Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Rheumatoid Arthritis (RA). 
Treatment: Olumiant. 

The insurer denied coverage for Olumiant. 

The denial is overturned. 

This patient has a history of diabetes mellitus type 2, dyslipidemia, obesity and seropositive rheumatoid arthritis. Per the office visit note from Rheumatology specialist, the patient has failed methotrexate, Enbrel, Remicade, Rituximab, Actemra, Xeljanz, Humira and Rinvoq. Orencia was noted to help for a short time. The patient would prefer to remain on oral agent. This is a request for Olumiant for a patient with rheumatoid arthritis (RA) who has tried and failed multiple agents as noted above and below. 

Different patients respond differently to different medications therefore it cannot be certain the formulary drug would cause the patient an adverse reaction. 

Per letter details from Rheumatology specialist, the patient has failed most agents including Plaquenil, methotrexate, Enbrel, Remicade, Rituximab, Orencia, Actemra, Xeljanz, Humira and Rinvoq. Side effects noted with Orencia, Actemra and Rituxan. 

They have tried alternatives of Actemra, Xeljanz and Rinvoq. As the patient has failed medication in the same class as Kevzara it cannot be certain Kevzara would be more effective than Olumiant. The requested medication, Olumiant is indicated in RA patients who failed other therapies. Given the patient's failed therapies Olumiant is likely to be more beneficial than the formulary alternative. 

Jorgensen, S.C., Tse, C.L., Burry, L. and Dresser, L.D. , "Baricitinib...is a small molecule reversible Janus-associated kinase (JAK)-inhibitor approved in over 65 countries for the treatment of adults with moderate to severe rheumatoid arthritis (RA)." 

Mogul A, Corsi K, McAuliffe L., "Baricitinib is the second medication in its class and has been proven efficacious for the treatment of RA. Given concerns for adverse effects associated with baricitinib, it should be reserved for patients who have failed one or more TNFis [tumor necrosis factor inhibitors]."                     

The insurer's denial of coverage for Formulary Exception for Olumiant is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type II Diabetes. 
Treatment: Ozempic, 1 milligram pen, quantity of three per 28 days. 

The insurer denied the Ozempic, 1 milligram pen, quantity of three per 28 days. 
The denial is upheld. 

This patient is a female diagnosed with type II diabetes mellitus (T2DM). This request is for Ozempic. As reported, the patient has tried and failed Metformin, Victoza and Farxiga which were discontinued by her due to ineffective treatment and adverse reaction (i.e., nausea and vomiting). 

No, the proposed treatment with Ozempic is not medically necessary. 

Ozempic is a glucagon like peptide one receptor (GLP1R) agonist [1] that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes [2-4]. There are no studies showing superiority of the requested medication over the formulary alternative, Trulicity. The patient can try the formulary alternative. The request is therefore not medically necessary. 

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient as the request is not medically necessary as described above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine fibroids. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay.  The health plan's determination is overturned. 

The patient is a female with a planned laparoscopic myomectomy for abnormal uterine bleeding that was converted to an abdominal myomectomy. She was admitted as an inpatient after her abdominal myomectomy. She developed postoperative bleeding, and her hemoglobin dropped from 10 to 7. Physical tamponade was obtained, and she was transfused 2 units of red blood cells. She also had intravenous (IV) Ferritin and Tranexamic Acid. She was discharged with a hemoglobin of 9.6 and meeting postoperative milestones. 

The requested Inpatient Hospital Admission is medically necessary for this patient. 

The patient had an open (abdominal) myomectomy with a large incision into the peritoneum. She had an extensive myomectomy (41 total fibroids removed) with her laparotomy incision. After a laparotomy, it is reasonable and standard of care to require 2 days postoperatively in the hospital. The patient also had a complication of hemorrhage requiring medical and physical intervention with tamponade and medication including blood transfusion. It is also reasonable to monitor the patient for fluid balance and pain control after the procedure. Therefore, her inpatient hospital admission is medically necessary and standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease; Blindness. 
Treatment: Increase Consumer Direct Personal Care Assistance Services 24 Hours Per Day 7 Days Per Week, A Total of 168 Hours Per Week, Split Shift. 

The insurer denied the Increase Consumer Direct Personal Care Assistance Services 24 Hours Per Day 7 Days Per Week, A Total of 168 Hours Per Week, Split Shift. 
The denial is overturned. 

The patient is a female with PMH (past medical history) of DM (diabetes mellitus), neuropathy, poor balance and gait. She reportedly is blind, has end stage renal disease and is on long term hemodialysis. She needs extended hours of services. The patient needs more help with ADLs (activities of daily living) and help at night time. 

Yes, the Increase Consumer Direct Personal Care Assistance Services 24 Hours Per Day 7 Days Per Week, A Total of 168 Hours Per Week, Split Shift, is medically necessary. 
The patient has end stage renal disease and is on dialysis. She is blind and needs extended aid and services at home. She is blind and cannot perform her ADLs (activities of daily living). The patient is a fall risk due to blindness. She will benefit from 24/7 home health care support. She needs help at night time with going to the restroom. 

Patient currently receives a total of 84 hours per week. She will need 24 Hours Per Day 7 Days Per Week, A Total of 168 Hours Per Week. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The patient needs extended hours because of her blindness. She is on dialysis 3 times a week, and will need more help at night time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient Stay. The denial is upheld. 

The patient is a male with a past medical history of cerebrovascular accident (CVA), hypertension, intracerebral hemorrhage (ICH), chronic kidney disease and hyperlipidemia. He presented to the emergency department with an episode of loss of consciousness which was preceded by a shaking episode. On arrival, he was afebrile and hypertensive. His initial physical examination was unrevealing. 

His initial laboratory work up was revealing for a serum creatinine of 2.85. His 12-lead electrocardiogram (EKG) demonstrated normal sinus rhythm with early repolarization changes. A head computed tomography (CT) scan was obtained which showed non-specific white matter hypo densities and resolving hemorrhage in the right parietal lobe. In the emergency department (ED), he was given intravenous (IV) Keppra, and he was admitted to the inpatient unit for evaluation of syncope. He was evaluated by the neurology team and a brain magnetic resonance imaging (MRI) was obtained which was unremarkable. Additionally, he had an electroencephalogram (EEG) which showed "bilateral slowing seen suggestive of a mild encephalopathy of metabolic, degenerative or vascular origin, right worse than left. Localized right parietal sharp wave activity was noted." The neurology team recommended switching him from Keppra to Depakote which was initially at 500 milligrams (mg) twice daily but was switched to 500 mg three times a day due to low levels. Additionally, for better control of his blood pressure, labetalol was switched to hydrochlorothiazide. The patient did not have any further seizure like episodes during this hospitalization and was ultimately discharged.
At issue is the medical necessity of Inpatient Stay. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient. 

The patient presented with an episode of syncope which was preceded by a shaking episode. On arrival to the ED, he was hemodynamically stable and head imaging did not demonstrate evidence of an acute cerebrovascular accident (CVA). On exam, there was no evidence of neurologic deficits. His 12-lead EKG did not demonstrate any high-risk features and there were no immediate concerns for an arrhythmogenic cause of syncope, conduction disease (i.e., atrioventricular (AV) block), hypotension, respiratory distress, or pulmonary embolism. Furthermore, there was no evidence of acute coronary syndrome or severe electrolyte abnormalities. His syncopal episode was not unexplained, and it appeared to have been due to a seizure episode. Consequently, admission to inpatient level of care was not medically necessary. 

Therefore, the Inpatient Stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Nodules. 
Treatment: Inpatient Emergency Admission. 

The insurer denied coverage for inpatient emergency admission. 

The denial is upheld. 

The patient is a female with history of anxiety, depression, bulimia, and dyspnea on exertion. She was status post computed tomography (CT) guided biopsy for lung nodules on CT. She had been treated with oral antibiotics for possible respiratory tract infection (RTI). The patient was admitted as a direct admission for open lung biopsy as prior CT guided biopsy did not reveal any specific etiology to explain her symptoms. It was negative for malignancy. 

At presentation, the patient was afebrile with temperature 98.8 Fahrenheit, heart rate 99, respiratory rate 24, and blood pressure 126/88. She was in no acute distress. Oxygen saturations were normal. There were occasional rales on lung exam. The rest of the pulmonary exam was unremarkable. White blood cell count was 11.3 and electrolytes were within normal limits. CT chest revealed pulmonary nodules and small pleural effusion. 

The patient underwent video-assisted thoracoscopic surgery (VATS) lung biopsy. The procedure was complicated by a pneumothorax which required chest tube drainage. Lung re-expanded post procedure. The patient remained stable post procedure and was discharged with outpatient follow up. 

This patient did not require inpatient admission for the elective VATS procedure. It could have been done in an ambulatory surgery setting. 

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 emergency admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachycardia. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case involves a male with a past medical history of hypertension, coronary artery disease status post coronary artery stent, and hypothyroidism who was sent to the emergency department (ED) from outpatient endoscopy for evaluation of tachycardia, abnormal rhythm, and chest pain. In the ED, the patient was found to be in new onset atrial fibrillation with rapid ventricular response. The patient was treated appropriately with a beta-blocker, diltiazem, was started on subcutaneous Lovenox for prevention of stroke. The patient was admitted under inpatient level care for further evaluation and treatment of new onset atrial fibrillation and chest pain. 

The inpatient level of care was not medically necessary in this case. The patient presented with new onset atrial fibrillation but his heart rate was adequately controlled with oral medical therapy. There was no evidence of acute coronary syndrome (ACS) or decompensated heart failure. The patient remained asymptomatic during overnight monitoring and was discharged home in stable condition the following day. Given the patient's hemodynamic stability, lack of symptoms, and adequate rate control on oral medical therapy, the inpatient level of care was not medically unnecessary in this case. This approach is supported by peer-reviewed, evidence-based, medical literature on the management of new onset atrial fibrillation in patients presented to the ED.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Achilles Rupture

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned.

Urinary retention is common after surgery and is a significant cause of potentially avoidable postoperative morbidity. Age, benign prostatic hyperplasia, and lower urinary tract symptoms are patient factors that can predispose to urinary retention. Operative time, administration of intravenous fluids, type of anesthesia, and type of procedure are other factors that may contribute to the development of urinary retention. [1] Neuraxial anesthesia causes transient detrusor dysfunction that can lead to mild incomplete bladder emptying or severe urinary retention with bladder overdistension. Urinary retention can increase morbidity and increase hospital length of stay. [2]

Per clinical documentation, the patient underwent repair of a left Achilles tendon rupture with neuraxial anesthesia. The patient developed postoperative urinary retention. Alpha-blockers were prescribed. The patient was noted to have a post-residual volume of 900 cc (cubic centimeters) and required intermittent catheterization. The patient began to start voiding spontaneously and was subsequently discharged home. Per MCG (Milliman Care Guidelines), Ambulatory Surgery Discharge and Complications, surgery performed on an ambulatory basis may require inpatient stay for postoperative effects not resolved or adequately managed. [3] The patient had a side effect of neuraxial anesthesia that was properly managed postoperatively, and the patient was discharged on when the urinary retention resolved. Per provided clinical documentation, peer-reviewed literature and MCG criteria, the requested inpatient admission was medically necessary. 

The insurer's denial of coverage for a full hospital admission is overturned. Medical Necessity is medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal Problems. 
Treatment: Home Health Care. 

The insurer denied Social Day Care Service 3 days a week. 
The insurers determination is overturned. 

The patient is a female with past medical history of osteoarthritis, hypertension, hypothyroidism, dementia, osteoporosis, urinary incontinence, anxiety, and depression who had been assigned Social Day Care Service 2 days/week and Consumer Directed Personal Assistance Services (CDPAS) services 4 hours/day, 7 days/week. There was a request to increase Social Day Care to 3 days/week, and the patient underwent an assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, and bathing. With tasks of dressing lower body and transfer toilet the patient was assessed at limited assistance while supervision with tasks of managing medication, walking, and locomotion. The patient was assessed at set up only with task of managing finances and independent with tasks of phone use, personal hygiene, dressing upper body, toilet use, bed mobility, and eating. Notes from the assessment stated the patient lived alone. 

The subject under review is the medical necessity for Social Day Care Services 3 days per week. 

The health plan's determination is overturned. 

The requested Social Day Care Services (3 days per week) is medically necessary for this patient. The patient has services through Managed Long-Term Care (MLTC). The patient's primary care provider documented medical necessity for an additional day of Social Day Care based on the patient's diagnosis of mild dementia and severe depression. Social Day Care would not be the primary form of service offered to the member as she receives CDPAS services on a daily basis. There has been a change in clinical status based on the primary care physician (PCP) letter documenting worsening cognitive function and worsening depression. Taking into account all the information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Social Day Care is medically necessary for this patient 3 days/week. In summary, Social Day Care services are medically necessary for this patient with stated medical conditions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cystic fibrosis (CF)

Treatment: Kalydeco 150 milligrams (mg) OR (oral) tabs to treat CF (cystic fibrosis)

The insurer denied coverage for Kalydeco 150 milligrams (mg) OR tabs to treat CF

The denial is overturned.

This female patient with a history of cystic fibrosis (CF) presented to the Pediatric Pulmonologist's office for the evaluation of CF. The patient has been coughing for 2 weeks. She has taken Cipro for 10 days with some improvement. The patient has an increased cough with sputum production. She takes albuterol, Pulmozyme, Cayston, and Tobi. The physician recommended continuing Ciprofloxacin and starting 100 milligrams (mg) of oral Minocycline twice a day (BID) to cover for Stenotrophomonas maltophilia. Chest physical therapy (PT) would continue. The patient would continue pancreatic enzymes and vitamin supplements. The treating practitioner recommended Kalydeco 150 mg OR tabs to treat CF.

The patient experienced multiple CF exacerbation and patient has decreased Forced expiratory volume (FEV) /Forced vital capacity (FVC).  The potentiators can treat the exacerbation and halt the irreversible damage.  Patient also has hemoptysis and if untreated patient can progress to irreversible lung parenchymal and restrictive lung disease.  Ivacaftor (KALYDECO [TM], VX-770 [gene-base therapy]) is a cystic fibrosis transmembrane conductance regulator (CFTR) potentiator that increased CFTR channel activity and improved lung function in young patients with CF who have the G551D-CFTR (cystic fibrosis transmembrane conductance regulator) gating mutation. But many animal and clinical studies showed that ivacaftor is a broad acting CFTR potentiator and could be used to help stratify patients with CF who have different CFTR genotypes including the w12826 (type of genotypes) mutation. Hence given the immense medical benefit, Ivacaftor is medically necessary. 

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

The insurer's denial of coverage for Kalydeco 150 milligrams (mg) OR tabs to treat cystic fibrosis (CF) is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Uterine Fibroids

Treatment: removal of uterine fibroid tumors

The insurer denied coverage for removal of uterine fibroid tumors

The denial is overturned

According to the clinical documentation provided for review, the patient presented to the Obstetrician/Gynecologist's office for a surgical consultation regarding fibroids. The patient has three uterine fibroids. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

The requested treatment, surgery (laparoscopic ablation with imaging guidance or Acessa procedure) for the treatment of growths in uterus (uterine fibroids), is medically necessary, based on recent and relevant peer literature. This patient has a history of uterine fibroids (uterine leiomyomata).  The Acessa procedure is supported by current medical literature and the American College of Obstetricians and Gynecologists. Therefore, the requested treatment, surgery (laparoscopic ablation with imaging guidance or Acessa procedure) for the treatment of growths in uterus (uterine fibroids). 
Removal of uterine fibroid tumors has final approval from the appropriate regulatory bodies for this diagnosis.  The desired procedure, radiofrequency ablation, does not remove the uterine fibroids.  This patient is a good candidate for removal of uterine fibroid tumors.

The requested service is likely to be more beneficial than any of the standard treatments and/or procedures for this patient.

A systematic review by Taheri, et al., compared studies looking at uterine volume after uterine artery embolization (UAE), focused ultrasound (FUS) and more recently, radiofrequency ablation (RFA) of fibroids. They found "The pooled fibroid volume reductions at six months seen with RFA were 70% (percent), UAE 54% and FUS 32%. All three types of nonresective treatment result in fibroid volume reduction. However, fibroid volume reduction is most marked with RFA, with UAE resulting in the next most volume reduction."                                                    

The carrier's denial of removal of uterine fibroid tumors should be overturned
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Uterine Fibroids

Treatment: removal of uterine fibroid tumors

The insurer denied coverage for removal of uterine fibroid tumors

The denial is upheld

The patient has a chief complaint of dyspareunia. Evaluation revealed 3 uterine fibroids, the largest being 7 cm (centimeters). The physician discussed options including uterine artery embolization, myomectomy, hysterectomy, and leiomyoma ablation. The patient would like to move forward with the Acessa procedure. Laparoscopic radiofrequency ablation (Lap-RFA), known as the Acessa procedure is used to treat women with symptomatic myomas not interested in future fertility. It was approved by the US (United States) Food and Drug Administration.

Based on a randomized, prospective study, compared to myomectomy, Lap-RFA is associated with significantly lesser intraoperative blood loss, shorter procedure and hospitalization times, lesser consumption/use of disposable and reusable surgery equipment, reduced health care resource utilization, and faster return to work through 3 months post treatment. A meta-analysis of 8 studies showed that all subscales of quality of life improved significantly, and most of the changes remained stable in long-term follow-up. The overall reintervention rate was 4.39% (percent) and the median uterine volume reduction was 69.17 cm3. The overall procedure-related adverse events rate was 1.78% and patients missed an average of 4.35 days of work. 

In conclusion, laparoscopic radiofrequency ablation therapy is an efficacious way to treat small-sized and nonpedunculated symptomatic uterine fibroids, providing stable long-term symptom relief and quality of life improvement with a low risk of adverse events and reintervention and just a few days of missed work. However, this patient has a large fibroid. The standard of care for such patients is to do a myomectomy. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. Removal of uterine fibroid tumors have final approval from the appropriate regulatory bodies for this diagnosis. Removal of uterine fibroid tumor using Acessa procedure is not the best available treatment for this patient at this time. More established and safe procedures like a myomectomy are available.  The adverse risks may be increased over standard treatment/services. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient, specifically a myomectomy.

The carrier's denial of removal of uterine fibroid tumors should be upheld.