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

Diagnosis: Trauma/injuries - assault victim
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

This patient is a woman who presented as a trauma patient following a reported assault. The patient reported that she was assaulted by three people and run over with a car. This occurred on the day prior to presentation to the hospital. The patient reported unbearable pain and she was also concerned that she was having a miscarriage as she noted vaginal bleeding. At the time of presentation, the patient walked into the emergency department (ED) and was awake and alert with a Glasgow coma score of 15/15.

The inpatient hospital admission was not medically necessary. 
The patient presented to the ED the day following a reported assault by multiple assailants that included being run over by a car. Her trauma assessment identified essentially normal vital signs, normal Glasgow coma score, no abrasions or lacerations, normal lab and imaging data and no acute injuries that required trauma service admission. Her reported mechanism of injury was inconsistent with her exam findings per the trauma service. The patient was evaluated by the psychiatry service and was without need for acute psychiatric admission.

Inpatient care was not needed in this case as the care provided could have been rendered with a lower level of care with subsequent outpatient mental health follow up as recommended by the psychiatry service. This lower level of care would have provided for ED assessment, trauma and medical evaluations, imaging as prescribed, monitoring, mental health evaluation, and provision of pain medications during this period of time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment: Dupixent 300 mg (milligrams) every week
The insurer denied Dupixent 300 mg every week.
The denial is overturned.

The patient is an approximately adolescent female with atopic dermatitis (AD), treated with numerous topical steroids, topical calcinuerin inhibitors, eucrisa, prednisone, cyclosporine, multiple antibiotics, anti-histamines, and Opzelura. She has responded favorably to weekly dosing of Dupixent. Her provider requests continuation of this weekly dose, which was denied coverage by the health plan, as it exceeds the FDA (United States Food and Drug Administration)-recommended dosing.

The study performed by Gao, et al published in 2021 sought to characterize the real-world experience for recurrence of AD prior to the next dose of dupilumab and how patients on weekly dosed dupilumab did in the cohort, all of whom were inadequately controlled on the approved dosing.

17 patients were found to have tried weekly dosing. It was observed that 12/17 patients (71% [percent]) reported recurrence prior to their next dupilumab dose, and all of them (100%) claimed that increasing EOW (every-other-week) dosing of dupilumab to EW (every-week) dosing helped control their symptoms, this benefit was worth the effort of injecting oneself twice as often, and they planned to remain on weekly dosing.

The study by Worm, et al also examined dosing regimens for Dupixent. In this trial, continued response over time was most consistently maintained with dupilumab administered weekly or every two weeks. Longer dosing intervals reduced efficacy. This further supports that some patients may need weekly dosing.

While limited, there is support in current peer-reviewed medical literature that biologic drugs often need dose adjustment in psoriasis, AD, and other conditions. Therefore, given the failure of this patient on every-other-week dosing, and given the support in the current literature, the request is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Asthma.
Treatment:  Alvesco.

The health plan denied Alvesco.  The health plan's determination is overturned.

The patient is an adult female with asthma. She was prescribed Alvesco. The patient has tried and failed inhaled corticosteroids (arnuity, flovent, pulmicort), due to oral thrush. The patient has been on Alvesco with good clinical outcomes and has not developed oral thrush. The Alvesco was denied coverage by the health plan based on formulary requirements. This denial is being appealed.

The formulary drug would be ineffective for this patient, since it has given the patient oral thrush as side effects and has not been tolerated. The formulary drug would not be as effective as the requested non-formulary drug due to side effects. The formulary drugs have adverse effects for this patient. The formulary alternative(s) are Qvar Redihaler, Arnuity Ellipta, Asmanex Twisthaler, Asmanex HFA (hydrofluoroalkane-134a), which all have inhaled corticosteroids with similar side effects of oral thrush. The patient has tried and failed arnuity, flovent, pulmicort. The Alveso has been well tolerated without any side effects. Continuation is appropriate to maintain proper asthma control and maintain good quality of life as well as reduce doctor's visits.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower Urinary Tract Symptoms (LUTS) due to benign prostatic hypertrophy (BPH). 
Treatment: Prostate Artery Embolization. 
 
The determination is the Prostate Artery Embolization is medically necessary. 

The patient is an adult male with lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH). The request is for prostate artery embolization (PAE). 

Prostate artery embolization is a procedure and does not need FDA (United States Food and Drug Administration) approval. The embolic particles used during the procedure, Embosphere and Embozene, were FDA (United States Food and Drug Administration) approved in 2017 and 2018 respectively. 

This patient has lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH). One of the standards of care treatment options is prostate artery embolization (PAE) which has been proven to be efficacious in the peer-reviewed medical literature and is medically necessary. 

The request is not unproven, as it does not need FDA (United States Food and Drug Administration) approval as it is a procedure; there is sufficient evidence published in peer-reviewed scientific literature to assess the effectiveness of the treatment; there is measurable improvement (progress toward a normal or functional state of health) in health outcome and the therapeutic benefit outweighs the risk, as shown in scientific studies; the treatment provided is as safe and effective as any established modality; and the treatment demonstrates effectiveness when applied outside of the investigative research setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath and near syncope
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This adult male with shortness of breath and near syncope was hospitalized. The patient presented to the emergency department by ambulance for evaluation of cough, sneezing and rhinorrhea for two days. A rapid COVID-19 (Coronavirus 2019) test was negative. The patient's past medical history is significant for permanent pacemaker insertion 6 years ago for symptomatic bradycardia, hypertension, hyperlipidemia and aortic stenosis. The patient's vital signs were stable. A Grade 3/6 systolic ejection murmur radiating to the carotids was noted. The Troponin panel was negative. Echocardiogram showed an ejection fraction (EF) of 61-65% (percent) and severe aortic stenosis. A pacemaker interrogation revealed normal function. The request for coverage for inpatient hospitalization has been denied by the policy and the patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the current peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. The provided Milliman Care Guidelines (MCG) criteria for inpatient stay are not met, including suspicion of imminently dangerous cause, like pericardial tamponade, pulmonary embolism, syncope causing injury requiring hospitalization, inpatient admission required rather than a lower level of care because of a significant finding or clinical condition judged too severe or too persistent to be within the scope of a lower level of care, such as hemodynamic instability that is severe or persistent, cardiac arrhythmias of immediate 
concern, acute coronary syndrome or myocardial infarction, stroke, structural cardiac disorder like severe aortic stenosis or suspected a cause that requires immediate correction, respiratory distress, stroke, seizures, altered mental status, severe electrolyte abnormalities requiring inpatient care or other significant finding, or clinical condition judged not to be within scope of a lower level of care. 

In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospitalization. The care the patient received, including management of worsening aortic stenosis which can be treated with transcatheter aortic valve replacement (TAVR) on an elective outpatient basis like in his case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tardive Dyskinesia 
Treatment: Ingrezza 40 milligrams (mg) OR (oral) caps (capsules)
The insurer denied coverage for Ingrezza 40 milligrams (mg) OR caps
The denial is overturned

This adult patient has motor movements of the tongue and lips which are reported to be due to tardive dyskinesia. The patient was taking Ingrezza (Valbenazine) 40 milligrams (mg) per day for 2-3 years and it was effective.
  
The insurer denied the request for Ingrezza (Valbenazine) 40mg per day to treat this patient's tardive dyskinesia stating that there was no indication that the patient had taken or had a poor response to the medication on the preferred formulary list, which was tetrabenazine.
  
This reviewer disagrees with the decision to deny coverage for Ingrezza (Valbenazine) 40 mg per day to treat this patient's tardive dyskinesia as Ingrezza (Valbenazine) is a Food and Drug Administration (FDA) approved medication for treatment of tardive dyskinesia. According to the Journal of Clinical Psychiatry, FDA Approved Medication to Treat Tardive Dyskinesia, it states that there are only two FDA approved medications to treat tardive dyskinesia and they are Ingrezza (Valbenazine) and Austedo (Deutetrabenazine). Ingrezza was FDA approved in 2017. Both Ingrezza (Valbenazine) and Austedo (Deutetrabenazine) are vesicular monoamine transporter 2 inhibitors (VMAT2) that act by decreasing abnormal dopamine functioning. It was also reported that other medications have been used off label to treat tardive dyskinesia including tetrabenazine which was the recommended formulary medication, amantadine, clonazepam, ginkgo biloba, lithium, and botulism toxin. Not only is the requested medication, Ingrezza, FDA approved for the treatment of tardive dyskinesia, but it also was effective, as the patient had been taking it for 2-3 years. This medication is considered a medically necessary treatment for this patient. The formulary medication was not one of the two approved FDA medications to treat tardive dyskinesia. Tetrabenazine is FDA approved for the treatment of Huntington's disease related chorea movements and not tardive dyskinesia. As a result, the recommendation is to overturn the previous decision and approve coverage for Ingrezza (Valbenazine) 40mg per day to treat this patient's tardive dyskinesia.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Ingrezza 40 milligrams OR caps is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eosinophilic granulomatosis with polyangiitis (EGPA). 
Treatment: Nucala. 

The insurer denied Nucala. 
The determination is overturned. 

This is a female patient with eosinophilic granulomatosis with polyangiitis (EGPA) characterized by lung involvement, vasculitis, nasal polyps, recurrent asthma and sinusitis, mononeuritis multiplex and negative antineutrophil cytoplasmic antibodies (ANCA). Eosinophilia was reported at 10 percent (%) with an absolute eosinophilia count of 700. The patient has frequent exacerbations requiring prednisone use as well as Advair and Montelukast. She was on Xolair but stopped after a pulmonary embolism (PE). Nucala 300 milligrams (mg) every 4 weeks was being denied by the health plan. The reason for the denial was that the patient does not have an eosinophil level of at least 10% of an absolute eosinophil count of more than 1000 cells per microliter and the patient does not have the inability to self inject. However, per the provider's notes the patient's eosinophils were 10%. At issue is the medical necessity of Nucala. 

Yes, the requested health service/treatment of Nucala is medically necessary for this patient. 

There is no reason in office injections are required and that the patient cannot self inject at home, however, there is documentation that the patient's eosinophil count was 10%.  As per UpToDate, 'for adults with nonsevere eosinophilic granulomatosis with polyangiitis (EGPA), we suggest adding mepolizumab to systemic glucocorticoids rather than cyclophosphamide, rituximab, or methotrexate in agreement with the American College of Rheumatology (ACR) /Vasculitis Foundation (VF) guidelines'. Therefore, the Nucala is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple joints pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient is an adult with a history of Graves hyperthyroidism and maxillary sinus mass, who presented to the Emergency Room (ER) with multiple joints pain, with difficulty opening hands and difficulty with ambulation. Labs showed increased liver enzymes and first degree atrioventricular (AV) block on the electrocardiogram (EKG). She also had low thyroid stimulating hormone (TSH) and high C-reactive protein (CRP). The patient was given oral steroids, propranolol and after improvement, she was discharged home. The request is for inpatient level of care. 

The care and testing the patient received could have been done at a lower level such as observation. Additionally, the patient was given oral medications for her pain, and did not require intravenous pain medications. 

Per Akhondi H, Gupta N. (2023), "Clinicians frequently encounter patients with a complaint of "all my joints hurt." In reality, many of these patients have either transient self-limiting or non-significant problems. The art of history taking, and physical examination should narrow the broad differential diagnosis of polyarticular arthritis to a manageable few, and then confirmatory tests should prove or rule out the exact etiology. This activity reviews the etiology, presentation, evaluation, and management of polyarticular arthritis and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition. Rheumatoid arthritis is usually polyarticular and in hands/wrists (small joints) in a symmetric distribution. It starts slow and lasts weeks to months before we make the diagnosis. Seronegative spondyloarthropathies are usually pauciarticular with axial involvement and large joint inflammation. Osteoarthritis is in weight-bearing joints, is mostly asymmetric, and is worse with movement and better with rest. Inflammatory arthritis is symmetric with severe inflammatory patterns and in non-weight-bearing joints. Morning stiffness of over than an hour is pathognomonic of inflammatory arthritis such as seronegative spondyloarthropathies. Rheumatologists use NSAIDs as a palliative measure for advanced disease and significant damage before they consider surgical approaches. Many new biologic agents are in the market and used in oral or injectable forms for a variety of approved indications." 

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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypercholesterolemia 

Treatment: Lab testing Apolipoprotein B

The insurer denied coverage for Lab testing Apolipoprotein B

The denial is overturned
 

Asked to review the case of an adult patient with a family history of premature atherosclerotic cardiovascular disease (ASCVD) and has no past history of Diabetes Mellitus.   Initial evaluation for hypercholesterolemia took place in 2016 when he was found to have hypercholesterolemia with a low-density lipoproteins (LDL C) cholesterol of 170 and an elevated Lipoprotein (a) level of 300.  Following treatment with pravastatin and Zetia, LDL C and lipoprotein (a) levels were significantly reduced.   His physician ordered testing of Apolipoprotein B in order to ascertain risk of future atherosclerotic cardiovascular disease. 

The scientific evidence in peer reviewed literature supports a result of improvement in health outcomes. Apolipoprotein B (Apo B) has been shown to have atherogenic potential. (Reference1) The American Heart Association (AHA) cholesterol clinical practice guidelines consider elevation of Apo B a risk enhancing factor.(Reference 2). The US National Lipid Association and the European Society of Cardiology guidelines recommend testing for Lp(a) and Apo B in patients with premature coronary artery disease and or a strong family history of ASCVD. (Reference 3,4). Multiple clinical trials have reported an elevated level of major adverse cardiac events in patients with good reduction in LDL cholesterol and elevated Apo B (Reference 5,6). Several studies have demonstrated that Apolipoprotein B is a better predictor of coronary artery disease risk that LDL-C or Triglycerides. One large prospective cohort study that included more than 600,000 individuals with hypercholesterolemia determined that the risk of myocardial infarction was best predicted by Apo B containing lipoproteins. This finding was independent of total cholesterol, triglyceride or LDL-C levels. (Reference 7). In conclusion, testing of apoprotein B is medically necessary for this patient and will help to determine patient future risk of ASCVD and guide lipid lowering therapy.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for laboratory service(s) received from NM Lab on 10/13/22 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abscess

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

This patient was a young toddler who presented to the Emergency Department with a history of left buttock pain and a small erythematous pimple for 4 days. He had been prescribed Bactrim, but there was no improvement after 2 doses. Two days later, the area became more red and swollen and he could not sit without pain. Abscess drainage by the primary doctor on the day of presentation yielded a small amount of blood. Surgery performed incision and drainage with drainage of approximately 5 to 7 milliliters (ml) of purulent fluid with vessel loop under Ketamine sedation. 

Laboratory studies were significant for leukocytosis 23,000 with slight neutrophil predominance, but only mildly elevated inflammatory markers.

In summary, the patient was brought in for persistent soft tissue bacterial infection (cellulitis with abscess) in the gluteal area, he was stable hemodynamically, looked well before and after the procedure, tolerated the procedure well, and so the justification for admission recorded ("Failed outpatient management: patient has worsening infection despite use of outpatient antibiotics") is inadequate. There was not enough time or doses (2 doses ) of Bactrim as outpatient to assess failure. Bedside incision and drainage (I&D) was indicated and performed, and parenteral antibiotic therapy was not clinically indicated. His vital signs were stable and he was not toxic-appearing or with any signs of sepsis. There is no documentation of hypotension that would warrant fluid resuscitation or inpatient care.

The use of a vessel loop, left in place to be retracted after several days, is now standard, and this could be removed as an outpatient. (Ladde 2020)

There was no evidence of sepsis, fasciitis, local spread of the purulent infection, or toxic shock syndrome. The infection could have been treated with follow-up as an outpatient after drainage by surgery. There is no medical-decision-making statement that justifies admission and a need for intravenous (IV) antibiotics. A small gluteal abscess can be treated as an outpatient after incision and drainage (Lawrence, 2012) because it is not in danger of spreading to  any vital structure or organ. IV antibiotics are usually unnecessary (Kaplan, UpToDate; Stevens, 2014).

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 the inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity

Treatment: Wegovy

The insurer denied coverage for Wegovy

The denial is overturned
 

The patient has a history of Crohn's disease, gastric bypass, and cervical fusion and was requesting Wegovy for weight loss. A progress note states that the Body Mass Index (BMI) is 28.7. However, in 2023 it is noted that the BMI went up to 31.56. She has been seeing an endocrinologist for an elevated parathyroid hormone (PTH) level. The endocrinologist has also recommended Wegovy. She is also receiving treatment for anxiety and depression. 

UpToDate has an article titled "Obesity in Adults: Drug Therapy." The article states that a number of medications are approved by the Food and Drug Administration (FDA) for the treatment of obesity in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those with a BMI over 30 or a BMI over 27 with related comorbidities. Semaglutide is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction, as well as improvement in glycemia and lipids. It has also demonstrated cardiovascular benefits. 

The FDA has approved Wegovy as an adjunct to diet and increased physical activity for chronic weight management if the BMI is over 30 or is over 27 with a comorbid condition. This patient has a BMI that is over 30. Although increased physical activity is needed, there is no requirement that the patient has to be in a weight loss program. In view of the elevated BMI, giving Wegovy is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Wegovy is substantiated.