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

Diagnosis: Hypothyroidism
Treatment: Synthroid
The insurer denied Synthroid.
The health plan's determination is overturned. 

This is a female with Graves' disease with post-ablative hypothyroidism. She is stable on Synthroid and liothyronine. She has tried and was intolerant to levothyroxine due to depression and fatigue. The request is for the continuation of Synthroid.

A formulary exception is indicated in this case.

This request is for the continuation of Synthroid. The formulary alternatives are Euthyrox, levothyroxine capsule/tablet, Levo-T, Levoxyl, NP Thyroid, liothyronine, and Unithroid. This patient has tried and was intolerant to levothyroxine. She is currently on liothyronine and taking liothyronine alone is not appropriate for the management of hypothyroidism. The American Thyroid Association clinical guidelines recommend that patients stable on a brand of thyroid supplementation continue on the same brand of thyroid supplementation due to a high risk of hypothyroidism/hyperthyroidism with switching to another brand because the strength between brands is not equivalent even at the same prescribed dose. This patient has hypothyroidism and is stable on Synthroid. Switching to one of the remaining alternatives is not clinically appropriate due to the risk of hypothyroidism/hyperthyroidism. Without Synthroid, this patient will be at increased risk of the complications of untreated hypothyroidism, which can cause myxedema coma.
Appeal type: Medical necessity
Decision: Overturned

Skin
Oxygen therapy

Diagnosis: leg ulcers
Treatment: Topical Oxygen Wound Therapy (TOWT) 
The insurer denied Topical Oxygen Wound Therapy (TOWT). The health plan's determination is overturned. 

This is a female patient who began external oxygen therapy for a right leg venous ulcer. The ulcer appeared and had not improved with compression wraps, diet, leg elevation, exercise and hydrofera blue application. 

The requested Topical Oxygen Wound Therapy (TOWT) is medically necessary for this patient because it is an effective treatment and had decreased wound volume by 44% after the first 3 months of treatment thereby justifying additional treatment.
Topical Oxygen Wound Therapy is effective and valuable in managing venous ulcers at reduces the time required for healing as well as the recurrence rates. Tawflick and Sultan showed 76% of ulcers healed at 12 weeks with Median time to full healing 57 days and mean ulcer surface area reduction of 96% at 12 weeks. In this case, the wound went from 20 cm3 in 8/2022 to 11.21 cm3 at time of the 11/2022 request for additional oxygen therapy treatments. Continued oxygen therapy is more likely to heal the wound with a lower risk of recurrence.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Anal warts
Treatment: Veregen (sinecatechins) 
The insurer denied Veregen (sinecatechins).
The health plan's determination is upheld.

The patient is a male who was diagnosed with anal warts. The patient admits to having pain associated with them. Exam demonstrated perianal cauliflower like warts. The patient was advised to see a colorectal specialist. He started podofilox prior to meeting with colorectal surgeon. 

A formulary exception is not indicated. 

It appears the patient is using the Veregen for internal anal condyloma. Internal anal condyloma are not treated with the requested drug. Imiquimod and podofilox are not appropriate for this condition either. There is no patient applied topical medications for anal condyloma in the anal canal. Therefore, Veregen is not indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD (gastroesophageal reflux disease). 
Treatment: LINX procedure. 

The insurer denied the LINX procedure. The health plan's determination is overturned. 

This is a case of male patient who has refractory gastroesophageal reflux disease (GERD). The patient has a PSH (past surgical history) of gastric bypass. Before that, the patient had Toupet fundoplication and extensive surgical history for his GERD. Most recently, the patient had a Bravo study, which also showed GERD. The patient has a 4 centimeter (cm) hiatal hernia. The Linx device is under review. 

The LINX Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
This patient had Nissen fundoplication f/b, Toupet fundoplication, endoscopic plication and then redo endoscopic trans oral approach. Despite all this, the patient is continuing to have GERD. There's no other surgical treatment of GERD for this patient. The patient is a great candidate for Linx. 

According to Society of American Gastrointestinal and Endoscopic Surgeons (SAGES):
Longer-term (3-5 years) experience with the LINX Reflux Management System confirms the initial safety profile that led to Food and Drug Administration (FDA) approval of the device. The LINX device has been demonstrated to result in long-term GERD control based on symptomatic outcomes, proton pump inhibitor (PPI) utilization, and potential hydrogen (pH) studies. 

LINX is a reasonable treatment option for appropriately selected patients with GERD, who meet indications for antireflux surgery. The LINX procedure is part of the armamentarium in the treatment of GERD. As such, it should be performed by surgeons familiar with the workup and different management alternatives of GERD and not offered in isolation.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD (gastroesophageal reflux disease). 
Treatment: LINX procedure. 

The insurer denied the LINX procedure. The health plan's determination is upheld. 

This patient is a man who sought surgical evaluation for the condition of refractory and recurrent gastroesophageal reflux disease (GERD). Significantly, the patient has undergone prior hiatal hernia repair and fundoplication. This was reportedly complicated by an esophagogastric fistula. He has also had prior endoscopic interventions to ameliorate his condition of gastroesophageal reflux. Despite these multiple procedures, he had refractory reflux. He subsequently underwent roux en Y gastric bypass as treatment of refractory GERD. His current symptoms include daily continuous reflux. 

The LINX Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. In this case, the patient has undergone prior surgical intervention (prior hiatal hernia repair and surgical fundoplication, revisional endoscopic therapy, and subsequent conversion to roux en Y gastric bypass). LINX has not been adequately studied and is not a proven effective therapy in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD (gastroesophageal reflux disease). 
Treatment: LINX procedure. 

The insurer denied the LINX procedure. The health plan's determination is upheld. 

This patient is a with history of prior bariatric surgery including RYGB (Roux-en-Y Gastric Bypass). A 24-hour potential hydrogen (pH) study revealed gastroesophageal reflux disease (GERD) with significant reflux episodes and a 4 centimeter (cm) hiatal hernia. An UGI (gastrointestinal study) revealed a small natal hernia containing the gastric pouch of RYGB anatomy and GERD. 

The LINX Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
LINX is considered a standard surgical treatment for GERD within the medical community and is recommended in updated published guidelines from the Society of Gastrointestinal and Endoscopic Surgeons to be a safe, effective and durable treatment for GERD for mid to long-term outcomes based on published findings. There are only a few exclusions to the treatment which include: Barrett's esophagus with dysplasia, age < 18 years, prior bariatric or gastric surgery and body mass index (BMI) >35 and large hiatal hernia > 3 cm. This patient has several exclusions to LINX treatment. This patient has had prior gastric bypass with a large 4 cm hiatal hernia and a gastric pouch herniating into the mediastinum as the most likely cause of GERD. LINX is currently being evaluated in post bariatric settings, however, there is no long term, high level or randomized controlled trial (RCT) data available at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion/cardiac related.
Treatment: Cardiac catherterization with coronary intervention.
The insurer denied coverage for the inpatient hospital admission. 
The insurer's denial was upheld.

This is a patient with dyspnea on exertion, hyperlipidemia, and coronary artery disease noted on computed tomography (CT) angiogram, presented to the hospital for elective cardiac catheterization.  Cardiac catheterization revealed a 90% lesion in the mid left anterior descending (LAD) artery and an 80% lesion in the mid circumflex artery.  Left ventricular (LV) ejection fraction was 55%.  A drug eluting stent was placed in the left anterior descending artery.  No perioperative complications were noted, and the patient was discharged the following day.

This patient presented for elective cardiac catheterization and underwent revascularization.  He underwent an uncomplicated procedure, and a stent was placed in the mid LAD artery. He was discharged the following day.  Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. (Reference1-4) Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care. (Reference 4) In conclusion, inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care.

The health plan acted reasonably, with sound medical judgment and/or in the best interest of the patient.

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

This is a patient with dyspnea on exertion, hyperlipidemia, and coronary artery disease noted on computed tomography (CT) angiogram, presented to the hospital for elective cardiac catheterization.  Cardiac catheterization revealed a 90% lesion in the mid left anterior descending (LAD) artery and an 80% lesion in the mid circumflex artery.  Left ventricular (LV) ejection fraction was 55%.  A drug eluting stent was placed in the left anterior descending artery.  No perioperative complications were noted, and the patient was discharged the following day.

This patient presented for elective cardiac catheterization and underwent revascularization.  He underwent an uncomplicated procedure, and a stent was placed in the mid LAD artery. He was discharged the following day.  Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. (Reference1-4) Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care. (Reference 4) In conclusion, inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care.

The health plan acted reasonably, with sound medical judgment and/or in the best interest of the patient.

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

Diagnosis: Dental Disorder - anterior crossbite
Treatment: Braces
The insurer denied the braces.
The determination is overturned.

This is a male patient with teeth number (#) 8 and #9 in edge-to-edge anterior crossbite. The patient was treatment planned for interceptive orthodontics to correct the crossbite. At issue is the medical necessity of braces.

Treatment for the patient's anterior crossbite in the mixed dentition is medically necessary. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. These problems are much more time consuming to correct than the patient's existing orthodontic problem. It is a generally accepted practice guideline in orthodontics to treat anterior crossbites as soon as feasible because of the damage that can occur to the patient's dentition if left untreated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal

Treatment: Hospital admission 

The insurer denied coverage for hospital admission

The denial is overturned
  
This adult patient was admitted to this inpatient hospital for treatment of alcohol withdrawal and confusion, and encephalopathy. The patient reportedly had withdrawal symptoms including tremors, nystagmus, elevated blood pressure of 183/107, and had electrolyte abnormalities including elevated glucose of 368, low platelets of 105, low calcium of 7.8, and an elevated lactic acid of 5.4. The patient reportedly had a past seizure and past confusion as well and a history of drinking 2 pints of vodka with last use the day prior to admission. The patient was given intravenous (IV) Ativan and IV Phenobarbital and put on a phenobarbital protocol. The patient received 130 milligrams (mg) IV Phenobarbital and was started on Phenobarbital 64.8 mg every 8 hours for detoxification and placed on the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. The patient received IV thiamine. There was consideration of Wernicke's encephalopathy. The patient continued with withdrawal symptoms and received detoxification medication including the day of discharge. The patient requested to leave after treatment that day.
 
The medical records provided enough evidence to support that the patient required this level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. The United States Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent.

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 the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a teenage female who started menses at an adolescent  and reports it to be heavy. She had a routine annual at her pediatrician and was found to have a low hemoglobin, so she was sent to the emergency department. The patient did not have any shortness of breath, chest pain, fatigue, dizziness, or pain. She was given intravenous access and had blood work which revealed a hemoglobin of 5.5. She was admitted and given intravenous fluids and two units of blood.  The patient had a consultation with gynecology which revealed on examination an enlarged uterus. She had an ultrasound revealing a large submucosal fibroid measuring 9.7 by 9.6 by 6.2 centimeters. She had negative vaginal cultures and minimal bleeding. Her vitals were stable. She had repeat blood work the next day which improved to 7.1. The plan was for surgery to remove the fibroid as well as oral contraceptives. The patient was discharged with follow up.

The proposed inpatient hospital admission was not medically necessary.

An outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management. It is an area where the patient is observed and assessed following surgery or medical interventions to determine a need to be admitted to the hospital as an inpatient. In review of the medical record provided, the patient did require care in the hospital setting given the severe anemia. However, the patient was stable. There was no hemodynamic instability, bleeding was not heavy, and there was no pain. The patient did not have any nausea or vomiting. The care she received including receiving a blood transfusion could have been performed at a lower level of care with the same outcome. The inpatient care was not needed.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Ulcerative Colitis
Treatment: Lialda (Mesalamine delayed release)
The insurer denied the Lialda (Mesalamine delayed release).
The denial is upheld.

The patient is a female with left sided ulcerative colitis. She is currently on Lialda and has been treated with Rowasa and Canoas as well steroids in the past. The medial records provided do not indicate that the patient has tried and failed other mesalamine agents such as Apriso or balsalazide. The attending provider is requesting continued use of Lialda to treat this patient's ulcerative colitis.

The formulary drug (balsalazide, mesalamine delayed-red, mesalamine ext-rel, sulfasaiazine, sulfasalazine delayed-rel.) would not be less effective than the non-formulary drug (Lialda) or would not have more adverse effects than Lialda. Clinical guidelines for the management of ulcerative recommend the use of any 5-aminosalicylic acid (5-ASA) (mesalamine agent) since they are all equally effective in treating mild to moderate ulcerative colitis.

The covered formulary drugs available for use in treating the patient's ulcerative colitis have the potential to cause headache, diarrhea, upper abdominal (stomach) pain, nausea, nasopharyngitis (inflammation of the nasal passages), flu and flu-like illness, and inflammation of the sinuses. These side effects are common to all mesalamine agents and usually pass in a few days. These can be minimized by drinking plenty of fluids and staying well hydrated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Idiopathic Constipation
Treatment: Motegrity
The insurer denied Motegrity. 
The health plan's determination is overturned.

This is a female patient with chronic idiopathic constipation in the setting of connective tissue disease and autonomic dysfunction, as well as congenital sucrose isomaltase deficiency. She has had constipation, nausea, vomiting, abdominal pain, and incomplete evacuation. A breath test was positive for small intestinal bacterial overgrowth. A colonoscopy showed a sessile polyp in the distal rectum, which was removed, hemorrhoids, and an otherwise unremarkable ileum and colon. An x-ray of the abdomen (obstructive series) showed considerable amounts of stool throughout the colon, most marked in the sigmoid colon and rectum. An x-ray of the abdomen showed gas and fecal material throughout the colon. Anorectal manometry was reportedly normal. She has failed fiber, Miralax (which caused dizziness), Senna (which was ineffective), magnesium, lactulose, Trulance (which caused diarrhea and bloating), lubiprostone, and Linzess (which was not effective). Motegrity was effective. Motegrity 2 milligrams (mg) daily for the treatment of chronic idiopathic constipation is requested and was not approved due to the lack of an attempt of Lactulose, lubiprostone, and Linzess.

The formulary drugs in this case have been reported ineffective, and the use of Motegrity is supported. The patient has already reportedly failed Linzess, Amitiza (lubiprostone), and Lactulose. Additionally, the patient has already attempted osmotic laxatives (such as Miralax) and stimulant laxatives (such as Senna). The most recent American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as lubiprostone (Amitiza) or Linzess should be used if non-pharmaceutical laxatives fail, which has been reported in this case [1]. Motegrity is an effective therapy for the treatment of constipation, and has demonstrated efficacy in high-quality clinical trials [2-7]. As the patient has failed Amitiza, Linzess, and stimulant and osmotic laxatives including lactulose, the request for Motegrity is supported in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent. 

The insurer denied Dupixent. 
The denial is overturned. 

The patient is a female with atopic dermatitis, treated with numerous topical therapies, cyclosporine, prednisone, and Dupixent in a clinical trial. She has responded well to Dupixent and uses topical Opzelura to areas as well. The treating provider is requesting coverage of Dupixent. The request was denied as Dupixent is not to be used in combination with Opzelura. 

The requested treatment with Dupixent is medically necessary. The patient has responded well to this therapy and continuation is medically necessary. There is no literature regarding the use of Opzelura with Dupixent. Dupixent is not immunosuppressive, and therefore the combination of Opzelura and Dupixent will not increase risk of infection. Opzelura is indicated for use on less than 20% body surface area in any patient. No literature could be found to support avoidance of the combination of Opzelura with Dupixent.