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

Diagnosis: Atopic Dermatitis
Treatment: Rinvoq 15 mg (milligram) tablets
The insurer denied coverage for Rinvoq 15 mg (milligram) tablets.
The denial is upheld.

The patient is an adult female with a diagnosis of atopic dermatitis affecting the legs and alopecia totalis. The patient has failed topical therapy and is currently using clobetasol and triamcinolone for her atopic dermatitis. The atopic dermatitis has been treated with topicals, without any documentation of systemic therapies or light therapy. The requested medication is Rinvoq tablets.

Based on the submitted documentation, the use of Rinvoq tablets is not medically necessary for the patient's atopic dermatitis over alternative therapies. The documentation indicates that the atopic dermatitis is located on the legs only. Topical therapy in combination with light therapy would offer a therapeutic option for treatment of the atopic dermatitis, which is documented in the clinical note provided, as well as serving as a therapeutic option for alopecia totalis. Furthermore, no documentation is provided regarding contraindication to treatment with methotrexate or Dupixent or other therapies commonly used in the treatment of atopic dermatitis. There is no documentation regarding tried and failed therapies for alopecia totalis, a condition for which multiple treatment options are available including an Food and Drug Administration (FDA) approved oral medication. 

Based on the documentation submitted, the use of Rinvoq would not be supported over other reasonable alternatives. 

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 Rinvoq 15 mg (milligram) tablets services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Evaluation for left eye blurry vision
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The determination is upheld.

The patient is a male with a past medical history (PMH) of glaucoma who was admitted to the hospital with complaints of (c/o) eye pain associated with discharge and erythema after hitting his head. His vital signs were unremarkable. His physical exam was notable for abnormal right extraocular movement and an injected left eye conjunctiva. The patient's lab work was unremarkable. A computed tomography (CT) of the orbits was done and it showed a partial dislocation of the left lens with the lateral aspect in normal position along with possible globe rupture. The patient was diagnosed with blunt trauma to the left eye and acute iritis. He was treated with multiple ophthalmic medications. The patient was cleared to be discharged home by ophthalmology and was to follow-up with outpatient ophthalmology the following day. The patient was discharged in stable condition.

The requested health service/treatment of an inpatient stay was not medically necessary for this patient. The patient presented to the emergency department (ED) with c/o eye pain associated with discharge and erythema after hitting his head. The patient was found to have blunt trauma to the left eye. Ophthalmology evaluated the patient and prescribed multiple important medications for which strict adherence was required. Ensuring that the patient could comply was vital prior to discharge and this was a concern due to the patient's decreased ability to differentiate between the medications because of his decreased vision. However, the ophthalmologist's consultation suggested close, outpatient follow-up for the patient's injury. Unfortunately, due to the patient's brother's unavailability during the day to help the patient administer his medications properly, the patient could not be discharged and did not require acute inpatient care to ensure that the medical condition was treated and monitored appropriately. The patient was otherwise medically stable and did not require acute inpatient care for medication administration, as evidenced by the ophthalmologist's recommendation for close outpatient follow-up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations.  
Treatment: Inpatient Hospital Admission.  

The insurer denied: Inpatient Hospital Admission.  The denial is upheld.  

The patient is an adult female with a history of palpitations and supraventricular tachycardia documented on home monitor electrocardiogram.  The patient's symptoms persisted despite treatment with metoprolol, and she presented to the hospital for elective electrophysiologic study and ablation.  Orthodromic atrioventricular tachycardia was noted utilizing a posteroseptal accessory pathway.  Successful ablation of the posteroseptal accessory pathway and the slow inputs to the atrioventricular (AV) node transpired.  The procedure and post operative course were uncomplicated and the patient was discharged the following day.  

The proposed treatment was not medically necessary.  Inpatient hospital admission was not medically necessary.  

This patient presented for an elective electrophysiologic study and ablation.  Successful left poster septal accessory pathway ablation was performed without complication and the patient was discharged the following morning.  

Several studies have demonstrated both feasibility and safety of same day home discharge following radiofrequency ablation. In one study, a cohort of over 1300 individuals undergoing catheter ablation were discharged on the day of their procedures following a six-hour observation period.  Two hundred of these patients underwent accessory pathway ablation. (Reference 1) The authors of this study concluded that more than 90% of patients presenting for elective electrophysiology (EP) study with ablation could be discharged the same day.  In a second study of 11,000 patients undergoing catheter ablation of accessory pathways, the median length of stay following ablation was one day. (Reference 2).  

This patient had a successful and uncomplicated accessory pathway ablation performed.  The patient was observed overnight and discharged the following morning.  Treatment at a higher level of care was not medically necessary.  This patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Monitoring post PCI (percutaneous coronary intervention) with drug-eluting stent (DES) to the right coronary artery (RCA) and mid left anterior descending (LAD) artery.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

This patient presented to the hospital for elective cardiac catheterization. Stress testing and Cardiac computed tomography (CT) revealed abnormalities in the setting of angina.  Catheterization was performed utilizing a right radial approach. Obstructive lesions were noted in the mid right coronary and mid left anterior descending arteries. Drug eluting stents were successfully placed in both arteries and the patient was admitted to the telemetry unit for observation. There were no perioperative complications.

This patient presented for elective percutaneous revascularization. The patient underwent an uncomplicated procedure and stents were placed in the mid left anterior descending and right coronary arteries. She was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. (Reference 1-4). Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care (Reference 4). The patient could have been managed at a lower level of care. 

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

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

Diagnosis: Influenza
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This patient is a female who has a history of hypertension, hyperlipidemia, diabetes, gastroesophageal reflux disease (GERD), and hypothyroidism. She presented to the hospital with history of (H/O) syncope and 2 days of fever, cough, some retrosternal chest pain (CP) and constitutional symptoms. The patient reported being exposed to a sick contact at home. At presentation, temperature 98.4 degrees Fahrenheit (F), heart rate 82, respiratory rate 17, blood pressure 115/56 mm Hg (millimeters of mercury) and oxygen saturation at 98% (percent) on room air. Maximum Temperature was 102 degrees F. The patient was in no distress with clear lungs, negative cardiac exam, unremarkable abdominal exam and a non-focal neuro (neurological) exam.  Laboratory results were white blood count (WBC) 5.8 K (thousand), hemoglobin (Hb) 11.4, Sodium (Na) 133 with normal BUN (blood urea nitrogen) / Creatinine. Chest X-ray showed some left lower lobe (LLL) infiltrate. Electrocardiogram (EKG) showed sinus tachycardia with no acute ST-T (interval on EKG) changes. The Troponin was negative. Influenza Test was positive for Influenza A. COVID-19 (Novel 2019 Coronavirus) was negative.

The patient was admitted for Influenza / Sepsis / Syncope rule out (R/O) acute coronary syndrome (ACS). The patient was started on (intravenous) IV fluids, IV antibiotics, Tamiflu and Tylenol. She improved with treatment and remained stable after admission.

The patient had apparent Influenza. Cardiac Enzymes and EKG were unremarkable. Her syncope was likely vasovagal. The patient's pneumonia (PNA) was mild. She could have been discharged home on oral medications and antibiotics with follow up in outpatient setting after a period in Observation.

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

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

Diagnosis:  Brain Tumor.
Treatment: Xpovio.

The insurer denied Xpovio.  The denial is upheld.

The patient is an adult female with relapsed glioma, progressed on Lomustine.  The attending physician (AP) has now requested Xpovio.

The proposed treatment is not medically necessary.

The drug Xpovio is not currently approved or supported to treat glioblastoma (GBM).  While there have been small phase I/II studies of this agent in glioblastoma, this is not supported by the National Comprehensive Cancer Network (NCCN) to treat glioblastoma (GBM).  It is not in line with accepted standards of practice.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/gastrointestinal/Crohn's Disease
Treatment: Pharmacy/Prescription Drugs/Stelara 90 milligrams every 4 weeks
The health plan denied the requested increase in dosage of the prescription medication, Stelara, to 90 milligrams every 4 weeks, as not medically necessary. 
The health plan's determination is overturned.

This patient is a male. He has a history of severe stricturing Crohn's disease (CD). He previously tried and failed Infliximab and Humira. He was started on Stelara at the standard dose, however, he continued to have active disease.
The requested service is a Stelara dose escalation to 90 mg (milligrams) every 4 weeks.

I overturn, in whole, the health plan's determination of medical necessity.

Yes. Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease. The safety and efficacy of Stelara are well established. However, some patients do not respond adequately to the standard dose. There are many peer reviewed literature reports showing that low Stelara levels were associated with poor clinical response.
Dose escalation is often required in biologics in order to achieve therapeutic levels. The requested dose of 90 mg every 4 weeks is proven to be effective in patients who fail the standard dose.
Per Ollech, Jacob E., et al.: "Shortening the ustekinumab 90 mg dose interval to 4 weeks for patients with CD who did not respond to doses every 8 weeks improved clinical and biological indices of disease activity. Patients who lose response to the standard dose of ustekinumab might benefit from dose interval shortening, which was effective and safe."
Per Cohen, Erica et al.: "A majority of patients with moderate to severe CD benefited from ustekinumab (UST) dose escalation suggesting the clinical utility of optimizing dosing in the treatment course. "
This patient has a history of refractory and severe Crohn's disease which failed anti-tumor necrosis factor alpha (Infliximab and Humira). The patient also failed to respond to Stelara standard dose (90 mg every 8 weeks) and continued to have an active disease. Entyvio has inferior efficacy when it comes to stricturing and fistulizing Crohn's disease.
Therefore, Stelara dose escalation is the most appropriate option for this patient and is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ataxia
Treatment: Personal Care Aide (PCA) 12 hour per day, 7 days a week, 12 hours per day, 7 days a week, for a total of 168 hours
The health plan denied: Personal Care Aide (PCA) 12 hour per day, 7 days a week, 12 hours per day, 7 days a week, for a total of 168 hours
The denial is upheld.

The patient is a female with past medical history of glutamic acid decarboxylase (GAD)65 antibody related cerebellar ataxia, hypothyroidism, dysphagia, hearing loss, severe protein/calorie malnutrition depression, and dementia who had been assigned Personal Care Aide (PCA) services 5 hours/day, 7 days/week, to total 35 hours/week. The patient had a universal assessment performed via video assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, bathing, and dressing lower body. With tasks of stairs, transportation, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of personal hygiene. 

The health plan's determination is upheld.

Although the patient has documented assistance needs with multiple activities of daily living (ADL)/Instrumental activities of daily living (IADL) tasks and has unscheduled and unpredictable care needs, there is no documentation of frequent overnight needs that would not allow a PCA 5 hours of uninterrupted sleep. Furthermore, there is no documentation of medical necessity of turning and repositioning at least every 2 hours. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, split shift, 7 days/week, 12 hours per day, 7 days per week to total 168 hours/week are not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin Disorders/Psoriasis
Treatment: Pharmacy/Prescription Drugs/Triamcinolone 0.2% Spray
The health plan denied the requested prescription medication, Triamcinolone 0.2% Spray, as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with psoriasis. He has used Calcitriol ointment. He was also prescribed Triamcinolone aerosolized solution. The prescriber is a dermatologist.
The medication under review for medical necessity is Triamcinolone 0.2% Spray.

The health plan's determination is upheld, in whole.

The formulary drugs Betamethasone Valerate, Fluticasone, Hydrocortisone Butyrate cream, Hydrocortisone Butyrate ointment, Hydrocortisone Butyrate solution, Hydrocortisone Valerate, Mometasone, Triamcinolone cream, Triamcinolone lotion, Triamcinolone ointment (except Triamcinolone ointment 0.05%) would not be and have not been ineffective. They would be as effective as the non-formulary drug, Triamcinolone 0.2% Spray. They would not have adverse effects.
According to the American Academy of Dermatology Psoriasis Guidelines and current evidence-based dermatology literature, the preferred topical medicines which are covered by the patient's insurance plan, are effective treatments for the management of psoriasis [1-4]. The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents are appropriate agents for the treatment of the patient's psoriasis. There are no comparative, controlled studies showing that Triamcinolone 0.2% Spray has a superior efficacy or safety profile to all of the formulary alternatives. The formulary medications should be tried and failed prior to initiating Triamcinolone 0.2% Spray. It is noted that the patient has tried and failed Calcitriol ointment for his psoriasis. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Triamcinolone 0.2% Spray prior to the formulary alternatives. There is no documentation provided that he has tried and failed, has a contraindication to, or intolerance to the preferred medications, which have been shown to be effective for psoriasis according to the current dermatology literature and psoriasis guidelines.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: eosinophilic esophagitis.
Treatment: Esomeprazole Magnesium 40mg Delayed-Release Powder for Suspension.
The insurer denied Esomeprazole Magnesium 40mg Delayed-Release Powder for Suspension. 
The health plan's determination is upheld.

This patient is male with a history of eosinophilic esophagitis. He has been well controlled on esomeprazole (packets for suspension). Based on the appeal letter, he is unable to swallow tablets or capsules. He did not tolerate the capsules opened into applesauce. His records indicate that he receives Zyrtec, Xyzal and Singulair tablets.

There is no evidence that all of the formulary drugs will be ineffective or would be associated with increased risk of adverse events.
The formulary list includes many suitable treatments for this patient, including dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole.
There is no evidence that esomeprazole packets are superior to all of the listed alternatives. The current literature does not indicate that one proton pump inhibitor is superior to others in treating eosinophilic esophagitis.
The records indicate that the patient takes other medications in pill form (Zyrtec, Xyzal and Singulair tablets). Therefore, the formulary alternatives can be tried in this case.
Furthermore, lansoprazole comes in disintegrating tablets, which has not been tried and failed in this case. Therefore, a formulary exception is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic lung cancer
Treatment: Increase Consumer Directed Personal Assistance Services: Total of 30 Hours Per Week
The insurer denied: Increase Consumer Directed Personal Assistance Services: Total of 30 Hours Per Week
The denial is overturned.

This adult female patient is appealing the denial of an increase of consumer directed personal assistance services for a total of 30 hours per week.  The plan has approved 15 hours per week.  The patient is reported to have unsteady gait, amnesia, poor coordination, pain, and fatigue.  There is a letter from the Provider noting that the patient has metastatic lung cancer and her condition is rapidly deteriorating.  She is confined to the bed and depends on caregiver for activities of daily living.  The patient's daughter has provided a statement that since the assessment in May, the patient is "unable to stand up, sit down, prepare for food, move around the home including going to the bathroom (even with a walker) by herself."  She notes that the patient is also bedridden for most of her day.

The proposed treatment is 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 metastatic lung cancer.  She is appealing denial of an increase in consumer directed personal assistance services (CDPAS) for a total of 30 hours per week.  The plan has approved 15 hours per week. The provider notes that the patient's condition is rapidly deteriorating.  The daughter notes the patient's condition has deteriorated since May and she is mostly bedridden.  She needs assistance with activities of daily living and ambulation with a walker.  The information provided supports that the member needs assistance that is not covered with the approved CDPAS 15 hours per week.  The proposed increase in CDPAS to 30 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Gastrointestinal Bleeding.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

The patient had a history of chronic obstructive pulmonary disease (COPD), a pulmonary embolism and anticoagulation. He presented with rectal bleeding. He was afebrile and the vital signs were stable. The abdominal exam was benign. The hemoglobin was 12.9, which was his baseline. The Xarelto was held. Hemorrhoids and mild diverticulosis were seen. Small polyps were removed. There was no evidence of active bleeding. 

Milliman Care Guideline (MCG) clinical indications for admission for Lower Gastrointestinal Bleeding (MCG M-182) include hemodynamic instability, ongoing active bleeding, failure to control bleeding after a colonoscopy, a coagulopathy that is not reversible, shock index greater than 1, severe anemia, and peritoneal signs. The patient did not have these conditions. 

This patient required a colonoscopy for evaluation of rectal bleeding. He was stable to have this performed as an ambulatory procedure. He was not actively bleeding and the hemoglobin was at his baseline. He could have been treated with observation status. He did not meet MCG criteria for admission for Lower Gastrointestinal Bleeding.

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

The insurer's denial of coverage for an inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type II Diabetes Mellitus.
Treatment: Rybelsus 7 mg (milligrams) tablets
The insurer denied the Rybelsus 7 mg (milligrams) tablets.
The health plan's determination is overturned. 

This is a female diagnosed with T2DM (type II diabetes mellitus). This request is for Rybelsus. The provider states that the patient has been on Rybelsus and metformin. She has hyperlipidemia and hypertension (HTN). She has been on Rybelsus for a year. Prior to Rybelsus, she couldn't get her hemoglobin A1C under control. She also has an aversion to needles and the health plan's current FA (formulary alternatives) are injectable.  

A formulary exception is indicated in this case.
Rybelsus is a GLP1R (glucagon-like peptide-1 receptor) agonist that is Food and Drug Administration (FDA) approved in the treatment of adults with type II diabetes. The patient has been on the requested medication and has benefited from the requested medication. Continuation is consistent with generally accepted standards of medical practice.
The requested medication is an oral tablet. The formulary alternatives in the same class will be ineffective as the patient has an aversion to needles. The patient has a clinical condition for which the listed formulary alternatives will likely be ineffective or less effective for the patient. Also, the patient tried and failed an injectable alternative in the same class - Trulicity. The requested Rybelsus is Food and Drug Administration (FDA) approved for the indication and the dose falls within FDA approved labeling.