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

Diagnosis: osteoarthritis, allergies, dizziness and giddiness, essential hypertension

Treatment: Personal Care Services, per 15 minutes increase to 49 hours per week

The insurer denied coverage for Personal Care Services, per 15 minutes increase to 49 hours per week

The denial is upheld

 
The patient is an elderly female who lives in a rented private house room on the 3rd floor with walkup access. She has diagnosis of bilateral knee osteoarthritis, allergies, dizziness and giddiness, essential hypertension, functional urinary incontinence, neuralgia and neuritis, abnormalities of gait and mobility, chest pain, constipation, fatigue, insomnia, low back pain, and glaucoma. Her medications include Meclizine, Meloxicam, Aspirin, Celecoxib, Levocetirizine, Zolpidem, Alendronate, Diclofenac, Docusate, Gralise, Latanoprost, Vitamin D, Exforge, Hydralazine, Nitroglycerin, and Synthroid. 

There are 40 steps from the entrance of the home to the patient's room. She is cognitively and physically able to press her personal emergency response system. She is alert and oriented but does have frequent forgetfulness due to age related cognitive decline. She is totally dependent for meal preparation, housework, She requires maximal assistance with shopping. She requires extensive assistance with stairs, and bathing. She requires limited assistance with personal hygiene, dressing, toileting, and ambulation. She reports that she has chronic fatigue, muscle weakness, and an unsteady gait due to osteoarthritis. She is occasionally incontinent for bladder. She is continent for bowel. She denies any falls within the 90 days preceding her assessment. The record indicates that she attends adult day care three days a week, Tuesday, Thursday, and Saturdays. 

According to the tasking tool, the patient requires 20 hours per week of personal assistance services four days per week.  She lives in one room in a house. The tasking tool allotted 2 hours per week of housework. The awarded 24 hours per week is sufficient to meet the needs of this patient. The decision to deny the increase to 49 hours per week is upheld. 

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 home care/personal care HHC- Level 2 Personal Care Services, per 15 minutes increase to 49 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eczema
Treatment: Dupixent Syn 300

The health plan denied: Dupixent Syn 300
The determination is: Upheld.

The patient is a female with atopic dermatitis. She has tried and failed triamcinolone, hydrocortisone, and Eucrisa. She has also tried Opzelura. The medication under review is Dupixent Syn 300.
The health plan's determination of medical necessity is upheld.
The requested health service/treatment of Dupixent Syn 300 is not medically necessary for this patient if being prescribed concomitantly with Opzelura. Scientific evidence has not been established via well-designed, controlled studies with adequate follow-up that demonstrate the safety and efficacy of the proposed treatment. There are no randomized-controlled studies that show the efficacy of safety of Opzelura when administered concomitantly with Dupixent. Combination therapy of Dupixent with Opzelura is not generally accepted medical practice and management of atopic dermatitis in the United States[1-3]. Further studies are necessary to determine the role and utility of co-administration of these medications for atopic dermatitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: L20.89 - Other atopic dermatitis
Treatment: Dupixent Syn 300
The insurer denied: Dupixent Syn 300
The denial is overturned.

The patient is an adult female with a history of atopic dermatitis affecting her hands and lower extremities. She has a history of failure of oral prednisone, high potency topical steroids, Eucrisa, tacrolimus, and emollients. She has a history of previous good response to Dupixent (dupilumab) 2 years ago for an unclear length of time. She has a history of environmental allergies and treatment with immunotherapy. Her flares of atopic dermatitis severely impact her quality of life and ability to work.

The requested Dupixent is medically necessary.

The Dupixent prescription requested will not be used with another biologic or targeted synthetic drug and the patient has no history of using another biologic. Current medical standards and guidelines support the use of Dupixent to control moderate to severe atopic dermatitis patients who have failed multiple therapies including oral and topical steroids, tacrolimus, and Eucrisa. Atopic dermatitis of the hands can be particularly debilitating for quality of life and functionality. Involvement of the hands is considered a crucial body area. Dupixent is a safer medication to control atopic dermatitis. Intermittent prednisone use is not a cure for atopic dermatitis and overuse of this medication can potentially lead to long-term sequelae.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Parkinson's Disease
Treatment: Ropinirole extended release (ER) 
The insurer denied Ropinirole extended release.
The determination is upheld.

The patient is a female with a medical history of PD (Parkinson's disease). She failed immediate release ropinirole. Ropinirole extended release is requested.

The health's plan determination is upheld in whole.

The patient failed ropinirole. There is no documentation of a trial of pramipexole.

There is insufficient evidence to conclude that pramipexole has been ineffective, would not be as effective as the non-formulary drug, Ropinirole extended release, or would have adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease

Treatment: Personal care assistance (PCA) services, two 12 hour split shifts, 7 days per week

The insurer denied coverage for personal care assistance (PCA) services, two 12 hour split shifts, 7 days per week.

The denial is overturned.

This is an older adult with chronic medical problems including Parkinson's disease with severe tremors, depression, degenerative spine disease with deformity of the spine and heart failure. The Uniform Assessment System for New York (UAS-NY) Comprehensive Assessment form was reviewed. The patient's cognitive skills are impaired. The patient is assessed as requiring  assistance for most Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL) tasks. The patient needs maximal assistance for bathing, weight bearing, personal hygiene, upper body dressing, eating and phone use. The patient is totally dependent with lower body dressing, locomotion, toilet use and toilet transfer. The patient is also totally dependent for shopping, meal preparation and housekeeping. The patient's primary mode of transportation is a wheelchair.
Personal assistance services (PAS) hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance. 
Based on the documents reviewed, the patient's health and safety cannot be appropriately provided and maintained with 84 PAS hours/week. The patient is at high risk for falls and their physician notes that repositioning and diaper changes are required frequently during the day and night to prevent skin breakdown and pressure ulcer development. The patient is essentially bed and wheelchair bound and lives alone. Because of the patient's Parkinson's disease and tremors they are also unable to use the phone independently to call for help in an emergency. 
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 personal care assistance (PCA) services, two 12 hour split shifts, 7 days per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment: 140 hours per week of Consumer Directed Personal Assistant Services
The insurer denied 140 hours per week of Consumer Directed Personal Assistant Services.
The health plan's determination is overturned. 

This is a female patient with a history of dementia with occasional behavioral disturbance, unsteady gait, depression, hypertension, hyperlipidemia, and diabetes mellitus type 2. The patient's son states that she needs more hours because she is in danger of injuring herself at night when she wakes up and wanders. He states that she also needs help with diaper changes at night.

The 140 hours per week of Consumer Directed Personal Assistant Services is medically necessary for this patient.

There is documentation from the patient's PCP (primary care provider) of medical necessity of increased CDPAS services. There is documentation in the Uniform Assessment System (UAS) of the patient requiring maximal assistance with the task of toilet use/diaper changes. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs outside the approved CDPAS hours. A tasking tool should not have been utilized to calculate hours given that the patient has unscheduled and unpredictable care needs.

The patient lives with her son and granddaughter and therefore has informal support. However, it cannot be assumed that the informal support person can provide all needed care outside of the approved aide hours as informal supports must be voluntary. Although the patient's son indicated at the time of her UAS that he usually changes the patient's diaper at 10 pm and 6 am, this does not necessarily mean that the patient does not have toilet use needs between 10 pm and 6 am as her son may simply be unavailable or unable to provide care during that time. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS is not solely for safety and supervision but to assist the patient with ADLs (activities of daily living).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne Muscular Dystrophy (DMD)
Treatment: Emflaza
The insurer denied Quantity Increase for Emflaza 6 mg Tablet (beyond 30 tablets per 30 days)
The health plan's determination is overturned.

This is a case review for a male being prescribed Emflaza 6 milligrams (mg) Tablets for the diagnosis of Duchenne Muscular Dystrophy (DMD). 

The requested Quantity Increase for Emflaza 6 mg Tablet (beyond 30 tablets per 30 days) is medically necessary for this patient.
The patient is being prescribed (and has been stable for some time) on Emflaza 12mg per day. The plan is requesting that he go on 18mg per day as that would be a single tablet per day. The guidelines for using glucocorticoids in the management of DMD do not recommend this practice as outlined here: "Although practice is variable, many clinicians do not make weight-based dose adjustments of prednisone or deflazacort as patient weight increases over time, and the DMD care guidelines do not mandate such adjustments in the absence of functional decline. The author ordinarily does not make dose adjustments with weight gain (Darras)."
The plan's recommendation of using a 0.9mg/kg/day (milligrams/kilogram/day) is the useful starting dose, but DMD is usually diagnosed in childhood with much lower body weights. If the patient is stable on his current dose of 12mg per day and his specialist agrees with keeping the dose there, the requested increase is medically necessary for the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Toenail fungus
Treatment: Jublia 
The insurer denied Jublia.
The determination is upheld.

The patient is a female who was treated for toenail fungus. She was treated with ciclopirox topical medication. She was also given Itraconazole. She had been treated by a different podiatrist and tried Formula 3 and terbinafine orally with minimal improvement. The patient was recommended and prescribed Jublia. At issue is whether the formulary drugs will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

Based on the review of medical records, standards of care, and literature, all of the formulary drugs (Kerydin, tavaborole solution, terbinafine tablets, itraconazole tablets and ciclopirox) are known to be as effective as or more effective then the non-formulary drug. The patient has tried terbinafine tablets, itraconazole tablets, and ciclopirox solution. However, the patient does not have documentation of trying Kerydin or tavaborole solution.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pre-diabetes
Treatment: Ozempic
The insurer denied Ozempic
The health plan's determination is upheld.

This is a female diagnosed with pre-diabetes. The patient states that she has been on Ozempic for a year now with improvements. As per visit note; she has hypertension (HTN); HLD (hyperlipidemia); and pre-diabetes. 

Ozempic is not medically necessary.
Ozempic (Semaglutide) is a GLP1R (glucagon-like peptide-1 receptor) agonist that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity. Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. This medication is now available for the treatment of obesity in the form of Wegovy. There are no studies showing the safety or efficacy of the requested medication for patients who do not have diabetes, such as this patient. There are no extenuating circumstances in this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Glaucoma. 
Treatment: Rhopressa (netarsudil dimesylate). 
The insurer denied coverage for Rhopressa (netarsudil dimesylate). 
The denial is overturned. 

The patient has glaucoma and a formulary exception for Rhopressa is being requested.  

Based on a single visit note, the patient presented for eye pressure check. Medications listed at the time include dorsolamide-timolol, latanoprost and acetazolamide. The patient was noted to be blind in the left eye and elevated intraocular pressure was noted. The pressure was noted as 21 in the right eye. The patient had run out of Diamox and was complaining of side effects of Diamox. Recently, the plan included adding Rhopressa. Discussion included consideration of surgery, but the patient refused. 

Although the medical literature does not support that Rhopressa is superior to the formulary drugs, Rhopressa is a different class of medication than the formulary alternatives. 

Note that the patient has been on a prostaglandin analogue and the formulary alternatives are all prostaglandin alternatives. Studies have shown limited benefit from switching within the same class (4). 

The formulary drugs are not expected to cause adverse effects. 
There is no documentation that the patient has tried and had an inadequate response to the formulary alternatives. However, the patient has been on a prostaglandin analogue and the formulary alternatives are all prostaglandin alternatives. Also, the patient's intraocular pressure is elevated. 
The formulary drugs are expected to be ineffective, as the patient has been on a prostaglandin analogue and the formulary alternatives are all prostaglandin alternatives. 

The non-formulary drug is expected to be more effective than the formulary alternatives. 

The carrier's denial of a request for a Formulary Exception for Rhopressa (netarsudil dimesylate) to treat glaucoma is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Muscular Dystrophy
Treatment: Physical Therapy (23 Additional Visits to total 39 Visits)
The insurer denied: Physical Therapy (23 Additional Visits to total 39 Visits)
The denial is overturned.

The patient is an adult male with a history of Duchenne muscular dystrophy (DMD), cardiac transplant, immunosuppression, and osteoporosis. He has weakness of intrinsic hand muscles on the left associated with contracture and decreased muscle strength. In addition, he lacks fine motor and dexterity movements and has orthotics. The patient has generalized weakness and contractures in all four limbs due to the Duchenne muscular dystrophy and is wheelchair-bound. Even though he is dependent on most activities of daily living, he is able to use his arms to operate his power-assist wheelchair, able to operate small devices, and type with his hands. The request for continued occupational therapy (OT) and physical therapy (PT) each three times a week is more preventive to prevent worsening contractures, maintain pulmonary health, and prevent further bone loss. It is noted that progress is limited. At physical therapy assessments of last month, it was noted that the patient is dependent on help and has bed mobility, durable medical equipment-related issues, endurance issues, contractures with limited range of motion, high risk of falls, risk of skin breakdown and wounds, standing/ambulation, weakness, transfer, postural, respiratory, etc.

The proposed treatment is medically necessary.

Physical therapy is medically necessary for this patient with muscular dystrophy to prevent contractures and to maintain range of motion and also to address issues raised in the physical therapy notes of last month as stated above. Therefore, the proposed treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteomyelitis.
Treatment: Skilled Nursing Facility.
The insurer denied Continued Sub-Acute Rehabilitation (Skilled Nursing Facility) Stay.
The health plan's determination is overturned.

The patient is a male with right lower limb cellulitis and osteomyelitis who was admitted to a skilled nursing rehabilitation facility for intravenous (IV) antibiotics, wound care, and rehabilitation. 

Continued Sub-Acute Rehabilitation (Skilled Nursing Facility) Stay is medically necessary for this patient.
The patient requires continued Skilled Nursing Facility (SNF) level of care. He is now set up level for bed mobility, transfers, and supervision to ambulate 90 feet. Stairs require minimum assistance. He has bilateral lower limb weakness. He requires setup and supervision for activities of daily living including dressing, feeding, bathing, and grooming. It is medically necessary to continue SNF-level rehabilitation with therapeutic exercises, neuromuscular re-education, ambulation training, and activities of daily living. He needs upper limb strengthening and continued work with activities of daily living (ADL). The goal is independence with mobility and ADLs.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: chronic obstructive pulmonary disease (COPD).
Treatment: inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is overturned in part.

The patient is a female with severe chronic obstructive pulmonary disease (COPD), chronic hypoxemic respiratory failure on 3-4 L (liters) home O2, hypertension (HTN), coronary artery disease (CAD), gastroesophageal reflux disease (GERD), with recent admission to the hospital for a COPD flare. She returned less than a week after discharge with chest pain and worsening dyspnea. For respiratory distress, she was started on NIV (non-invasive ventilation) by the Emergency Medical Services (EMS).

An inpatient admission was medically necessary for 5 days.

The patient presented with respiratory distress and acute or chronic respiratory failure requiring NIV in the setting of severe underlying COPD. She also presented as a failure of outpatient treatment, having just been discharged with a COPD flare and returning while still on the treatments from the prior admission. All of this indicates a high baseline level of severity and a high level of acuity for the acute presentation. Given all of this, she was severely ill at presentation and was at high risk of worsening. For this reason, she required an inpatient admission for close monitoring (especially given NIV requirements failure risk and the need for invasive mechanical ventilation). However, she had been weaned off of rescue non-invasive ventilation and was only on nocturnal NIV and had also improved to baseline (had persistent, gradually improving shortness of breath (SOB) that was still worse than baseline and still quite severe. Therefore, an inpatient admission was indicated.
However, after 5 days, she was at baseline and felt to be medically ready for discharge. Her discharge was held up not for medical reasons but as they were waiting to see if she could go to rehab. The team felt she was ok for discharge. As such, an inpatient admission was needed on these days.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: hyperlipidemia
Treatment: Praluent 150 mg/ml
The insurer denied Praluent 150mg (milligrams)/ml (milliliters)
The health plan's determination is upheld. 

A patient is a man with hyperlipidemia. Recently, his low-density lipoprotein (LDL) cholesterol level was 210. Per the physician's note, he was "intolerant to statins due to severe myopathy". His medication list on that date included atorvastatin 10 milligrams (mg) daily. The visit note did not include any details regarding other statins, if any, that the patient had tried or their dosages.

Praluent is not medically necessary for this patient. Based on the limited documentation provided, current guidelines do not support the medical necessity of Praluent in this instance.
The patient's most recent LDL cholesterol level (LDL-C) of 210 is consistent with a diagnosis of phenotypic heterozygous familial hypercholesterolemia (HeFH). Published studies have indicated that the long-term atherosclerotic cardiovascular disease risks for US (United States) adults with a baseline LDL-C greater than or equal to 190 are increased approximately 5-fold compared to those with average levels of LDL-C, even after adjustment for other cardiovascular risk factors.

Based on the limited documentation provided it cannot be determined that this man has complete statin intolerance and that he would not be able to tolerate any statin at any dose. Per the 2022 National Lipid Association scientific statement on statin intolerance, statin intolerance is defined as "side effects associated with statin therapy, which resolve or improve with dose reduction or discontinuation and can be classified as complete inability to tolerate any dose of a statin or partial intolerance, with inability to tolerate the dose necessary to achieve the patient-specific therapeutic objective. To classify a patient as having statin intolerance, a minimum of two statins should have been attempted, including at least one at the lowest approved daily dosage." As mentioned, the names and doses of statins other than atorvastatin (if any) this patient has tried were not provided.