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

Diagnosis: Erosive Rheumatoid Arthritis. 
Treatment: Rasuvo. 
The insurer denied Rasuvo. 
The denial is overturned. 

This patient is an adult female with a history of rheumatoid arthritis. The patient has previously tried and failed oral methotrexate due to gastrointestinal issues  The patient has been receiving Rasuvo for the last four years due to difficulties with dexterity.  

The request for Rasuvo was initially denied due to the patient not having tried and failed generic methotrexate by mouth and either did not work or caused too bad of a side effect. The reason the provider is appealing the determination is because the patient has been receiving Rasuvo with overall good clinical response to therapy and the request is for continuation of therapy.  

The proposed treatment is medically necessary. 

The patient has severe erosive rheumatoid arthritis. The patient has tried and failed oral methotrexate. The patient has been receiving Rasuvo for the last four years due to dexterity issues and the inability to use generic injectable methotrexate. It is in the patient's best interest to continue on current therapy in which the patient has been doing well on for the last four years.  

The patient has been stabilized on Rasuvo for four years because the patient has poor dexterity and is unable to utilize generic injectable methotrexate. Clinical studies do show that non-medical switching was more often associated with negative or neutral effects than positive effects on an array of important outcomes. Among patients with stable/well controlled disease, non-medical switching was associated with mostly negative effects. It is in the patient's best interest to continue on therapy in which the patient has been doing well for the last four years.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the emergency department with concerns of shortness of breath for over a month and neck pain for 3 weeks. Pertinent history included hypertension and hyperlipidemia. The patient was admitted with an impression of acute on chronic diastolic congestive heart failure. Treatment included oral furosemide daily, resumption of home medications, and an echocardiogram. The patient remained afebrile, hemodynamically stable, and without hypoxia. An echocardiogram revealed a left ventricular ejection fraction (LVEF) 55% with unremarkable findings. Pulmonary consultation was obtained who noted patient had chronic shortness of breath of two years duration. Recommendations were for a lung ventilation-perfusion (V/Q) scan and outpatient pulmonary function tests. A computed tomography angiography (CTA) chest was obtained which did not reveal a pulmonary embolism. There was no clinical change. Diuretics were discontinued. Azithromycin was added. The patient was discharged with inhalers.
The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is upheld.

The inpatient admission was not medically necessary based on the clinical documentation provided, evidence based literature and standards of care. The patient presented with neck pain of 3 week duration and shortness of breath of 2 year duration. On arrival the patient was afebrile, hemodynamically stable, and without hypoxia. An electrocardiogram (EKG), Troponin, brain natriuretic peptide (BNP), chest x-ray (CXR), Carotid ultrasound (US), computed tomography (CT) of the head, CT of the chest, computed tomography angiography (CTA) of the chest, and echocardiogram were all relatively unremarkable. Following a period of monitoring, diuretics were discontinued. No other issues or complications requiring an inpatient level of care were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have hemodynamic instability, cardiac arrhythmias of immediate concern, severe electrolyte abnormalities requiring inpatient care, acute cardiac ischemia, pulmonary edema that is very severe or persistent (e.g. new oxygen requirement from baseline), persistent tachypnea, altered mental status, progressively (ongoing) rising creatinine (known from past laboratory test) with reduction of more than 25% in estimated glomerular filtration rate (GFR), acute renal failure, or any other associated condition requiring inpatient level monitoring.[3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Chest Pain
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

The patient is a male with a history of coronary artery disease (CAD), diabetes, gout, hypothyroidism, obesity, diverticulitis, and asthma. He presented to the emergency room with chest pain and shortness of breath, associated with nausea and abdominal cramping. He also complained of bloody stools. He was afebrile, and the vital signs were unremarkable. The physical exam revealed left lower quadrant tenderness without distention, guarding, rigidity, or rebound. Except for a hemoglobin A1C of 7.3 percent (%), the labs were normal. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The chest x-ray was non-contributory. An abdominal/pelvic computed tomography (CT) scan showed colonic diverticulosis with "subtle fat stranding" that was unchanged compared to a previous study. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with his usual home medications and intravenous antibiotics. The remainder of the stay was clinically uneventful, and the patient was discharged.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medically necessity is upheld in whole.
The requested health service/treatment of inpatient admission was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no credible evidence of an acute coronary syndrome. In addition, he was afebrile, was stable hemodynamically, there was no gastrointestinal (GI) bleeding, the CT findings were minimally supportive of diverticulitis, and the abdominal exam was benign except for some left lower quadrant (LLQ) tenderness. Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Female infertility
Treatment: Infertility Treatment- Infertility services
The health plan denied the Infertility services as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

Patient is an adult female with a history of multiple myomas and tubal factor. She attempted 4 intrauterine insemenization (IUI) cycles that were unsuccessful. She was noted to have a uterine polyp but refused treatment to remove it. She then underwent a robotic laparoscopic surgery to remove her multiple myomas. She was noted to have endometriosis. A prior hysterosalpingogram (HSG) showed a right distal tubal block. She was told by the operating surgeon that she would need to wait a minimum of 6 months prior to conceiving due to the extensive surgery on her uterus.

Patient underwent her first cycle of in vitro fertilization (IVF). Eleven eggs were retrieved, 3 embryos grew to blast and after preimplantation genetic testing for aneuploidies (PGT-A) - one embryo was found to be euploid (containing the normal number of chromosomes). Grade: 5BB (embryo grading). She then underwent a hysteroscopy with polypectomy. Baseline hormone levels at this time were within normal limits: Anti-Mullerian hormone (AMH) 1.69, antral follicle count (AFC) 7, follicle-stimulating hormone (FSH) 8.6. Semen analysis on partner showed 26million/ milliliter (ml), 63% motility, 3% strict morphology. He has had proven fertility.

The patient is requesting coverage for a second and possibly third cycle as described in her coverage of benefits. She has seen multiple different physicians who have stated that the longer she waits, the lower her chances will be of getting a normal embryo. They feel that embryo banking (continuing to do fresh IVF cycles and creating embryo prior to transfer of other embryos already created) is her only way of having the opportunity to have more than one child. Extensive files show multiple articles that discuss the decrease in pregnancy rates, decrease in stimulation, decrease in euploid embryos as one ages to support her need to move forward with another IVF cycle immediately and bank embryos rather than proceed with a transfer of her 5BB (embryo grading) euploid embryo.

The requested health service/treatment of Infertility services is not medically necessary for this patient. The patient has not completed her IVF cycle. She has a viable normal embryo frozen of good quality. Since she has not undergone a transfer, there is no medical necessity for another fresh IVF cycle. Although, the idea of embryo banking is used quite often in the infertility community to offer patients multiple opportunities of conceiving, it is not a medical necessity. Embryo banking is not a treatment for infertility.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Gender Dysphoria. 
Treatment: Delestrogen 20 mg/ml vial. 
The insurer denied coverage for Delestrogen 20 mg/ml (milligrams per milliliter) vial. 
The denial is upheld. 

The patient is requesting coverage for Delestrogen 20 mg/ml vial. In their Final Adverse Determination letter, they stated that the generic form of the medication is on the formulary. Based on the information provided, the patient has not had an adverse reaction to an inactive ingredient that is in the generic formulation. Formulary alternatives are estradiol patch, estradiol tablet, estradiol valerate oil injection. The requirement is 3 in a class with 3 or more alternatives, 2 in a class with 2 alternatives, or 1 in a class with only 1 alternative. 

This patient is requesting coverage for Delestrogen 20 mg/ml. The patient is said to have headache with estradiol tablets and a skin rash with estradiol patches. The next step is to use IM (intramuscular) estradiol. The formulary alternative estradiol valerate is the generic name for Delestrogen. 

Generic medicines are copies of brand-name medicines. Generic medicines have the same active ingredient as the brand-name medicine they copy. 

Makers of generic medicines must follow the same government rules about strength, quality, and purity as makers of brand-name medicines. In the United States (US), the government requires careful testing of generic copies to make sure they will work as well as the brand medicines. As per Food and Drug Administration (FDA), generic medicines are as good as brand. 

In summary, the generic estradiol valerate contains the same ingredients as the brand product Delestrogen. It has the same side effects, safety and efficacy as the brand name and is approved by the FDA with the same indication and warnings and therefore Delestrogen for this patient is not likely to be more effective than the generic form. 

The insurer's denial of formulary exception for coverage for Formulary Exception for Delestrogen 20 mg/ml vial should be upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus.
Treatment: Afrezza
The insurer denied Afrezza. 
The health plan's determination is overturned.

This is a male diagnosed with Type 2 diabetes mellitus with hyperglycemia. This request is for Afreeza. As reported, he has a severe phobia of needles making it so that he has been unable to give rapid-acting insulin injections. He has previously prescribed Novolog for treatment but failed due to his inability to inject due to his phobia.

The formulary alternative will be ineffective as the patient cannot self-inject insulin due to needle phobia.
Afrezza is FDA (Food and Drug Administration) approved for the treatment of diabetes. It has been shown to be beneficial in patients with diabetes. Studies have demonstrated the safety and efficacy of the medication and treatment of diabetes. There are no studies showing the superiority of Afrezza over injectable insulin. The patient is unable to self-inject to due needle phobia. A formulary exception is indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Panic and Generalized Anxiety Disorders
Treatment: clonidine HCl ER
The insurer denied clonidine HCl ER.
The determination is upheld.

The patient is prescribed clonidine at a dose of 0.1 milligrams (mg) twice daily for the treatment of panic and generalized anxiety disorders. The patient has co-morbid bipolar disorder and no diagnosis of a substance use disorder.
The patient is also being treated with lithium, Vraylar, pregabalin, alprazolam, and zaleplon at clinically appropriate dosages targeting the mood and anxiety disorder symptoms. The clonidine, as well as the alprazolam, is to be used on an as needed basis due to breakthrough anxiety/panic or "treatment resistant" anxiety.
The denial is on the basis of plan guidelines indicating that the use of clonidine in the treatment of anxiety is not Food and Drug Administration (FDA) indicated or approved. No formulary alternatives are offered.
The prescribing clinician is requesting coverage of clonidine to address the treatment resistant anxiety indicating that this is an off-label use of the medication.
The health plan documents and correspondence were reviewed with reference to the rationale for denial of coverage for clonidine. Case summary and records, and the patient's appeal documents, correspondence from the prescribing clinician were reviewed. This case is a New York State mandated review. At issue is the medical necessity of the requested clonidine.

No, the requested health service/treatment of clonidine HCl ER is not medically necessary for this patient.
The requested benefit of clonidine hydrochloride (HCL) extended release (ER) for the treatment of anxiety or panic is not supported in the scientific literature, nor an approved use of this medication. The appeal does not provide a rationale for the use of clonidine in this case other than to indicate that the anxiety is treatment resistant. Reasonable alternatives are available for treatment of the patient's anxiety disorders in keeping with published guidelines, referenced below, and in keeping with prevailing standards of medical practice for the treatment of this patient's conditions.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Xgeva
The health plan denied the requested medication, Xgeva, as not medically necessary. 
The health plan's determination is upheld.

This is a female with recurrent, metastatic breast cancer. Xgeva has been recommended, as the patient is stated to have difficult intravenous (IV) access and lymphedema.
At issue is the medical necessity for the requested medication, Xgeva.

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

In this patient with boney metastatic disease, Xgeva is a covered benefit when the patient is not a candidate for an intravenous bisphosphonate. In this case, the patient has received multiple IV therapies and if she wishes to maximize her treatment options will require additional IV therapies. Further, IV access cannot be completely compromised, given the laboratory studies that were drawn and are included. Lack of easy vascular access can generally be overcome with implantable devices. This patient has no contraindications to intravenous bisphosphonate therapy which is widely considered a standard of care in this setting by national guidelines, the peer-reviewed literature, and by the authors of UpToDate. For these reasons, the medical necessity cannot be established for this service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The determination is upheld.

The patient has a past medical history (PMH) of hypertension (HTN) and was admitted with complaints of (c/o) HTN after stopping his blood pressure (BP) medication two months prior. His vital signs were notable for a blood pressure (BP) of 212/146. The physical exam was notable for no apparent distress (NAD), the neurological exam was without focal deficits. Lab work was notable for a creatinine of 5.6. Imaging studies, a chest x-ray (CXR) showed no acute pathology, a renal ultrasound (US) showed a complex renal cyst. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with asymptomatic HTN without evidence of acute end-organ damage and end stage renal disease (ESRD) / chronic kidney disease (CKD) due to long-standing hypertensive nephropathy and treated with anti-hypertensives. Nephrology was consulted and recommended outpatient follow-up after the renal cyst work-up. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The admission was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o asymptomatic HTN and was found to have a significant BP elevation. He did not have any evidence of acute end-organ damage as there was no alteration of consciousness, neurologic deficits, encephalopathy, cerebrovascular accident (CVA), intracerebral hemorrhage (ICH), retinal hemorrhage/papilledema, acute coronary syndrome (ACS), aortic dissection, or acute heart failure. The patient's creatinine was elevated, but nephrology consulted on the patient and determined that the renal failure was chronic in nature and secondary to long-standing untreated HTN. The patient was treated in the ED with anti-hypertensives and responded appropriately to the medication with a reduction in the BP. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems 
Treatment: Nerve treatment on molar tooth for tooth 31 and operating room services
The health plan denied the nerve treatment on molar tooth for tooth 31 and operating room services.
The health plan's determination is upheld. 

The patient is a female who presented to the office for evaluation and treatment of tooth #31. Provided for review are previous letters of appeal and denial, American Dental Association (ADA) claim forms, and health plan language. Not included are any clinical notes, any radiographs, or any other items pertaining to the case to explain the current status of the tooth or the patient. At issue is the medical necessity of the planned treatment of root canal treatment (3330) for tooth #31 as well as anesthesia for the procedure (9500).
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of nerve treatment on molar tooth for tooth 31 and operating room services are not medically necessary for this patient. As there are no clinical findings, no radiographic images, no clinical images, no clinical notes, and no other diagnosis or diagnostic information, there is not any medical basis to support the necessity of the requested therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: New Onset Type 2 Diabetes
Treatment: Full hospital admission 
The insurer denied: Full hospital admission 
The denial is: Upheld

The patient is a female with hypertension who presented with chest pain and dizziness and diagnosed with new onset type 2 diabetes. Temperature was 97.8, heart rate was 108, blood pressure (BP) was 137/92, respiratory rate was 18, and oxygen (O2) saturation was 98%. Glucose was 448 milligrams per deciliter (mg/dL), beta hydroxybutyrate was 1.37, potential hydrogen (pH) was 7.4. glycated hemoglobin (A1C) was greater than (>)14%. The patient was seen by endocrinology and started on multiple daily insulin injections. She was alert and oriented. The subject under review is the medical necessity for the full hospital admission.

The health plan's determination is upheld.

The requested full hospital admission was not medically necessary for this patient. This patient presented with hyperglycemia in the setting of newly diagnosed type 2 diabetes. She was hemodynamically stable. She did not have acidosis to support a diagnosis of diabetic ketoacidosis. She did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. The documentation does not support that she failed management under a lower level of care. Therefore, the requested full hospital admission was not medically necessary for this patient. She could have been managed appropriately at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent 300MG (milligrams) per 2ML (milliliters) SC (subcutaneous) SOPN (Solution Pen-injector).

The insurer denied: Dupixent 300MG per 2ML SC SOPN.  The denial is upheld.

The patient is an adult female with atopic dermatitis to the face and hands, treated with topical steroids, prednisone, Opzelura and emollients. The request is for Dupixent. The patient has also required iron infusions for anemia.

The health plan denied coverage of the request because the health plan requires use of formulary agents' cyclosporine, topical Tacrolimus, and phototherapy. The denial is being appealed.

The requested Dupixent is not medically necessary.

This patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis. The documentation does not support aggressive topical measures with emollients and wet-to-dry wraps, bleach baths, and phototherapy, which are considered first- and second-line therapies for eczema. Systemics such as cyclosporine can also be used in atopic dermatitis. According to the recommendations provided by Simpson, et al. (2017), steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy. Dupixent is not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Migraine.
Treatment:  Formulary exception for Botox Injection.

The insurer denied: Formulary exception for Botox Injection.  The denial is upheld.

The patient is an adult female with chronic migraine headache disorder. She has tried and failed topiramate, duloxetine, propranolol and divalproex sodium for migraine prevention. The provider has requested Botox. The requested medication was denied coverage as the patient has not tried and failed the preferred formulary agents: Aimovig, Ajovy and Emgality.

The health plan should not cover the proposed formulary exception for Botox injection.

There is no reason the patient cannot be treated with the preferred formulary agents. Ajovy, Aimovig and Emgality are considered standard of care migraine preventive agents (Khan et al., 2019) and are Food and Drug Administration (FDA) approved for the patient's condition based on data derived from high quality clinical trials demonstrating efficacy (Khan et al., 2019). The clinical trial leading to the Food and Drug Administration approval of Botox tested efficacy against placebo (Frampton and Silberstein, 2018). There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Botox relative to the preferred calcitonin gene-related peptide (CGRP) inhibitors. There is no evidence to support that Botox would have less side effects than the preferred agents.