis, multiple outpatient or ED visits, and new findings of pyloric stenosis by ultrasound. She had an elevated AG (anion gap) with normal electrolytes, and clinical findings consistent with dehydration. She underwent surgical intervention and progressed towards discharge. An inpatient level of care was necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of diabetes mellitus type 2 (DM2) and hypertension (HTN) who was admitted with complaints of (c/o) a seven-day history of intermittent dizziness. She denied any altered mentation/confusion. Her vital signs were unremarkable. The physical exam was notable for a normal neurological examination. Lab work was notable for transaminitis, positive (+) hepatitis B, normal coagulation studies. Imaging studies, a computed tomography (CT) scan of the head showed no acute intracranial pathology, an ultrasound (US) of the abdomen showed a fatty liver a computed tomography (CT) scan of the cervical (C)-spine was unremarkable. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) without acute ischemic changes. The patient was diagnosed with benign paroxysmal postural vertigo (BPPV) and hepatitis B and treated with meclizine, avoiding hepatotoxins, and expert consultations. Gastroenterology (GI) evaluated the patient and recommended outpatient follow-up due to no evidence of liver failure. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with dizziness and vertigo without associated focal neurological deficits. The patient did not have any acute hearing loss, double vision, fixed neurologic deficits, severe headache, associated head trauma, fever, high clinical suspicion for central vertigo or cerebrovascular accident (CVA), cerebellar infarct or hemorrhage, vertebrobasilar insufficiency, acute suppurative labyrinthitis, intractable nausea/vomiting or inability to ambulate. All imaging performed showed no acute pathology. The patient was treated with meclizine and supportive care. The patient was found to have an impressive transaminitis, for which GI was consulted, but work-up was deferred to the outpatient setting as there was no evidence of hepatic failure and the patient's synthetic liver function was intact. Given the patient's clinical stability and provided interventions and clinical monitoring, these could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Reviewer Findings:

According to the medical records, the patient is an adult male diagnosed with anemia. The patient presented to the emergency room (ER) with fatigue, diminished appetite, weight loss, pallor, constipation, pins and needles in both extremities for five (5) months. Hemoglobin was noted as 6.4. The request is for inpatient admission which is under review.

The patient had chronic anemia. Vital signs were stable on presentation. The patient required transfusion and was admitted and discharged on the same day. Care given to this patient could have been provided at a lower level of care, such as observation, after which point if it was deemed necessary, an admission could have been done. 

"Anemia is a common condition and is diagnosed on laboratory assessment. It is defined by abnormally low hemoglobin concentration or decreased red blood cells. Several classification systems exist. Laboratory markers provide important information. Acute anemia presents with symptoms owing to acute blood loss; chronic anemia may present with worsening fatigue, dyspnea, lightheadedness, or chest pain. Specific treatments depend on the underlying anemia and etiology. Iron is an alternative treatment for patients with microcytic anemia owing to iron deficiency. Hyperbaric oxygen is an option for alternative rescue therapy. Most patients with chronic anemia may be discharged with follow-up if hemodynamically stable." (Mulay, S. B. et al. 2013).

Transfusion may also be indicated in patients with active or acute bleeding as well as in patients with symptoms related to anemia (for example, tachycardia, weakness, dyspnea on exertion) and hemoglobin less than 8.

Unless the patient is actively bleeding, it is recommended to transfuse 1 unit of packed red cells at a time, which will typically increase the hemoglobin value by 1 gram per deciliter (g/dL) and hematocrit by 3%. Follow up by checking post-transfusion hemoglobin.[9]" (Lotterman, S., & Sharma, S., 2021).                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: migraines
Treatment: Nurtec ODT (oral disintegrating tablet)
The insurer denied Nurtec ODT
The health plan's determination is upheld. 

The patient is a man who is diagnosed with severe refractory migraines. Treatment with Nurtec ODT (oral disintegrating tablet) is the subject of this review. The drug was denied because documentation was lacking to show the indication for this drug as the drug can be prescribed for both preventative treatment of migraine and acute migraine treatment.

Nurtec ODT is not medically necessary. The intended use for Nurtec ODT is not clear from the records provided. This drug can be used for prevention of migraine, and for treatment of acute migraine. In this instance, the patient is noted to have severe refractory migraine, which suggest that the patient has chronic migraine. In that case, Knotek ODT is not an approved medication for treatment of the patient's condition. Next, if Nurtec ODT is prescribed for acute treatment of migraine, it is necessary to show that the patient is on preventative therapy. The use of preventative therapy helps to limit the need for abortive therapies. In this instance, there is no documentation that the patient is treated with a recognized preventative medication. Overall, there is insufficient information in the letter of appeal and any clinical documentation to show the intended use of the drug and other medications that are also being used for headaches in order to demonstrate medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity. 

Treatment: OZEMPIC .25 OR 0.5 PEN INJCTR (Injector). 

The insurer denied coverage for OZEMPIC .25 OR 0.5 PEN INJCTR (Injector). 

The denial is upheld. 

The patient is diagnosed with obesity. This request is for Ozempic. 
As reported, the patient has responded to Ozempic therapy. Prior to Ozempic, the patient tried and failed diet and exercise. As per the letter, the patient has a past medical history of obesity and has been unsuccessful on diet and exercise. The patient failed Victoza.  The patient's most recent weight was 352 pounds, and their body mass index (BMI) was 52.2. 

Semaglutide is a glucagon-like peptide-1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer reviewed medical journals have shown safety and efficacy of Semaglutide for the treatment of obesity (5-7). This medication is now available for the treatment of obesity in the form of Wegovy. There are no randomly controlled trials with long follow-up showing safety or efficacy of the requested medication for patients who do not have diabetes such as this patient. There are no extenuating circumstances in this case. The request is, therefore, not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the Ozempic .25 or 0.5 Pen Injctr (injector) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: arthritis
Treatment: Home Care / Personal Care HHC (Home health care) - Level 2 Personal Care Services, per 15 Minutes Increase to 84 Hours per Week
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 84 Hours per Week
The health plan's determination is overturned. 

This is a female patient with a history of breast cancer, rheumatoid arthritis, chronic pain syndrome, degenerative joint disease, obesity, functional incontinence, fibromyalgia, tremors, and memory impairment. 
An in person Uniform Assessment System (UAS) was completed. She was assessed at total dependence for housework; maximal assistance for meal preparation and shopping; extensive assistance for stairs, transportation, bathing, dressing lower body, and toilet use; limited assistance for dressing upper body; supervision for walking, locomotion, and transfer toilet; and independent for managing finances, managing medications, phone use, personal hygiene, bed mobility, and eating. A tasking tool was used to determine that she requires 33.67 hours per week of assistance with activities of daily living (ADL) / Instrumental activities of daily living (IADL).

Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 84 Hours per Week are medically necessary for this patient.
There is documentation in the UAS of the patient requiring at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. There was a significant change in care needs per the UAS  as compared to the previous UAS. The insurer should not have utilized a tasking tool to calculate hours given patient's unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) and plastic surgeon of medical necessity of increased PCA (personal care aide) services. The patient does not have informal support for the entire time outside of the previously assigned PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance, a total of 50 hrs a week
The insurer denied Consumer Directed Personal Assistance, a total of 50 hrs a week.
The determination is upheld.

This is a male patient with a medical history notable for coronary heart disease, diabetes, and dementia. The patient was approved for 30 hours per week of consumer directed personal assistance care. The patient and his care team requested an increase to 50 hours per week, and this request was denied by the health plan.
A Uniform Assessment System (UAS) was completed. The assessment was conducted in person. The patient lives with his wife. He directs his own care. He was alert and oriented with modified independence for cognition. He had some forgetfulness. This mini mental state examination score was 20 out of 30, consistent with mild to moderate cognitive impairment. For his instrumental activities of daily living, the patient requires maximal or extensive assistance for all. For his activities of daily living, he requires extensive assistance for bathing and dressing lower body. He requires limited assistance for dressing upper body, walking, locomotion, toilet transfer, and toilet use. He is independent for all other activities. He is unsteady on his feet but does not use any assistive device due to dementia. The assessment notes that he would benefit from a cane but does not use one. He is continent of urine and stool. There was no pressure ulcer present. There was one fall in the previous 90 days; he got up to use the bathroom at night and fell without any significant injury. A task tool associated with the assessment recommended 23 hours per week to address his personal care needs. There were no medical records or letters of medical necessity provided as part of this appeal. At issue is the medical necessity of Consumer Directed Personal Assistance, a total of 50 hours (hrs).
The requested health service of Consumer Directed Personal Assistance, a total of 50 hrs a week has not been demonstrated to be medically necessary for this patient.
The patient requires assistance primarily with instrumental activities of daily living. His functional deficits are driven by his dementia and inability to direct his own care. It is unclear which personal care needs, if any, are not being met with his current allotment of personal care hours. The task tool recommended 23 hours per week and he is receiving 30 hours per week. It has not been clearly demonstrated that the requested increase is medically necessary for the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Basivertebral nerve radiofrequency ablation (The Intracept System). 
The insurer denied Basivertebral nerve radiofrequency ablation (The Intracept System). 
The determination is overturned. 

This is a female patient with a past medical history (PMH) of migraines and lower back pain (LBP) for greater than (>) 3 years. She has tried these modalities: massage therapy, physical therapy (PT), chiropractic and home exercises. She has had these interventions: radiofrequency ablation (RFA), sacroiliac (SI) joint injections, epidural steroid injections. She has tried nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxant medications. Her pain is a 6-10 on the Visual Analog Scale (VAS). It impacts her sleep, household chores, work, and leisure activities. Her physical exam was notable for tenderness at the spinous process of lumbar (L) 5 and lumbar pain with both active and passive range of motion (ROM). She has magnetic resonance imaging (MRI) evidence of L5-sacral (S)1 severe disc degeneration with Modic 1 changes. At issue is whether basivertebral nerve radiofrequency ablation (The Intracept System) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The proposed health service or treatment basivertebral nerve radiofrequency ablation (The Intracept System) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The proposed health service will likely be more beneficial than standard treatment. The patient has tried prior interventions without significant benefit. She has also tried PT, massage, and chiropractic. She has MRI evidence of L5-S1 modic changes in the setting of severe degenerative disc disease (DDD) at that level. Therefore, the proposed treatment basivertebral nerve radiofrequency ablation (The Intracept System) is likely to be more beneficial than any standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Basivertebral nerve radiofrequency ablation (The Intracept System). 
The insurer denied Basivertebral nerve radiofrequency ablation (The Intracept System). 
The determination is upheld. 

This is a female patient with complaints of chronic low back pain. The pain impacts her activities of daily living. The pain ranges from 6-10 out of 10. Prior treatments have included chiropractic care, lumbar injections, massage therapy, physical therapy, as well as multiple medications. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic type I changes in the lumbar (L) 5 and sacral (S) 1 vertebral bodies. At issue is whether basivertebral nerve radiofrequency ablation (The Intracept System) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The proposed health service or treatment basivertebral nerve radiofrequency ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. 
Given the above, the proposed health service or treatment basivertebral nerve radiofrequency ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cerebrovascular accident
Treatment: home health care
The insurer denied Personal Care Aide: 40 Hours per Week
The health plan's determination is upheld. 

This is a case review for a male with medical history notable for prior cerebrovascular accident in the middle cerebral artery, diabetes, and hyperlipidemia. Personal Care Aide: 40 Hours per Week is under review. 

The requested Personal Care Aide: 40 Hours per Week, Consumer Direct is not medically necessary for this patient.

The patient requires assistance with several tasks as outlined in the notes. These tasks revolve primarily around instrumental activities of daily living. He does require some assistance with dressing and hygiene. The patient is approved for 19.25 hours per week of consumer directed personal care. This allotment is intended to accommodate time for these needs, including bathing, hygiene, dressing, and other activities. There is no documentation that any personal care activities are not currently being addressed at this level of personal care hours. The appeal request letter specifically states that the additional hours are intended to help in the event of a fall or a seizure. This activity is defined as safety monitoring, and is not a covered personal care function. Therefore, the requested increase to 40 hours per week is not medically necessary for the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Carrier of Breast Cancer gene 1 (BRCA1).
Treatment:  Combipatch (estradiol-norethindrone).

The insurer denied coverage for Combipatch (estradiol-norethindrone).  The denial is overturned.

According to the provider, the patient is a carrier of Breast Cancer gene 1 (BRCA1) and underwent a risk reducing bilateral salpingo-oophorectomy.

The provider requested coverage for Combipatch. The insurer has denied coverage for Combipatch (estradiol-norethindrone). In their Final Adverse Determination letter, they stated that the medication may be covered when the requested product cannot be switched to a formulary alternative. A formulary alternative is Climara PRO. The requirement is trial of 1 in a class with 1 alternative.

The patient then used Climara Pro but reports that the patch does not re-adhere after a shower. The patches do not stay on for a whole week.

Estrogen is available in many forms: oral, transdermal, topical gels, emulsions and lotions, intravaginal creams and tablets, and vaginal rings. All estrogens are equally effective for managing menopausal symptoms such as hot flashes. Transdermal estrogen administration is associated with a lower risk of venous thrombosis and stroke, and it has less of an effect on serum lipid concentrations when compared with a comparable dose of oral estrogen.

There are many transdermal estrogen preparations available that contain 17-beta estradiol. There is a wide range of dosing options. There are no studies suggesting that any of these preparations is better, more beneficial or better tolerated than the others. The scientific literature suggests that all those formulations are equally effective with the same benefits and same side effects. 

Climara Pro is an estrogen plus progestin indicated in a woman with a uterus for: Treatment of Moderate to Severe Vasomotor Symptoms due to Menopause.

CombiPatch is indicated in a woman with a uterus for: Treatment of moderate to severe vasomotor symptoms due to menopause. 

While there are no data suggesting that one of these products is better tolerated, safer, more effective or has less side effects than the other, the patient is having issues with the Climara Pro patch adhering to her skin. As such she is not receiving the recommended dosage of medication.  A trial of CombiPatch is indicated.

The formulary drug(s) is not likely to cause the patient an adverse reaction.

The formulary drug(s) has been ineffective based on the patient's clinical history.  The Climara pro patch is not adhering adequately to the patient's skin and as such the patient is not receiving the adequate amount of hormone needed.

The requested drug may be more effective than the formulary drug as it may adhere better.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Combipatch (estradiol-norethindrone) is overturned.
Appeal type: Formulary Exception
Decision: Upheld


Diagnosis: Migraines.
Treatment: Sumatriptan-naproxen.
The insurer denied Sumatriptan-naproxen. 
The health plan's determination is upheld. 

The patient is a female who has a history of migraine headaches. 

There is insufficient evidence to conclude that the requested non-formulary drug is more effective or has fewer adverse effects than the formulary drugs.
Sumnatriptan-naproxen combination tablet is a fixed-dose combination tablet that contains 119 milligrams (mg) of sumatriptan succinate, which is equivalent to 85 mg of sumatriptan and 500 mg of naproxen sodium. Sumatriptan and naproxen are available separately as generic products. There have been no clinical studies to demonstrate that the combination tablet is superior to the combination of both generic agents.