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

Diagnosis: altered mental status and repeated falls

Treatment: subacute rehabilitation

The insurer is denied coverage for subacute rehabilitation.

The denial is upheld. 

This male patient has a history of altered mental status and repeated falls

The patient is unfortunately not an appropriate candidate for subacute rehabilitation at a skilled nursing facility (1, 2, 3).  He has progressive neurocognitive and physical impairments that are not specifically amenable to subacute rehabilitation.  His functional and cognitive status has continued to decline; consistent with his underlying diagnosis.  There are no acute medical or complex nursing needs to support physician or skilled nursing services at the inpatient subacute rehabilitation level of care.  Long term care or home custodial care (with visiting physical and occupational therapy) is the more appropriate level of care for this patient.  

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

The carrier's denial of coverage for the subacute rehabilitation is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcoholic Hepatitis and Status post fall

Treatment continued inpatient subacute rehabilitation admission

The insurer denied coverage for continued inpatient subacute rehabilitation admission

The denial is upheld

This is a patient with a past medical history of alcoholic withdrawal seizures.  He was admitted for rehabilitation and nursing from an outside hospital for alcoholic hepatitis and status post fall.  Under review is the medical necessity for continued inpatient subacute rehabilitation admission.      

The patient was initially an appropriate candidate for subacute rehabilitation at an skilled nursing facility care (SNF) (1, 2, 3).  He had physical impairments amenable to subacute rehabilitation.  The physical and occupational therapy evaluation notes were reviewed.  Initially, the patient had only fair standing balance, unable to ascend/descend stairs safely or ambulate more than 25 feet with a rolling walker.  He gradually improved.  

Later, standing balance had increased to good, his ambulation distance increased to 320 feet and he was ascending/descending steps.  Similar level of improvement was documented by the occupational therapist.  During the time period under review, the patient had improved to the supervision/independent level for activities of daily living including dressing, hygiene and toileting.  

Ongoing care could have been safely provided at a lower level.  In addition, there were no acute medical or complicated nursing issues that required ongoing physician or skilled nursing services at the inpatient subacute rehabilitation level of care.  

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, based on the enclosed clinical records, continued inpatient subacute rehabilitation admission was not supported as medically necessary.

The insurer's denial of coverage for continued inpatient subacute rehabilitation admission is upheld. Medical is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left hip end-stage osteoarthritis

Treatment: outpatient procedure 27130 x 1 (hip replacement)

The insurer denied coverage for outpatient procedure 27130 x 1 (hip replacement)

The denial is overturned.

This is the case of an adult male with a medical history of left hip end-stage osteoarthritis with cystic deformation and avascular necrosis, chronic back pain, chronic obstructive pulmonary disease, fistula of intestine, kidney stones and pneumonia. The patient reports having had left hip pain for years, but it has recently become severe. A left total hip arthroplasty is planned.

The medical records demonstrate last consultation reporting the patient has stopped smoking for several weeks. Taking that fact into consideration, his surgical date would likely be greater than the 4 weeks required. 

All practitioners have acknowledged his risk with associated pulmonary problems. The facts are his pulse oxygenation is quite low and he has had a previous bout of pneumonia. Nevertheless, he is functionally disabled and has fulfilled the criteria of no smoking greater than 4 weeks. The surgery would thus be necessary and appropriate at this time.

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

The outpatient procedure 27130 x 1 (hip replacement) is considered medically necessary for this patient.

The insurer's denial of coverage for outpatient procedure 27130 x 1 (hip replacement) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: history of dementia, hypertension, peripheral vascular disease and coronary artery disease
Treatment: Increase PCA Services For A Total Amount Of 168 Hours Per Week (split shift)
The insurer denied the Increase PCA Services For A Total Amount Of 168 Hours Per Week (split shift)
The denial is overturned. 

The patient is a male with a history of dementia, hypertension, peripheral vascular disease and coronary artery disease. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 168 hours/week Personal Care Aide Services to offer increased ADL (activities of daily living) support.

Yes, the requested Increase PCA (personal care aide) Services For A Total Amount Of 168 Hours Per Week (split shift) is medically necessary.
This is a male with a history of dementia, hypertension, peripheral vascular disease and coronary artery disease. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).

Although an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and noted that the currently approved plan of 35 hours/week Personal Care Aide Services is sufficient to meet the patient's current needs; the patient's advocate relates this reduced schedule leaves the patient him home alone, completely unassisted for numerous hours/day. This is problematic as he has had numerous recent hospitalizations including a traumatic fall with head injury resulting in bleeding. Furthermore, the patient requires continued support for eating, extensive assistance for dressing upper and lower body, personal hygiene, bed mobility, toilet transfer and toilet use. Furthermore, he continues to require maximum assistance for dressing his lower body, walking locomotion, bathing, meal preparation and medication management. He is totally dependent for housework.

Hence, provision of 168 hours/week Personal Care Aide Services can reasonably be expected to be beneficial for the patient, and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 168 hours/week Personal Care Aide Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: right frontal glioblastoma multiforme (GBM)

Treatment: Lynparza 150 milligrams (mg)

The insurer is denied coverage for Lynparza 150 milligrams (mg)

The denial is overturned. 

This male patient has a history of right frontal glioblastoma multiforme (GBM)

The patient had a history of GBM. The patient has recurrent glioblastoma refractory to multiple surgical resections, radiation, immunotherapy, chemotherapy, and antiangiogenic treatment. In this case, the patient has a serious and lethal disease and has exhausted various modalities of treatment. There is medical literature to support Lynparza for the treatment of GBM. Therefore, trying a different medication with different mechanism of action is medically necessary for this patient. In conclusion, Lynparza is medically necessary.

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

The carrier's denial of coverage for the Lynparza 150 milligrams (mg)  is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Fall (left shoulder pain). 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male who was evaluated in hospital for left shoulder pain. He was ambulatory. He reported having fallen two weeks prior and injuring his left shoulder. He was found to have limited motion. An x-ray showed minimally displaced tuberosity fracture. A social worker noted "confusion and frequent falls." 

The patient was admitted to Medicine for expedited neurology evaluation and safe discharge planning. He was admitted with the listed diagnosis of vascular dementia, non-displaced shoulder fracture, failure to thrive and hyperkalemia. He was admitted on Observation status with change for the reason of concerns about patient safety at home. 

The patient was isolated for Covid precautions. He was discharged to home with services in place. 

No, the Inpatient admission was not medically necessary. 

According to the medical records, the patient sustained a non-displaced fracture to his left proximal humerus. The injury occurred at least 2 weeks prior. The management of this problem is a sling. The orthopedic consultant recommended follow up in outpatient clinic in weeks. 

The reported cognitive defects were previously evaluated weeks prior. An MRI (magnetic resonance imaging) had been completed. There were no focal deficits to require acute management. An appointment had been provided for Neurology. 

The admission was based upon social issues. The concerns were made by family member and social worker. All of the services that were provided were non-acute. The delays in obtaining placement (secondary to multiple refusals) does not substantiate a medical reason to spend time in hospital. The exposure to Covid and need for isolation also does not support the need for acute hospitalization. 

The facts were that the patient did not have a fever. He had no open wounds. He did not require surgery. His pain level could be managed with oral analgesia. He did not require additional acute imaging. Subspecialty consultations could and were provided without delay. The management of any underlying medical condition could have been completed at a lower level of care. 

There were no extenuating circumstances to substantiate the admission and ongoing length of stay.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 Diabetes.
Treatment: Invokana.
The insurer denied Invokana.
The denial is overturned.

The patient is an adult male with type 2 diabetes. The request for continuation of Invokana is under review. The prior request was denied, as approval requires and failure of the two formulary alternatives, Farxiga and Invokana. The attending physician is appealing this determination. The appeal letter indicates that the patient has tried and failed Jardiance, and that the patient has tried and failed samples of Farxiga. The patient is currently stable on Invokana.

Yes, the health plan should cover the formulary exception for Invokana.

This patient has type 2 diabetes. He is stable on Invokana. He has tried and failed Jardiance. He has tried and failed samples of Farxiga, so he can be expected to fail a prescription of Farxiga as well. Without Invokana, this patient will be at risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the health plan should cover the formulary exception for Invokana.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: memory loss as well as prior deep vein thrombosis (DVT) and saddle embolism.

Treatment: PCA services of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The insurer is denied coverage for the PCA services of 12 hours per day, 7 days per week for a total of 84 hours per week.

The denial is overturned. 

This female patient has a history of Alzheimer's disease, hypertension, osteoarthritis, type 2 diabetes mellitus, deep vein thrombosis and saddle embolism, glaucoma, urinary tract infections, and abnormality of gait and mobility.

This case involves afemale who has been recommended for personal care assistance (PCA). She was seen pertaining to memory loss as well as prior deep vein thrombosis (DVT) and saddle embolism. The documentation indicated symptoms began 2 years prior. Associated symptoms include bladder incontinence with gait disturbance. She has difficulty with activities of daily living (ADLs) as well as dizziness. She also complains of neck stiffness and has mood swings. The patient does need help with ADLs and does live with her son. Upon physical examination she was not oriented to time, place, person, and situation and had a poor insight. The physician indicated laboratory studies were recommended. She has not had any new interval changes since her prior visit. She was wanting some documents to be filled out. The patient does utilize Aricept and had multiple continued complaints. It is noted she does continue to require moderate assistance for most ADLs. She utilizes a wheelchair for transport and walks with a walker in her home with supervision. 
The physician indicated the patient requires 24-hour care for safety. The physical exam revealed she had an unsteady gait. She was confused and had impaired balance. She remained disoriented to time or place. It was recommended they promote brain memory games and continue with additional follow-ups as needed. The submitted documentation indicated she has been allowed to receive 9 hours of PCA services 7 days a week for a total of 63 hours a week. The recommendation was made for services 12 hours a day 7 days a week for total of 84 hours.
This patient with dementia and increasing difficulty with ADLs is declining based on the provided medical records. She would definitely benefit from increased PCA services. She is at high risk for adverse events including falls due to her gait disturbance and lack of insight and therefore, the prior denial should be reversed.

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

The carrier's denial of coverage for the PCA services of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned.  The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II Diabetes Mellitus
Treatment: Formulary exception for Invokamet, Pre-service
The insurer denied the formulary exception for Invokamet, pre-service.
The denial is upheld. 

The patient is a female diagnosed with T2DM (type 2 diabetes mellitus). This request is for Invokamet. As reported, she tried and failed Synjardy 12.5 mg (milligrams)-1000 mg (milligrams).

No, the health plan should not cover the Formulary exception for Invokamet.

Farxiga (Dapagliflozin), Jardiance (Empagliflozin), and Invokana (Canagliflozin) are SGLT-2 (sodium-glucose cotransporter-2) inhibitors used to treat type II diabetes [1, 2]. SGLT-2 inhibitors are good options for treating diabetes, based on the latest American Association of Clinical Endocrinologists recommendations [3-6]. They are at the same level as GLP1 (glucagon-like peptide-1) agonists and DPP4 (Dipeptidyl Peptidase-4) inhibitors on the latest AACE (American Association of Clinical Endocrinologists) recommendations [6].

The requested medication is a combination of metformin and Invokana.

There are no studies showing superiority of the requested medication over the formulary alternative Xigduo. The side effect profile is similar between the requested medication and the formulary alternatives. The patient can try the formulary alternative. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia, hypertension.
Treatment: Repatha (Pre-Service).
The insurer denied the Repatha (Pre-Service).
The denial is overturned.

The patient is a female with hyperlipidemia. The attending physician stated that she was intolerant of rosuvastatin, Zetia and simvastatin, as well as higher dose atorvastatin. The patient has a history of hypertension, smoking, diabetes and elevated calcium score. Low-density lipoprotein (LDL) was 167 and high-density lipoprotein (HDL) was 41. Echocardiogram stress test was mildly positive. With a positive stress test, multiple risk factors for coronary artery disease (CAD) including diabetes and hypertension, and intolerance to three statins, it was recommended that a PCSK9 (Proprotein convertase subtilisin/kexin type 9 serine protease) inhibitor be started.

Yes, the proposed Repatha is medically necessary.
Medical records confirm this patient's intolerance to at least three statins, as well as allergic reaction to Zetia. While she did not have a clinical cardiac event, she is at a very high risk with a positive stress echocardiogram, positive coronary artery calcium score, and multiple comorbidities including diabetes. She has an elevated low-density lipoprotein (LDL) of 167 and low high-density lipoprotein (HDL) level. 

This patient has well documented medical records of the inability to use a statin or Zetia. Her lipid profile of high low-density lipoprotein (LDL) and low high-density lipoprotein (HDL) as an indication for PCSK9 (Proprotein convertase subtilisin/kexin type 9 serine protease) inhibitor use is considered appropriate in the community and most literature.

This patient has well documented medical records of the inability to use a statin or Zetia. Her lipid profile of high low-density lipoprotein (LDL) and low high-density lipoprotein (HDL) and comorbidities defines her as very high risk of having an acute cardiac event. PCSK9 (Proprotein convertase subtilisin/kexin type 9 serine protease) use is considered sound medical judgement in this clinical scenario.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes. 
Treatment: Formulary exception for Kombiglyze XR (saxagliptin-metformin ER). 

The insurer denied the Formulary exception for Kombiglyze XR (saxagliptin-metformin ER). 
The denial is upheld. 

This is a female with type 2 diabetes. The request for Kombiglyze XR (extended release) is under review. The prior request was denied as approval requires trial and failure of Jentadueto and Jentadueto XR (extended release). The attending physician is appealing this determination. The patient has been on Kombiglyze XR (extended release) for several years. She has tried and had adverse effects to Synjardy and Janumet. 

No, the health plan should not cover the formulary exception for Kombiglyze XR (extended release). 

This request is for continuation of Kombiglyze XR (extended release). This patient has been on this medication for five years. The prior request was denied as the patient has not tried and failed Jentadueto and Jentadueto XR (extended release). Jentadueto XR (extended release) and Kombiglyze XR (extended release) are in the same drug class. The patient does not have a documented contraindication to Jentadueto XR (extended release). Both Jentadueto XR (extended release) and Kombiglyze XR (extended release) are expected to be equally safe and effective in this clinical situation. The American Diabetes Association clinical guidelines do not recommend the use of Kombiglyze XR (extended release) over Jentadueto XR (extended release). Therefore, no, the health plan should not cover the formulary exception for Kombiglyze XR (extended release).
Appeal type: Medical necessity
Decision: Upheld

Treatment: comprehensive orthodontic treatment

The insurer is denied coverage for comprehensive orthodontic treatment

The denial is upheld. 

This male with no documented history

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Labio-Lingual Deviation (HLD) index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initiate qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 8 points (1 overjet, 1 overbite, 5 mandibular protrusion, 1 labiolingual spread).

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

The carrier's denial of coverage for the comprehensive orthodontic treatment is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: being small for gestational age (SGA) at birth.
Treatment: Supprelin LA 50 mg.
The insurer is denied coverage for Supprelin LA 50 mg.
The denial is upheld. 

This female patient has a history of being small for gestational age (SGA) at birth

The definition of precocious puberty is children who have the onset of secondary sexual characteristics younger than age 8 in girls and younger than age 9.5 in boys[1-3]. Central precocious puberty (CPP) is diagnosed using a basal luteinizing hormone (LH)  of >0.3 or stimulation testing with a gonadotrophin-releasing hormone (GnRH)  GnRH analog such as luprolide showing a pubertal response defined as an LH >10[4]. CPP is treated with GnRH agonists[5-10] such as lupron[11] and supprelin[12]. The Food and Drug Administration (FDA) indication for GnRH agonists is for use in central precocious puberty (CPP). In addition when used for CPP the FDA recommends discontinuation of GnRH agonists before age 11 for females and before age 12 for males[11]. This is consistent with accepted recommendations for discontinuation of GnRH agonist therapy at a bone age of 12 in girls and 13y in boys[2, 4-7]. 

The patient's onset of secondary sexual characteristics in the form of thelarche is not documented to be before age 8.  Furthermore the LH is not pubertal and the patient does not appear to have had a leuprolide stimulation test.  The request is therefore not consistent with generally accepted standards of medical practice.  

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

The carrier's denial of coverage for the Supprelin LA 50 mg is upheld.  The medical necessity is not substantiated.