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

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a male admitted for diagnosis of sepsis in the setting of bilateral lower extremity ulcerations and purulent drainage. The patient presented with chief complaint of sepsis. Vital signs demonstrated blood pressure 118/61, pulse 75, respiratory rate 18, oxygen (O2) saturation 100%, and temperature 97.1 Fahrenheit (F). Physical exam showed no acute distress or altered mental status. Vascular surgery evaluated the patient in the emergency department and the patient was thought to have bilateral leg ulcerations which were likely infected. There was no evidence of osteomyelitis or subcutaneous gas. The patient was treated with broad-spectrum antibiotics and blood cultures were obtained. Infectious disease consult was requested, and wound care done with wet to dry dressing. The patient then left against medical advice. 

The health plan's determination is upheld.

The patient in this case had infected lower extremity ulcers but did not have tachypnea, altered mental status, systolic blood pressure less than 100, hypoxia, tachycardia, or fever. This would correspond to a qSOFA score of 0 and a NEWS aggregate score of 0. The patient was not felt to have evidence of osteomyelitis and there was no soft tissue gas on imaging.
Although the patient had needs best addressed in the hospital setting the monitoring, diagnostic workup and therapeutic interventions prescribed could have been safely administered at a lower level of care. Therefore, medical necessity of admission has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Lower Back Pain.

Treatment: current procedural terminology (CPT) code 62290 x4 [injection procedure for diskography, each level; lumbar], Healthcare Common Procedure Coding System (HCPS) code S0077 [injection, clindamycin phosphate 300 milligrams (mg)], HCPCS code 9966 [low osmolar contrast material, 200-299 milligrams/milliliter (mg/ml) iodine concentration, per ml], CPT code 72295 x 4 [discography, lumbar, radiological supervision and interpretation]- modifier 59 [Distinct Procedural Service] and CPT code 77003 [fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)]- modifier 59.

The insurer denied coverage for current procedural terminology (CPT) code 62290 x4 [injection procedure for diskography, each level; lumbar], Healthcare Common Procedure Coding System (HCPS) code S0077 [injection, clindamycin phosphate 300 milligrams (mg)], HCPCS code 9966 [low osmolar contrast material, 200-299 milligrams/milliliter (mg/ml) iodine concentration, per ml], CPT code 72295 x 4 [discography, lumbar, radiological supervision and interpretation]- modifier 59 [Distinct Procedural Service] and CPT code 77003 [fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)]- modifier 59.

The denial is upheld.

Based on lack of scientific evidence for the use of lumbar discography in guiding surgical decision making, and the lack of sufficient pain response with provocative injections, the requested service is not likely to be more beneficial than standard imaging and or treatments for this patient.

The carrier's denial of current procedural terminology (CPT) code 62290 x4 [injection procedure for diskography, each level; lumbar], Healthcare Common Procedure Coding System (HCPS) code S0077 [injection, clindamycin phosphate 300 milligrams (mg)], HCPCS code Q9966 [low osmolar contrast material, 200-299 milligrams/milliliter (mg/ml) iodine concentration, per ml], CPT code 72295 x 4 [discography, lumbar, radiological supervision and interpretation]- modifier 59 [Distinct Procedural Service] and CPT code 77003 [fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)]- modifier 59 should be upheld.   It is not more beneficial than any other standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This case involves a female diagnosed with multiple sclerosis and hypertension.

The patient was seen in the emergency department (ED) regarding worsening low back pain and spasms for 6 days. The examination documented tenderness and discomfort in the right lumbar spine. X-rays were without acute fracture or significant spondylolisthesis. The patient was unable to get out of the stretcher on her own and required admission due to poorly controlled intractable low back pain and physical therapy evaluation. Computed tomography (CT) of the lumbar spine showed mild discogenic degenerative changes most notable between the levels of L (lumbar) 3-L5. The patient was treated with physical therapy and there were reports of one bloody bowel movement during the stay secondary to constipation and hemorrhoids. The patient felt better and there was improvement in pain. The patient was then discharged home.

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. The patient is a female with past medical history significant for multiple sclerosis who presented to the ED with worsening low back pain with spasms over the past six days prior to admission. Diagnostic imaging studies demonstrated mild, osteoarthritic changes in the lumbar spine without evidence for spinal stenosis or fracture. Physical therapy was performed. The patient was treated with medical therapy including muscle relaxants with pain medication. Care provided, including medical management and diagnostic imaging, could have been performed in the ED and at an observation level of care. Care provided did not warrant inpatient hospital admission.

The inpatient hospital admission was not medically necessary.

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

Diagnosis: Endocrine/Metabolic/Nutritional/Obesity. 
Treatment: Pharmacy/Prescription Drugs. 

The health plan denied the requested medication, Wegovy as not medically necessary. 
The health plan's determination is overturned. 

This is a male with obesity with a body mass index (BMI) of 32.4 kg/m2 (kilogram force to square meter) being treated with Wegovy samples. 

At issue is the medical necessity of the requested medication, Wegovy. 

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

The Endocrine Society guidelines on obesity management recommend the use of Food and Drug administration approved weight loss medications (over no pharmacological therapy) to ameliorate comorbidities and amplify adherence to behavior changes, which may improve physical functioning and allow for greater physical activity in individuals with a BMI 30 kg/m2 or in individuals with a BMI of 27 kg/m2 and at least one associated comorbid medical condition such as hypertension, dyslipidemia, type 2 diabetes mellitus (T2DM), and obstructive sleep apnea. This patient has a BMI of 32.4 kg/m2. This patient has enrolled in the comprehensive weight management program with his provider. The Endocrine Society guidelines support the use of Wegovy in this clinical situation of a BMI over 30 kg/m2. Without Wegovy, this patient will be at increased risk of the complications of untreated obesity, including type 2 diabetes. Therefore, yes, the proposed Wegovy is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Dupixent. 
The denial is upheld.

The patient is a male with atopic dermatitis. His chest and arms are affected. He has tried and failed triamcinolone and Eucrisa. He has also failed cetirizine.  The subject under review is the medical necessity for Dupixent for this patient.

The health plan's determination is upheld.

The requested health treatment of Dupixent is not medically necessary for this patient.
Based on the evidence-based literature, the Dupixent is not medically necessary. There are no comparative, controlled studies showing that Dupixent has a superior efficacy or safety profile to all of the formulary alternatives.
According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan, such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis. (1, 2)
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults." (3)
It is noted that the patient has tried and failed triamcinolone. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The preferred agents, such as tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. Therefore, Dupixent is not medically necessary for this patient based on the evidence-based literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: psoriasis.
Treatment: Cosentyx
The insurer denied Cosentyx. The health plan's determination is upheld. 

The patient is a male with moderate to severe psoriasis (12% body surface area involvement) of the chin, pretibial regions, and forearms. The patient has tried and failed topical hydrocortisone and halobetasol. As per the paid claims, calcipotriene has also been prescribed. Methotrexate has been avoided because the patient has two alcoholic beverage every two weeks. Methotrexate and Cyclosporine have also been avoided because of hypertension.

Cosentyx is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, Cyclosporine, and/or Phototherapy. Particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, these preferred agents are appropriate for this patient's clinical scenario. Therefore, Cosentyx is not medically necessary.
Modern dermatology literature supports use of the preferred medications as similarly efficacious to the requested Cosentyx, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. The patient's relatively low alcohol intake does not preclude the patient from any first-line therapy, in that up to three or more drinks of alcohol per week are acceptable in patients who use Methotrexate. If the patient has elevated blood pressure or cholesterol, these can be controlled (and should be controlled) with appropriate medical intervention. It is understood that any concerns about blood pressure might make Cyclosporine less desirable to use than Methotrexate (and Cyclosporine is Food and Drug Administration (FDA) -approved and literature-supported for relatively short periods of treatment, ranging from 3-12 months). However, Methotrexate--the mainstay of first-line therapy for skin and joint psoriasis-is not contraindicated for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asteatotic eczema
Treatment: Dupixent
The insurer denied coverage for Dupixent
The denial is upheld 

The patient has a diagnosis of asteatotic eczema. According to the documentation provided, he has failed topical therapy only with steroids (triamcinolone, fluocinonide, and clobetasol). The requested medication is Dupixent for the treatment.  

Based on the provided documentation, the requested medication, Dupixent, is not medically necessary for this patient's condition. There is no medical and scientific literature that strongly support the administration of Dupixent for this patient's condition and disease severity as an accepted standard of practice in the U.S. compared to alternative therapies.  

The requested medication Dupixent is not medically necessary based on the standard of care, and there are no unique clinical circumstances to this particular individual in the documentation provided that would make it medically necessary.  

According to the dermatology literature, the conventional medications such as protopic, elidel, and (for moderate to severe disease) methotrexate are effective treatments for the management of atopic dermatitis (1,2).  Although asteatotic eczema can be treated systemically with agents used for treatment of atopic dermatitis, there is no FDA (food and drug administration) approved indications for treatment of asteatotic eczema with Dupixent. Within the peer-reviewed literature, in 2018, Gerbens writes "MTX (methotrexate) and AZA (azathioprine) seem to be effective and safe as maintenance treatments in moderate to severe AD (atopic dermatitis) up to 5 years" (3).  Shah 2018 writes "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk" (4). There are several published studies that show that methotrexate is effective and safe for moderate-severe atopic dermatitis (5-8).  The conventional medications, such as protopic and elidel topically and/or systemic methotrexate, should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient according to the standard 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 Dupixent to treat atopic dermatitis is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries/Spinal Cord Injury
Treatment: Skilled Nursing Facility/Custodial Care
The health plan denied the requested continued long term custodial care as not medically necessary.
The health plan's determination is upheld.

The patient is a male admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T (thoracic) 9 - L (lumbar) 1 posterior fusion, then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating, but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory, requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition via an oral diet, did not have an active complex comorbidity that needed treatment, and was participating in physical therapy.

At issue is the medical necessity for continued long-term custodial services.

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

No, the requested health service/treatment of continued long-term custodial services is not medically necessary for this patient.

The long-term custodial services would not be medically necessary, based on the clinical documentation reviewed. This patient was admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T9 - L1 posterior fusion then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition was via an oral diet, he did not have an active complex comorbidity that needed treatment, and he was participating in physical therapy. All of the above requirements did not require frequent nursing care > (greater than) 6.5 hours per day, daily physician assessments, or by themselves requiring facility-based treatment. The patient can undergo custodial care at home with physical therapy services as an outpatient. Therefore, the requested health service/treatment of continued long-term custodial services is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Lupron Depot 3.75mg. 
The denial is upheld. 

The patient is a female patient with abnormal uterine bleeding in the setting of fibroids. The patient is reported to have a history of fibroids and endometriosis with multiple comorbidities. She is reported to be a poor surgical candidate. The patient is planned for two years of Lupron with dual energy x-ray absorptiometry (DEXA) scans to monitor bone mineral density. The patient is considering future fertility with in vitro fertilization (IVF). The patient was counseled on multiple options for management and has opted for Lupron for therapy.
At issue is the medical necessity of Lupron Depot 3.75 milligrams (mg).

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

The requested health service/treatment of Lupron Depot 3.75mg is not medically necessary for this patient.
In this case, the patient is stated to have abnormal uterine bleeding. There is no documented history or physical exam and no noted evaluation of the uterine anatomy by ultrasound, exam, or endometrial biopsy for pathologic evaluation of the endometrium. There has been no trial of oral contraceptives, cyclic progesterone, intrauterine device (IUD), or nonsteroidal anti-inflammatory drug (NSAID)s reported in this case. Contraceptive steroids (estrogen and progestin combinations and progestin alone) are widely used for the control of abnormalities of menstruation. These agents often are first-line therapy for control of abnormal bleeding and painful menstruation in women with and without leiomyomas.
In this case, medical management would need to be shown for a three-month trial period with either oral contraceptive pills, cyclic progestin, or the Mirena intrauterine system which could provide direct control of bleeding with local progesterone. Menstrual blood loss is reduced by 40-50 percent (%) in women who used cyclic combined oral contraceptives (OC). Extended cycle and continuous combined OCs as well as many of the progestin-only contraceptive options (progestin-only pills, Depo-Provera (DMPA), progestin contraceptive implants, and levonorgestrel intrauterine system) reduce overall bleeding days and may achieve amenorrhea in women. This patient has no assessment of anemia or imaging by ultrasound or magnetic resonance imaging (MRI) of the pelvis. The time period over which this patient has been followed per the medical records is not sufficient to have established the trial and/or failure of medical therapy. There has been no trial of NSAIDs for three months to attempt to decrease and control bleeding. Based upon a review of the provided medical records, the requested health treatment of Lupron Depo 3.75mg would not be medically necessary for this patient given the lack of assessment of the total cause of the bleeding, imaging and trial and failure of first line therapies for this condition.
Therefore, the requested health service/treatment of Lupron Depot 3.75mg is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Paroxysmal Atrial Fibrillation
Treatment: Formulary exception for Eliquis
The insurer denied the Formulary exception for Eliquis
The denial is overturned.

The patient is a male with extensive cardiac history including ICD (implantable cardioverter defibrillator), RV (right ventricle) dysplasia, CHF (congestive heart failure), hypertension, hyperlipidemia, and paroxysmal atrial fibrillation.

A request was made for Eliquis 5 mg (milligrams), twice a day. The health plan's preferred formulary anticoagulants are Warfarin and Xarelto. The appeal is for the use of Eliquis.

Yes, the health plan should cover the formulary exception for Eliquis.
Recent published studies in respected journals, including New England Journal of Medicine and JAMA (Journal of the American Medical Association) have concluded that Eliquis is the preferred anticoagulant for this condition. Large population studies have shown that Eliquis is safer and causes less bleeding, fewer strokes, and fewer complications than either Xarelto or warfarin.

Eliquis was found to be more effective than warfarin in lowering the risk of stroke and systemic embolism. People who took Eliquis also had significantly fewer bleeding episodes than those who took warfarin.

Eliquis is the only NOAC (non-vitamin K oral anticoagulant) that is better than warfarin in the prevention of stroke and results in fewer bleeding complications. Overall, all-cause mortality from DOACs (directly acting oral anticoagulants) is evidenced to be lower than that from warfarin, driven primarily by a decrease in fatal intracranial bleeding risks.

Among Medicare beneficiaries with atrial fibrillation, treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events.

Therefore, given the above, the health plan should cover the formulary exception for Eliquis.