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

Diagnosis: Rheumatoid arthritis and sacroiliitis. 
Treatment: Humira injection once a week. 

The insurer denied the Humira injection once a week. 
The determination is upheld. 

The patient has rheumatoid arthritis (RA) and bilateral sacroilitis. The patient is currently on Humira 40 milligrams (mg) every 2 weeks but is having refractory back pain. The health plan's limit is 2 pens per 25 days for patients also taking methotrexate (MTX), which the patient is also taking. She is taking methotrexate (MTX) 15 mg weekly with (w/) folic acid (FA) 1 mg daily. At issue is the medical necessity of Humira injection once a week. 

No, the requested health service/treatment of Humira injection once a week is not medically necessary for this patient. 

The standard of care in the United States as well as the Food and Drug Administration (FDA) approved guidelines for Humira in patients also on MTX for ankylosing spondylitis (AS) (i.e, sacroiliits) is 40 mg every 2 weeks. If the patient is having refractory back pain due to sacroiliitis, there is no medical reason that another drug on the plan's formulary can be tried instead of Humira.  The Humira injection once a week is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Blood Clot. 
Treatment: Pharmacy/Prescription Drugs-Eliquis. 

The health plan denied the non formulary medication because it did not meet criteria. 
The reviewer has upheld in whole the health plan's determination. 

This is a patient a history of deep vein thrombosis and pulmonary emboli. She was started on Eliquis. The patient is heterozygous for factor (five) V Leiden. The patient was having heavy menstrual periods on Xarelto previously and is now on low dose Eliquis; this is under review. 

Neither Xarelto nor warfarin have been demonstrated to be inferior to Eliquis. The included documentation does not indicate that this patient is intolerant of either of the formulary alternatives nor that she has failed them. Bleeding and heavy periods are a known side effect of all anticoagulants, and none is noted as superior to another in this regard. Similarly, the patient was on full dose Xarelto, and this is being compared by the provider to only prophylactic dose Eliquis. There is a paucity of documentation indicating this patient has a contraindication to the formulary alternatives. Neither the authors of UpToDate nor the peer-reviewed literature recommend one of these agents as being superior to another and thus given their relative equivalency, the formulary options are reasonable and would not have adverse effects that the non-formulary alternative would.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 Diabetes. 
Treatment: Formulary exception for Metformin ER. 

The insurer denied the Formulary exception for Metformin ER. 
The denial is overturned. 

The patient is a female diagnosed with T2DM (type 2 diabetes mellitus). This request is for Metformin ER (extended release). 

As reported, the patient has tried and failed metformin and metformin extended release according to the letter.  As per visit note, the patient is managing her diabetes with Glumetza 2000 mg (milligrams) daily; Levemir 19 units; freestyle libre. As per most recent visit note , she is on metformin, Ozempic 0.5 mg (milligrams). She has GERD (gastroesophageal reflux disease). 

The patient's A1C (glycated hemoglobin) approximately 2 years ago was 5.7 %. Approximately six months ago, it was 8 %. 

Yes, the health plan should cover the formulary exception. 

The health plan should cover the formulary exception, because it is medically necessary as described below. The patient has tried metformin and metformin extended release and failed. 

Metformin is still the best first line medication for treating type 2 diabetes [1].  There are fewer adverse events and better compliance with extended release metformin [2, 3, 4, 5, 6, 7]. The request is for metformin ER (extended release)/Glumetza. The patient has tried and failed metformin XR (extended release) and metformin immediate release. 

Metformin commonly has side effects in the form of gastrointestinal discomfort, diarrhea, pain, nausea, vomiting. There are fewer adverse effects and better compliance with this formulation. Given the fact that the patient has failed the formulary alternatives, the request is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Breo Ellipta 200-25MCG/ INH IN AEPB. 

The insurer denied the Breo Ellipta 200-25MCG/ INH IN AEPB, Pre-service. 
The denial is upheld. 

The patient is female with a diagnosis of moderate persistent asthma. The prior denial reason was the patient is not over the age recommendation and that the patient has not trialed and failed or had a contraindication to a medication that is on the preferred drug list, including Fluticasone/Salmeterol powder for inhalation (generics of Advair Diskus and AirDuo RespiClick), or Wixela Inhub. 

No, the requested Breo Ellipta is not medically necessary. 

The patient has difficulty with adherence to Symbicort. She ran out of Symbicort and did not notify anyone. The treating physician intends to switch the patient to Breo to increase adherence, as Breo is a once daily medication and does not need a spacer. While the switch to Breo may increase compliance, Breo is FDA (United States Food and Drug Administration)-approved for the treatment of asthma in individuals 18 years and older. The safety and efficacy of Breo have not been demonstrated for those below the age of 18. There are other inhalers such as those in the formulary approved for this patient's age group. 

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient. 
Breo is not FDA (United States Food and Drug Administration)-approved for the treatment of asthma in individuals below the age of 18 years.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Juvenile rheumatoid arthritis. 
Treatment: Enbrel 50mg. 

The insurer denied the Enbrel 50mg, Pre-service. 
The denial is upheld. 

The patient is a female with a history of juvenile rheumatoid arthritis (JRA) diagnosed in childhood. She failed treatment with methotrexate, Plaquenil and gold. She has been treated with Enbrel for many years, and self-discontinued Enbrel a couple years ago to see how she would fare off therapy. When her symptoms returned, she restarted Enbrel again and did well, but ran out of Enbrel by the end of the year. Her only progress note attached is approximately two months later, and the plan was to re-order Enbrel. No additional clinical information is provided. The request indicates "unknown" TB (tuberculosis) status in the setting of risk factors for TB (tuberculosis). Enbrel was denied for this patient due to lack of recent chart notes (i.e., within one year) documenting positive response and percent of improvement on Enbrel, and absence of updated tuberculosis test results within past 12 months. The appeal is for Enbrel 50 mg (milligrams) weekly for the treatment of JRA (juvenile rheumatoid arthritis). 

No, the requested Enbrel 50 mg (milligrams) weekly for the treatment of JRA (juvenile rheumatoid arthritis) is not medically necessary. 

This patient with longstanding JRA (juvenile rheumatoid arthritis) has been treated with Enbrel for many years. She self-discontinued Enbrel a few years ago to see how she would fare off therapy. When her symptoms returned, she restarted Enbrel and did well, but ran out of Enbrel by the end of the year. Her only progress note indicates the plan was to re-order Enbrel at this time. No additional clinical information is provided. In addition, the attached request indicates "unknown" TB (tuberculosis) status in the setting of risk factors for TB (tuberculosis). Evidence of a negative TB (tuberculosis) test or initiation of treatment for latent tuberculosis is required prior to treatment with TNF (tumor necrosis factor) inhibitors such as Enbrel, as TNF (tumor necrosis factor) inhibitors increase the risk of latent TB (tuberculosis) reactivation. Furthermore, a recent update on her clinical status would be required prior to initiating therapy with Enbrel. Therefore, the proposed Enbrel 50 mg (milligrams) weekly for the treatment of JRA (juvenile rheumatoid arthritis) is not clinically appropriate or in accordance with standard of care in the rheumatology community, and 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: Bleeding gums
Treatment: D4341 Deep Gum And Root Cleaning, All Four Quadrants
The insurer denied the D4341 Deep Gum And Root Cleaning, All Four Quadrants
The denial is upheld

The patient is a male. The patient was recommended to have 4 quadrants of scaling and root planing. The health plan denied coverage, because there was no bone loss on x-rays, and no calculus present on x-rays.

No, the D4341 Deep Gum And Root Cleaning, All Four Quadrants is not medically necessary.
There is no evidence on the x-rays of bone loss. There also is no evidence of calculus formation along the roots of any teeth. Therefore, the scaling and root planing is not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Based upon clinical and radiographic findings, there was no need for the 4 quadrants of scaling and root planing.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left hip pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a male. He had worsening left hip pain for two years. His past medical history was reviewed. He was admitted to hospital for an elective procedure. He underwent an osteotomy and removal of deep implant. He also underwent a bursectomy.

The patient underwent a derotation osteotomy to his left femur. He underwent removal of hardware from his right hip.

Yes, the Inpatient admission was medically necessary.
The records show a complex and extensive surgical procedure was performed. The patient underwent several operations. He underwent procedures to both lower extremities. The removal of hardware procedure on the right was difficult and of long duration. The implant was firmly seated and required reaming to reach. Several accessory small incisions had to be completed at well. The derotation osteotomy to the left hip was likewise as complex. There were several steps where repositioning was required with careful attention to alignment. The duration of anesthesia and procedures were over 5 hours. The records also noted ongoing pain to require 23 doses of PCA (patient-controlled analgesia).

It would be extremely likely that mobilization would be difficult based upon the operations completed.

The above findings support necessity of the inpatient admission and services provided.

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: Pulmonary Embolism.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male for whom an inpatient level hospitalization is under review. He was transferred from another facility after having been diagnosed with bilateral pulmonary emboli and right heart strain. He was on anticoagulation.

On arrival, the patient's vital signs and O2 (oxygen) saturation were essentially normal. He was in no distress. There was near occlusive thrombus of the right pulmonary artery as well as a DVT (deep venous thrombosis). Troponins were elevated. Echocardiography was essentially normal, including normal RV (right ventricle) size and function. He remained stable and was transitioned to an oral anticoagulant.

No, the Inpatient admission was not medically necessary.
This patient had an established diagnosis of a PE (pulmonary embolism) and remained stable. There was no hemodynamic instability, no TPA (tissue plasminogen activator) administered, no invasive procedure, no bleeding, no unstable arrhythmia, no CHF (congestive heart failure), no ongoing acute coronary syndrome, no need for ongoing oxygen support, or requirement for prolonged inpatient intravenous medications. In this setting an acute inpatient hospitalization, compared to a lower level of care has not been established as standard of care towards improved PE (pulmonary embolism) outcomes. Thus, the inpatient admission is considered not medically necessary in this case.

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

Diagnosis: Fall with possible head strike
Treatment: Inpatient Rehabilitation Services

The insurer denied the Inpatient Rehabilitation Services.
The denial is upheld.

The patient is a female with a past medical history of obesity, hypertension, hyperlipidemia, transient ischemic attack (TIA), and right internal carotid artery (ICA) aneurysm who was brought to the emergency department (ED) after a fall and possible head strike. She was found to be in hypertensive urgency/emergency and was diagnosed with acute kidney infection (AKI) secondary to rhabdomyolysis. She also suffered a right wrist fracture. The patient was stabilized and discharged to acute rehab. Her acute rehab stay was denied. This is being reviewed upon appeal.

No, the proposed treatment was not medically necessary.
The patient suffered a fall with resultant wrist fracture and acute kidney injury secondary to rhabdomyolysis. She was stabilized and discharged to an acute rehab facility. As of the dates in question, the patient was transferring with supervision and ambulating community distances without an assistive device. She was able to complete stairs with supervision. She remained medically stable. As of the dates in question, the patient no longer required an intensive regimen of three hours per day of physical therapy (PT) and occupational therapy (OT). She no longer required three times weekly physician visits for medical management. The acute rehab stay was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgement and in the best interest of the patient.
The patient no longer required the intensity of service provided at the acute rehab facility. Her care could be provided in a less intensive setting. Acute inpatient rehab was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ST (interval on EKG) -Elevated Myocardial Infarction.

Treatment automatic external defibrillator, Zoll LifeVest.

The insurer denied coverage for automatic external defibrillator, Zoll LifeVest.

The denial is overturned.

The patient presented to the hospital complaining of chest pain that was first noted one week prior to presentation.  Upon arrival to the hospital, a 12-lead electrocardiogram revealed anterior Q (interval on EKG [electrocardiogram] waves and ST (interval on EKG) segment elevations in leads V1 (EKG leads)-V3 (EKG leads). These findings were consistent with ST segment elevation myocardial infarction.  The patient underwent cardiac catheterization and percutaneous revascularization of the left anterior descending artery. Echocardiogram revealed a left ventricular ejection fraction (LVEF) of 25-30% (percent) with a left ventricular apical thrombus. The patient was treated with antiplatelet and anticoagulant therapy as well as beta blocker therapy.  Prior to discharge, he was fitted with a wearable lifevest defibrillator for primary prevention of sudden cardiac death. 

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This patient presented 7 days following acute anterior wall myocardial infarction. Guideline statements from the Heart Rhythm Society/American Heart Association and the American College of Cardiology specify that external lifevest defibrillator therapy should be utilized during periods when patients are at risk of sudden cardiac death and require further cardiac workup/treatment (References 1-6). This patient underwent revascularization but already had Q waves on electrocardiogram on presentation and recovery of left ventricular function following treatment with guideline directed medical therapy was unlikely. In a real-world study of patients treated with external lifevest defibrillators, almost 5% of subjects received lifesaving therapy (Reference 4). The Vest trial specifically studied patients at risk of sudden cardiac death following myocardial infarction.  In a treated analysis wearing a lifevest defibrillator was associated with a 57% reduction in arrhythmic death (RR 0.43, 95% CI 0.21-0.91, uncorrected p = 0.03) and a 74% reduction in mortality (RR 0.26, 95% CI 0.14-0.48, Bonferroni corrected p < 0.001) (Reference 6).

Based on current available guidelines and clinical trial data the proposed treatment was medically necessary and was beneficial for the patient.

The insurer's denial of coverage for an automatic external defibrillator, Zoll LifeVest is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Medial and lateral meniscus tears, anterior cruciate ligament (ACL) tear, and moderate joint effusion

Treatment: Synvisc-One 8 milligrams/milliliter (mg/ml) injections

The insurer denied coverage for Synvisc-One 8 mg/ml injections.

The denial is upheld.

This is an adult male with a history of osteoarthritis. Magnetic resonance imaging (MRI) of the right knee revealed medial and lateral meniscus tears, anterior cruciate ligament (ACL) tear, and moderate joint effusion. The patient had multiple knee injections. Pain improved after injections. The physician recommended Synvisc-One 8 milligrams/milliliter (mg/ml) injections to treat osteoarthritis (OA). 

The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis if all other courses failed prior to surgery. 

The recommendations for use of viscosupplementation have changed. 

A review of the Clinical Practice Guideline (CPG) by AAOS (American Academy of Orthopaedic Surgeons) states the following: 

The OA [osteoarthritis] knee treatment CPG contains one significant recommendation change and this is with regard to the issue of viscosupplementation. The OA knee CPG included an 'inconclusive' recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG.

The second edition CPG recommendation reads, 'We cannot recommend using HA for patients with symptomatic OA of the knee,' with a 'Strong' rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see The Importance of Clinical Significance in AAOS CPGs, AAOS Now, May 2013).

The Orthopedic group reports "strongly do not recommend use."

There has been no change to this Guideline. Additional references and expert opinions vary with no consistent statement for the use of the injection. A meta-analysis was completed of multiple references. This is a high-level evidence based criteria which does not support use. 

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

The insurer's denial of coverage for Synvisc-One 8 milligrams/milliliter (mg/ml) injections is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shingles.
Treatment full hospital admission.
The insurer denied coverage for full hospital admission.
The denial is upheld.

The patient has a past medical history significant for encephalopathy after a traumatic brain injury, recurrent urinary tract infections, status post percutaneous gastrostomy tube placement, and functional paraplegia who presented to the emergency room with altered mental status. Vitals on presentation included: Temperature 98.9 F (Fahrenheit), Blood Pressure 115/76, Pulse 74, Respiratory Rate 18, oxygen (O2) saturation 96% (percent) on Room Air. Laboratory results included the following: white blood cell count (WBC) 3.9, hemoglobin (HGB)-10.6, hematocrit (HCT)-31.8, creatinine-0.87, glucose-108, urinalysis showed large leukocyte esterase, negative nitrites. 

The patient was admitted for altered mental status. She was noted to have shingles over her left thigh and was started on intravenous acyclovir. She was also started on ciprofloxacin for possible urinary tract infection. Head computed tomography (CT) scan showed no evidence of acute intracranial hemorrhage or acute territorial infarction. Chest x-ray (CXR) was negative. The patient remained afebrile and hemodynamically stable. She was discharged to continue oral antivirals (acyclovir) as an outpatient. 

According to documentation, the patient presented with possible change in mental status and noted to have skin rash consistent with shingles. Otherwise, the patient was afebrile, hemodynamically stable with normal white blood count (WBC). Although she had co-morbid conditions, these were chronic issues. The patient had no evidence of a disseminated infection. Based on above findings, the patient met criteria for observation level of monitoring. The patient did not fulfill criteria for acute hospital admission. 

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose Veins
Treatment: Liquid or Foam Sclerotherapy (Endovenous Chemical Ablation)
The insurer denied Liquid or Foam Sclerotherapy (Endovenous Chemical Ablation).
The determination is upheld.


The patient was seen for varicose veins, bilaterally. There is a lack of a complete medical history in the records. She underwent right lower extremity endovenous chemical ablation with liquid foam ablation (Varithena). The documentation notes her inability to exercise and the need for leg elevation as the reasons for intervention. According to the records, she has not had a right leg surgical saphenofemoral ligation, vein stripping nor endovenous ablation in the past. The provided ultrasound results do not document saphenofemoral incompetency (greater than [>] 500 milliseconds [ms]), saphenopopliteal incompetency nor large varicosities. There is no history of persistent pain and swelling that interferes with daily functional activity, with consistent use of graduated compression stockings, recurrent phlebitis, hemorrhage from varicosities nor symptomatic varicosities > 2.5 millimeters (mm).
At issue is the medical necessity of Liquid or Foam Sclerotherapy (Endovenous Chemical Ablation).
It is not medically necessary. According to the physician's medical forms, there is no information which adequately addresses the published guidelines regarding medical necessity in this case. There are specific indications for endovenous ablation, which in this case are not met. The indications are outlined above but specifically, liquid foam sclerotherapy is considered a medically necessary "adjunctive" treatment for symptomatic varicose veins, 2.5 mm or greater measured by ultrasound. This was not the case in this situation. There is a note that mentions previous "ablation" having been done by a different physician at a different facility. It does not note which leg was done, nor does it note the type of procedure. Therefore, the requested procedure is not medically necessary.