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

Diagnosis: Pyelonephritis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a history of a kidney infection who presented with back pain. She developed pain in her lower back. She also had turbid urine. Her past history is significant for a kidney infection when she was hospitalized for 3 days for intravenous antibiotics.
On physical examination, she was found to have right costovertebral angle (CVA) tenderness. A urinalysis and culture were obtained as well as laboratory values. The urinalysis showed greater than (>) 50 white blood cells (WBCs). She was also found to have an elevated white blood count and an elevated C-reactive protein (CRP) of 20.9. She was also found to have a coronavirus 2019 (COVID-19) infection. She received a bolus of intravenous fluids as well as ceftriaxone, but had ongoing tachycardia and back pain. She was therefore admitted to the hospital for further care.
In the hospital, she received intravenous fluids and ceftriaxone as well as ketorolac for pain. By the next day, she had improved and was felt to be stable for discharge to home with continued treatment and follow up as an outpatient. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital stay was medically necessary for this patient. She required parenteral antibiotics for pyelonephritis as well as intravenous fluids, which required an inpatient setting.
This was a patient who presented with acute pyelonephritis. She had a history of prior pyelonephritis and had both CVA tenderness and laboratory evidence of inflammation. She, therefore, required hospital admission for prompt treatment with parenteral antibiotics, fluids, and pain control, along with close monitoring in order to protect her kidneys from damage.
The decision making at the time of admission for this patient was consistent with her young age, the presence of a repeat significant infection that could potentially damage her kidneys, and the need for prompt treatment along with monitoring in an inpatient setting.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Morbid Obesity
Treatment: Mounjaro
The health plan denied the request for Mounjaro as it has not been determined that the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.
The health plan's determination is upheld.

The patient is a female being prescribed Mounjaro for the diagnosis of morbid severe obesity due to excess calories. The patient provided a letter of support on her own behalf for this appeal. The letter states that the patient has obesity related comorbidities including pre-diabetes, hyperlipidemia, and coronary atherosclerosis. The patient recognizes that using the requested medication for weight loss would be off-label, but cites the results of a recent publication which found that the medication was effective in treating obesity when used off-label. The patient reports that she had tried and failed to lose weight using diet and exercise alone.
The health plan denied coverage for the requested medication because they require a trial of at least three formulary alternatives within the same class. Formulary alternatives available to treat the patient's condition include Ozempic, Rybelsus, Trulicity, and Victoza.

There is no evidence to suggest that the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects. The patient is requesting the non-formulary drug to help with weight loss for obesity. The formulary contains multiple medications in the same class which can be effective in promoting weight loss. Furthermore, the requested medication does not have Food and Drug Administration (FDA) approval for the indication of obesity at this time. Although the request is correct that there is evidence to suggest that use of Mounjaro is associated with weight loss, it is not yet approved for that purpose and currently holds FDA approval for treatment of type 2 diabetes only. There is no documentation that the patient had a trial and failure of any other members of the glucagon-like peptide 1 (glp-1) agonist class medications, several of which do have FDA approval for the treatment of obesity. These medications are also on the plan formulary. There is no evidence of a previous trial or failure of these medications. 

The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Benzodiazepine withdrawal
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This adult male reportedly was admitted to this inpatient medical hospital treatment with a reported benzodiazepine withdrawal seizure (according to neurology) and also had other reported Xanax withdrawal symptoms including vomiting, diaphoresis, tremors and tongue fasciculations, anxiety, and abdominal pain. He reported flashes in his eye. He reportedly was seen by psychiatry and addiction medicine. He reportedly took his 1-week supply of Xanax at once and was abusing it. It was reported that he had been taking Xanax 8 milligrams (mg) per day but when his provider retired, his other provider was tapering it and referred him to a substance program, but he did not follow up. He reportedly had depression and anxiety and was taking Fluoxetine, Olanzapine, and Gabapentin, and also reportedly took Suboxone. His primary diagnosis for admission was benzodiazepine withdrawal and he had a diagnosis of benzodiazepine abuse also. He reportedly was put on a Xanax taper and then addiction medicine prescribed Valium 2 mg every (q) 8 hours for detoxification and withdrawal. It reportedly was recommended that he attend long term inpatient substance rehabilitation treatment, but he refused and was discharged.
  
The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. They stated that he was not unstable, had no signs of alcohol withdrawal with high-risk history. They stated that he did not require 24-hour hospital treatment and recommended a less restrictive level of care.
  
The medical records provided enough specific evidence to support that he required inpatient level of care. 

In this case, this patient had reports of a benzodiazepine withdrawal seizure and other active benzodiazepine withdrawal symptoms including vomiting, diaphoresis, tremors and tongue fasciculations, anxiety, and abdominal pain. It was reported that he used all his 1-week supply of Xanax and had withdrawal. It was reported that he continued to have withdrawal symptoms on the second day of admission, as he was tremulous and addiction medicine prescribed Valium 2 mg q 8 hours for detoxification and withdrawal as he was on a Xanax taper and was still experiencing withdrawal symptoms. He reportedly had a withdrawal seizure from benzodiazepines, and this requires inpatient medical detoxification treatment as he was considered at risk for even more severe withdrawal, or complicated or life-threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-7 days after benzodiazepine use so he was considered at high risk for life threatening withdrawal and in need of 24-hour hospital treatment then. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III malocclusion
Treatment: D8080 Braces, D8670 Monthly Visits
The insurer denied: D8080 Braces, D8670 Monthly Visits
The denial is overturned.

The patient is a teenage male. The request is for orthodontic benefits with monthly visits. The patient has a Class III malocclusion with mild upper and moderate lower jaw crowding. The patient also has a deep bite.

The requested health service is medically necessary.

The patient has a crossbite of an anterior tooth (#10, upper left lateral incisor). He also has clinical attachment loss with gingival recession. This is an automatic qualifier according to the 
handicapping index scale. Orthodontic treatment is medically necessary to correct this, and the monthly visits are needed to monitor progress. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is an adult male with a history of asthma who presented to the Emergency Department (ED) with complaints of shortness of breath (SOB), wheezing, and chest pain for 2 days.

Vital signs at presentation were Temperature 97.3 degrees Fahrenheit, pulse 100, respirations 24, blood pressure (BP) 135/76, and oxygen (O2) saturation 96 % on room air. Peak expiratory flow (PEF) was 280. The patient was in no acute distress. Lungs were described as clear, heart sounds normal and the patient was alert and oriented x 3.

White blood cells (WBC) were 4.9, Hemoglobin (Hgb) 16, electrolytes were within normal limits. Venous Blood Gas 7.36/43/94. Chest x-ray (CXR) had no acute infiltrates.

The patient was treated with intravenous (IV) steroids, bronchodilators (BD) via nebulizer, and Magnesium. There was improvement with treatment. The patient was admitted with a diagnosis of Asthma Exacerbation.

This patient did not need acute inpatient hospitalization. The patient was awake and alert, hemodynamically stable, without fever, and tolerating food and fluids.

This patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient had responded to treatment and signed out against medical advice (AMA) shortly after admission. This patient could have been placed in observation for some time and treatment initiated. The patient could have been discharged home on oral (PO) medications after a period of observation.

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal malocclusion
Treatment: D8080 Braces, D8670 Monthly Visit, D8680 Retainer
The insurer denied: D8080 Braces, D8670 Monthly Visit, D8680 
Retainer
The denial is overturned.

The patient is a school age male. The request is for orthodontic treatment with monthly visits and a retainer. The patient has a Class I skeletal malocclusion, moderate upper and lower crowding and an open bite. He also has a supernumery maxillary right lateral incisor. The prior denial was due to a score of 18 on the handicapping index scale.

The requested health service is medically necessary.

The patient has an impacted upper right permanent lateral incisor where extraction is not indicated. This is an automatic qualifier according to the handicapping index scale. The monthly 
visits are needed to make sure the treatment is progressing properly, and the retainer is needed at the end of treatment to prevent relapse. Orthodontic treatment is needed to correct this malocclusion and the case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal malocclusion
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is overturned.

The patient is a teenage female requesting orthodontic benefits with monthly visits. The patient has a Class I skeletal malocclusion with Class II canines. There is moderate upper and lower jaw crowding with severe overjet. The prior denial was due to a handicapping index score of 13.

The requested health service is medically necessary.

This patient has a severe overjet where her upper front teeth are way out in front of her lower front teeth. This will make the upper front teeth more prone to trauma such as fracturing. The patient also has an open bite where her upper front teeth do not cover her lower front teeth. This will make masticating (chewing) her food more difficult. Since she does not have her front teeth 
touch during the chewing cycle, there can be no "anterior guidance." This is when the lower teeth glide along the backs of the upper front teeth and allow the posterior teeth to disarticulate (open). This will cause trauma such as chipping and/or fracturing of her back teeth over time. Orthodontic treatment is needed to correct these issues, and the monthly visits are to make sure treatment progresses properly. Therefore, the requested health service is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Small fiber neuropathy
Treatment: Gammagard (J1569)
The insurer denied: Gammagard (J1569)
The denial is overturned.

The patient is an adult male with small fiber neuropathy. He was found to have elevated antibody level of fibroblast growth factor receptor three (FGFR3). Prednisone, while effective, needed to be increased to maintain effectiveness and was not without side effects. The provider wishes to prescribe Gammagard (intravenous immunoglobulin [IVIG]). The request was previously denied as it was considered experimental/investigative.

The health plan should cover the proposed treatment. 

The requested health service or treatment is more beneficial than any standard treatment for the patient's condition or disease. The patient has already tried and failed prednisone as this was losing effectiveness. Preliminary studies have shown that intravenous immunoglobulin can be effective in treating small fiber neuropathy that is autoimmune which the patient has. In 2018, an analysis found that intravenous immunoglobulin is safe and effective for small fiber polyneuropathy of autoimmune cause (1). Furthermore, intravenous immunoglobulin is an emerging treatment for small fiber neuropathy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Small fiber neuropathy
Treatment: Gammagard (J1569)
The insurer denied: Gammagard (J1569)
The denial is upheld.

The patient is an adult male with small fiber neuropathy. The provider has requested intravenous immunoglobulin (IVIG). The requested medication was denied coverage as experimental and investigational for his condition.

The health plan should not cover the proposed treatment.

The requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease. Review of the current medical literature indicates that there are no high-quality clinical trials published in the peer-reviewed medical literature demonstrating that intravenous immunoglobulin is effective for the treatment of small fiber neuropathy. None of the manuscripts submitted by the provider are considered high quality clinical trials. In contrast, a high quality, randomized, controlled trial (1) demonstrated that intravenous immunoglobulin was not effective for the treatment of small fiber neuropathy. Also, a smaller, but randomized, blinded, controlled trial, demonstrated that intravenous immunoglobulin was of no benefit to persons with small fiber neuropathy and elevated antibody titers to trisulfated heparin disaccharide (TS-HDS), which is the case here (2). Thus, there is no evidence to support the efficacy of the proposed treatment and there is high quality evidence to support that the proposed treatment is not effective. Finally, there are no standard of care guidelines to support that his treatment is appropriate or should be used for this patient's condition (3). Taken together intravenous immunoglobulin (IVIG) in this clinical context has been proven to not benefit patients, is not standard of care, and therefore is not appropriate.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Multiple Sclerosis
Treatment: Formulary exception for Vumerity
The insurer denied: Formulary exception for Vumerity
The denial is upheld.

The patient is an adult male with multiple sclerosis (MS). He has not been treated with any disease-modifying medication. The provider is requesting treatment with Vumerity. The requested medication was denied coverage by the health plan, as the patient has not tried and had a side effect from generic dimethyl fumarate, and he has not tried and failed two additional preferred medications. The denial is being appealed.

The health plan should not cover the Formulary exception for Vumerity.

There is no documented reason the patient cannot be treated with generic dimethyl fumarate or the other formulary agents for his condition. Generic dimethyl fumarate works via the exact same mechanism as Vumerity. The preferred agents are FDA (United States Food and Drug Administration) approved for his condition based on high-quality clinical trials published in the peer-reviewed medical literature (McGinley et al., 2021). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Vumerity relative to the preferred agents. There is no evidence that switching to a preferred agent would jeopardize his clinical stability. Therefore, given the above, the health plan should not cover the Formulary exception for Vumerity.
Appeal type: Experimental/Investigational
Decision: Overturned

Cardiac/Circulatory Problems/Heart Problem/Right Heart Failure
Treatment: Transcatheter tricuspid valve implantation (TTVI)/replacement with prosthetic valve and inpatient stay
The health plan denied the requested Transcatheter tricuspid valve implantation (TTVI)/replacement with prosthetic valve and inpatient stay as not medically necessary. The health plan's determination is overturned.

The patient is a man with a history of tricuspid valve endocarditis who eventually required a 29-millimeter (mm) bioprosthetic tricuspid valve. The bioprosthetic valve is failing with the development of tricuspid regurgitation and stenosis. The last transthoracic echocardiogram showed a mean tricuspid valve gradient of 14 millimeters of mercury (mmHg) and moderate tricuspid regurgitation. The left ventricular ejection fraction was 50%. The patient is highly symptomatic with severe peripheral edema. The patient also has hypertension, persistent atrial fibrillation, and diabetes. It is not clear from the documentation that the patient's case was reviewed by a cardiac surgeon, but the interventional cardiologist stated the patient was at high surgical risk. Further documentation stated that patient has refused repeat cardiac surgery. The provider recommended implantation of a percutaneously implanted tricuspid valve-in-valve.
The medical necessity for a transcatheter valve implantation (TTVI)/replacement with prosthetic valve is at issue.

The health plan's determination is overturned, in whole. As stated above, there is strong evidence that tricuspid valve is an effective treatment for treatment of tricuspid bio prosthesis dysfunction.

Yes. This patient has severe symptomatic prosthetic tricuspid valve disease. In order to improve symptomatic state, the valve abnormality needs to be corrected. This can be performed by repeat cardiac surgery. The patient has refused. There is strong evidence that percutaneous valve-in-valve treatment is effective. The current percutaneous valve, Edwards Sapien 3 valve, is Food and Drug Administration (FDA) approved for valve-in-valve treatment of bioprosthetic aortic and mitral valve dysfunction, but it has not been FDA-approved for bioprosthetic tricuspid valve dysfunction. As a result, it is considered investigational/experimental by policy. However, there is strong evidence that percutaneous tricuspid valve-in-valve treatment is effective. Thus, in this patient it is considered medically necessary to proceed with percutaneous tricuspid valve-in-valve in treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Cardiac/Circulatory Problems/Heart Problem/Right Heart Failure
Treatment: Transcatheter tricuspid valve implantation (TTVI)/replacement with prosthetic valve and inpatient stay
The health plan denied the requested Transcatheter tricuspid valve implantation (TTVI)/replacement with prosthetic valve and inpatient stay as not medically necessary. The health plan's determination is overturned.

The patient is a man with a history of infective endocarditis, atrial flutter and chronic kidney disease stage IIIb. He underwent tricuspid valve replacement and ventricular septal defect repair. He has symptoms of right heart failure due to degenerative bioprosthetic prosthetic valve disease with moderate to severe tricuspid regurgitation and severe tricuspid stenosis. His left ventricular systolic function is low normal. His right ventricular size and function are normal.
The medical necessity for a transcatheter valve implantation (TTVI)/replacement with prosthetic valve- is at issue.

I overturn, in whole, the health plan's determination that this service, in this instance, is not medically necessary.

Yes. This man has significant, symptomatic tricuspid regurgitation and stenosis due to degeneration of a previously implanted bioprosthetic tricuspid valve. His right ventricular systolic function is preserved. Treatment options include surgical or transcatheter valve replacement. Both early and late mortality rates for patients with degenerative prosthetic valve dysfunction who undergo re-do surgical valve replacement are high, with overall reported rates of in-hospital mortality ranging from 13-18%. This man's age and chronic kidney disease place him at particular risk for postoperative complications. Transcatheter valve-in-valve replacement (TVVR) allows for treatment of the valve dysfunction without the risks of repeat sternotomy and mitigates the risks for surgical site infection and possible complications of cardiopulmonary bypass, including acute kidney injury and neurologic sequelae. Data from the international registry including 152 patients in whom TVVR was attempted revealed successful implantation in all but two patients; thirty-day mortality was .03%. Thus, in this elderly high-risk patient, transcatheter valve replacement is likely to be safer and more beneficial than the standard treatment, operative tricuspid valve replacement.