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

Diagnosis: Below the knee amputation
Treatment: Consumer Directed Personal Assistance Services 
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 24 hours per day, 7 days per week (split-shift). The health plan's determination is overturned. 

The patient is a male with past medical history of urinary incontinence, bowel incontinence, vascular dementia, diabetes mellitus type 2, hypertension, osteoarthritis, hearing loss, low vision right eye, depression, right middle and ring finger amputation, status post amputation of right toes, status post left leg below the knee amputation with prosthesis, wheelchair dependence, and benign prostatic hyperplasia (BPH) who had been assigned Consumer Directed Personal Assistance Services (CDPAS). 

Consumer Directed Personal Assistance Services (CDPAS): 24 hours per day, 7 days per week (split-shift) is medically necessary for this patient. The patient has documented progressive medical diagnoses of vascular dementia, osteoarthritis, and is status post left below knee amputation (BKA), right toe amputations and is wheelchair dependent. The patient's medical providers have documented that the patient's condition will not improve. The patient requires assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs). The patient has unpredictable and unscheduled care needs over a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient has no informal support. The patient has been found multiple times on the floor in the morning when his aide arrives, as he has tried to go to the bathroom on his own. The assessment notes indicate that the patient had some redness on the buttocks, necessitating frequent repositioning to prevent skin breakdown. The patient is incontinent of both bowel and urine, also necessitating frequent changing to prevent infection and skin breakdown. The increase in CDPAS hours is not solely for safety and supervision, but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met with current hours and/or adaptive equipment and/or medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS 24 hours/day, 7 days/week (split-shift) is medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis.
Treatment: Home Care/Personal Care HHC [home health care] - Level 2 Personal Care Services, per 15 minutes, at 84 hours per week.
The insurer denied coverage for Home Care/Personal Care HHC [home health care] - Level 2 Personal Care Services, per 15 minutes, at 84 hours per week.
The denial is overturned.

This is a male patient with a past medical history of multiple sclerosis, type 2 diabetes mellitus, cognitive impairment, edema in the feet and legs, osteoarthritis, hypothyroidism, chronic pain, depression and hypertension. The patient is also non-ambulatory and wheelchair dependent. The patient lives in a private home with his wife. The patient needs assistance with all tasks of activities of daily living (ADLs) and instrumental activities of daily living. An increase in home care/personal care HHC [home health care] - Level 2 personal care services, per 15 minutes, from 42 to 84 hours per week is being requested.

The patient's needs are: total dependence for meal preparation and ordinary housework;
maximal assistance for shopping, bathing, dressing his lower body, toilet transfer and toilet use; extensive assistance for managing finances, managing medications, stairs, transportation, personal hygiene, dressing his upper body and bed mobility; supervision/independence for eating and locomotion (scooter, motorized wheelchair).

The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient. The reviewer does not agree with the plan's assessment of the patient's needs. 

The patient has multiple sclerosis and his medical doctor reports that the patient has an increasing loss of function both physically and cognitively. This is getting worse; Uniform Assessment System (UAS) documentation shows minimal cognitive impairment. The patient has more problems with incontinence than he previously had, and he uses a urinary catheter that needs to be maintained. Tasking tool demonstrated dependence for transfers. The patient's functional status has changed, and the patient's request is approved. 

The insurer's denial of coverage for the requested Home Care/Personal Care HHC [home health care] - Level 2 Personal Care Services, per 15 minutes, at 84 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Plaque Psoriasis
Treatment: Formulary exception for Taltz autoinjector 80mg/ml AUTO INJCT, Pre-service
The insurer denied the Formulary exception for Taltz autoinjector 80mg/ml AUTO INJCT, Pre-service.
The denial is upheld.

The patient is a woman with plaque psoriasis involving 10% body surface area on the scalp, trunk, and extremities. She has also been experiencing joint pain. She has tried and failed Otezla, clobetasol and betamethasone, which she is using currently and flaring. She has a history of basal cell carcinoma of the right eyebrow. She also has a history of breast cancer and lymphedema. Her treating physician does not want to use a TNF (tumor necrosis factor) alpha inhibitor because of her past medical history of breast cancer.

The request for Taltz was denied as there are formulary medications that were not tried and failed, such as Humira (requires prior authorization), Stelara (requires prior authorization), Skyrizi (requires prior authorization), Tremfya (requires prior authorization), Enbrel (requires prior authorization), Cosentyx (requires prior authorization), and Cimzia.

No, the health plan should not cover the formulary exception for Taltz.

There are formulary medications that were not tried and failed, and which are not TNF alpha inhibitors, such as Stelara, Skyrizi, Tremfya, and Cosentyx. None of these medications have a black box warning. Additionally, Stelara and Cosentyx are indicated for both psoriasis and psoriatic arthritis.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Treatment: Formulary exception for Ubrelvy (ubrogepant)
The insurer denied the Formulary exception for Ubrelvy (ubrogepant)
The denial is upheld.

The patient is a female with migraine headache disorder. She has tried and failed izatriptan, frovatriptan and Nurtec for abortive therapy. Her provider is requesting Ubrelvy.

No, the health plan should not cover the formulary exception for Ubrelvy.
There is no documented reason as to why the patient cannot be treated with another preferred formulary agent. All of the preferred agents are FDA (United States Food and Drug Administration)-approved for acute treatment of migraine headaches and are considered first-line, standard-of-care, abortive agents (Thorlund et al.). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Ubrelvy relative to the preferred agents.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain.
Treatment: Inpatient admission.

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

The patient is a female with a past medical history significant for HTN (hypertension), dyslipidemia, non-obstructive CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), seizure disorder, and alcohol abuse. She was evaluated in Detox, when she developed new onset sharp chest pain and was brought to ER (emergency room) for evaluation.

The patient was hypertensive, with a pressure differential in her arms 170/112 on the left and 111/79 on the right. Her high sensitivity troponin was elevated at 47.3. The patient was admitted for suspected ACS (acute coronary syndrome). Aortic dissection or aneurysm was suspected, given the pressure differential, and a CTA (Computed Tomographic Angiography) was done, which revealed no dissection. There was a chronic occlusion of right brachiocephalic artery.

The patient was diagnosed with combined systolic and diastolic CHF (congestive heart failure) and was treated medically. Troponins were trended and although remained elevated, they trended down, so no cardiac catheterization was planned. The patient improved clinically and was discharged from the hospital with a plan for outpatient follow-up.

Yes, the Inpatient admission was medically necessary.

The patient presented with new onset chest pain, with suspicion for unstable angina. The patient had multiple risk factors for CAD (coronary artery disease), as well as a known history of coronary artery disease. In addition there was suspicion for aortic dissection, for which further imaging was required. Troponin was elevated, consistent with myocardial injury. Given the presentation, hypertension with pressure differential in bilateral arms, as well as clinical suspicion for an acute coronary syndrome/unstable angina/dissection, she would not be an appropriate candidate for an ED (emergency department) chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and vomiting.

Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a female patient with a past medical history of polycystic ovarian syndrome (PCOS) and a surgical history of appendectomy who presented to the hospital with abdominal pain and vomiting. She was afebrile and her vital signs were stable. Her abdominal exam was benign. Her renal function was normal. She had a recent hospitalization for cannabinoid hyperemesis and was felt to have a recurrence of this condition. Intravenous (IV) hydration, antiemetic, and proton pump inhibitor (PPI) therapy were given. She responded to this treatment and her symptoms resolved.

Based on Milliman Care Guidelines (MCG), clinical indications for admission for vomiting include gastrointestinal obstruction, a significant metabolic derangement, hemodynamic instability, severe electrolyte abnormalities, severe pain, acute renal failure, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had vomiting that was felt to be related to cannabinoid use. IV hydration Zofran, and PPI therapy could have been given in the Emergency Room (ER) with observation status. She did not meet MCG criteria for admission for vomiting. 

The healthcare plan acted reasonably and with sound medical judgment. An inpatient 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: Dementia, vertigo, coronary artery disease, hypertension, urinary incontinence, depression and anxiety. 
Treatment: Increase Personal Care Aide (PCA) Services to 12 Hours Per Day, 7 Day(s) Per Week, a total of 84 Hours Per Week. 

The insurer denied the Increase Personal Care Aide (PCA) Services to 12 Hours Per Day, 7 Day(s) Per Week, A total Of 84 Hours Per Week. 
The denial is overturned. 

The patient is a female with a history of dementia, vertigo, coronary artery disease, hypertension, urinary incontinence, depression and anxiety. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support. 

Yes, the proposed treatment of 84 hours/week Personal Care Aide is deemed medically necessary. 

The patient is a female with a history of dementia, vertigo, coronary artery disease, hypertension, urinary incontinence, depression and anxiety. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

An in-home assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that the currently approved plan of 56 hours/week Personal Care Aide is sufficient to meet the patient's current needs. However, review of the medical records including recent progress report from the patient's provider indicates that the patient sustained a severe COVID-19 infection and is now experiencing severe residual symptoms of generalized weakness, worsening cognitive impairment, gait ataxia and dizziness. For these reasons, the proposed treatment of 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep apnea.
Treatment: Oral Appliance.
The insurer denied the oral appliance. 
The health plan's determination is overturned.

The patient is a male (73 inches, 287 lbs (pounds), body mass index (BMI) 37.86) with snoring, witness apneas, and excessive sleepiness (Epworth index 12/24). He was referred for a Type 3 portable sleep study.
His study showed 34 apneas (4% desaturation criteria) during an actigraphy measured sleep duration of 200 minutes with an apnea hypopnea index (AHI) of 7.8 events/hour interpreted by a board certified sleep specialist. The patient has had a 45 day trial of continuous positive airway pressure (CPAP) without the plan directed positive airway pressure compliance program. He is intolerant of therapy.
Under review is the medical necessity of an Oral Device for this patient.

The oral device is medically necessary for this patient.
The patient is symptomatic from his mild obstructive sleep apnea syndrome (OSAS) with excessive sleepiness even at this age with the potential to develop cardiovascular and metabolic conditions in the distant future, so treatment is recommended. He is obese with a body mass index (BMI) of 37. The AIM (AIM Specialty Health) Sleep Disorder Management Diagnostic and Treatment Guidelines specifically approves the use of an oral appliance if positive airway pressure has not been effective or tolerated despite a 45 day trial. This patient meets criteria for an oral appliance.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent 300mg/2ml SC SOSY, Pre-service.
The insurer denied the Dupixent 300mg/2ml SC SOSY, Pre-service.
The denial is overturned.

The patient is a male with widespread atopic dermatitis for whom Dupixent is requested. The medication was denied and Cyclosporine, Methotrexate, and Azathioprine were recommended. The patient has tried and failed multiple topical steroids, mupirocin, Protopic, and oral antihistamines. He worsens with exposure to light. He was stable on Dupixent in the past but skipped dosages due to loss of insurance.

Yes, the health plan should cover the proposed treatment with Dupixent.
The patient has severe atopic dermatitis affecting multiple areas of the body. He is a candidate for systemic therapy as the body surface area (BSA) is too large for reasonable control with topical medications. Topical therapies are not appropriate therapy for severe, widespread atopic dermatitis, affecting sensitive areas, which should be treated with systemic therapy. 

Dupilumab is a monoclonal antibody that inhibits IL-4 (interleukin 4) and IL-13 (interleukin 13) signaling by blocking the shared IL-4Ra (interleukin receptor 4) and originally demonstrated efficacy in phase II clinical trials. It was approved by the US Food and Drug Administration (FDA) for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It is a subcutaneous injection administered initially at a dose of 600 milligrams (mg) and then every two weeks thereafter.

Approval of dupilumab was based on clinical trials investigating dupilumab as monotherapy (SOLO 1 and SOLO 2) and in concomitant administration with topical corticosteroids (CHRONOS). Results from the SOLO 1 and SOLO 2  trials showed 36-38% of patients who received dupilumab had scores of zero or one (clear or almost clear) on the Investigator's Global Assessment scale compared with placebo (8-10%). Additionally, improvement from baseline to week 16 of at least 75% on the Eczema Area and Severity Index (EASI) was reported in significantly more patients who received each regimen of dupilumab than in patients who received placebo.

Given its unprecedented efficacy, dupilumab is now a first-line therapeutic for moderate-to-severe atopic dermatitis (AD). The patient has failed topical steroids and calcineurin inhibitors.

Cyclosporine, azathioprine, and methotrexate are not Food and Drug Administration (FDA) approved for use in atopic dermatitis (Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is.

Systemic steroids and cyclosporine are not a reasonable long term treatment for moderate to severe atopic dermatitis due to their severe side effect profile.

For the reasons above, Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, dementia and osteoarthritis. 
Treatment: Personal Care Services of 24 hours per day, 7 days per week (live-in). 
The insurer denied coverage for Personal Care Services of 24 hours per day, 7 days per week (live-in). 
The denial is overturned. 

This is a female patient with a past medical history of heart failure, osteoarthritis, hyperlipidemia, rheumatoid arthritis, insomnia, unspecified pain, unspecified convulsions, Alzheimer's disease, dementia and wandering. The patient lives alone on the 19th floor of a 2- bedroom apartment. It has an elevator and has wheelchair accessibility. Her children and grandson are supportive in her care. 

The patient's needs are: total dependence for meal preparation, ordinary housework, managing finances, shopping and transportation; maximal assistance for phone use;
extensive Assistance for managing medications, stairs, bathing, personal hygiene, dressing her upper and lower body and toilet use; limited assistance for walking, toilet transfer, bed mobility and eating (uses adult diapers). An increase of personal care services of 24 hours per day, 7 days per week (live-in) is being requested. 

The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient. The reviewer does not agree with the plan's assessment of the patient's nighttime needs. 
 
The patient has frequent urinary and occasional bowel incontinence. She has pull-ups, but is unable to change them or get herself out of bed to the bathroom (physical and cognitive limitations). She is already showing signs of the start of a pressure sore (heel). If it is starting in the heel, there would be concern about it happening in the sacral or other areas. Uniform Assessment System (UAS) documentation notes that the patient was instructed in proper diaper use, but given her cognitive and physical limitations she should not be expected to take care of herself at night. Lying in wet pull-ups for many hours would not be desirable, and she would need to be positioned after being cleaned. The provision of safety and supervision services in this case would be part of the larger services needed at night. The patient's request is approved. 

The insurer's denial of coverage for the requested Personal Care Services of 24 hours per day, 7 days per week (live-in) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied orthodontic treatment and visits. 
The denial is upheld.

The patient is a male with a diagnosis of Class I malocclusion, 2 millimeter (mm) overjet and a slight anterior open bite in the incisor region, but from the canines back the teeth are in occlusion. The upper and lower arches both have minimal crowding. The provider states that treatment must be started now to avoid future jaw surgery. The subject under review is the medical necessity for comprehensive orthodontic treatment and periodic visits.

The treatment is not medically necessary. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions and if he chose to have orthodontic treatment in the future, there will be no negative repercussions to waiting. This open bite is dental in nature (not skeletal), given the fact that the open bite is minimal and that teeth are in occlusion from the canines back. This case will not need surgical intervention if treatment is delayed to evaluate if the open bite could spontaneously correct.

The patient has appropriate overjet and minimal crowding that does not rise to the threshold of medically necessary. Anterior open bites of a dental nature may even close spontaneously in a growing patient. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. There does not appear to be any wear present on the teeth due to his occlusion. In the absence of a functional problem, orthodontic treatment would not be medically necessary to prevent future problems.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders-Psoriasis
Treatment:  Pharmacy/Prescription Drugs-Otezla
The health plan denied the requested Otezla as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

The patient has a history of guttate psoriasis. The condition affects her arms, legs, face, trunk, and groin/buttocks. Topical betamethasone ointment and home light exposure were tried without success, as well as over the counter hydrocortisone.
Otezla is not medically necessary in light of the insufficient systemic treatment used prior for this patient's extensive and guttate psoriasis. The patient and/or provider preference is not the same as true medical necessity. Guttate psoriasis is particularly sensitive to light therapy. Standard first-line therapies were not yet utilized for this patient prior to Otezla.
The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, alternative oral medications such as retinoids or Cyclosporine, and/or Phototherapy.
Modern dermatology literature [1-4] supports use of the preferred medications as similarly efficacious to the requested Otezla, 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. Therefore, as per current medical standards of care, Otezla is not medically necessary.