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

Diagnosis:  Musculoskeletal/Orthopedic. 
Treatment:  Fenoprofen. 

The insurer denied Fenoprofen.  The denial is upheld.

The patient is a female with multiple medical problems including Hashimoto's thyroiditis, allergies, intermittent urticaria, nonspecific autoimmune disease with arthralgias and mildly increased antinuclear antibody (1:80 nucleolar pattern-often seen with autoimmune thyroid disease). She is receiving treatment with multiple medications for presumed inflammatory disease despite normal erythrocyte sedimentation rate and C-reactive protein and completely negative serologic panel other than the mildly increased antinuclear antibody. Her therapies include montelukast, Proair, antihistamines, Ilaris, Minocin, Fenoprofen alternating with Naprosyn (naproxen) for a diagnosis of pain at multiple sites, as well as medications for allergies and Hashimoto's thyroiditis. The patient submitted additional medical records and photos for consideration which were reviewed. The provider is seeking authorization to continue treatment with Fenoprofen which is the subject of this review.

The health plan's determination is upheld.

The requested therapy with Fenoprofen which is approved for the treatment of musculoskeletal pain due to osteoarthritis or rheumatoid arthritis (which the member does not have) will not be and has not been more effective than the multiple formulary alternatives. The member has no contraindication to all of the formulary alternatives including naproxen (which she is already taking alternating with Fenoprofen), nabumetone, ibuprofen, sulindac or, oxaprozin. She had hives while on Mobic but has a history of hives, so it is unclear if hives were actually related to this therapy, and she is able to tolerate at least two other nonsteroidal anti-inflammatory drugs (NSAIDs). The prescribing information for Fenoprofen indicate that just as with other NSAIDs, this medication can also cause gastrointestinal bleeding and cardiovascular adverse effects.
There is no indication that the member would not be able to tolerate all of the plan preferred NSAIDs for her generalized joint pain and is already tolerating naproxen based on her medical records. She has no medical proven contraindication to the plan preferred NSAIDs including naproxen and related products, nabumetone, ibuprofen, sulindac or, oxaprozin which are likely to be as effective as Fenoprofen. Therefore, the prior denial for Fenoprofen is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Mixed Hyperlipidemia. 
Treatment:  Crestor. 

The insurer denied Crestor.  The denial was overturned. 

This patient is a male with a history of mixed hyperlipidemia managed with Crestor 40 milligrams (mg) daily. The patient has a significant history of intolerances including severe nausea, dizziness, and allergic reactions such as diffuse body rashes to generic statin therapy in the past. He has been prescribed Crestor 40 mg daily by his treating physician and tolerated this medication well without side effects.

The treating physician has submitted a formulary exception request for coverage of Crestor 40 mg, for medical necessity to aggressively treat hyperlipidemia for cardiovascular risk reduction in the context of intolerances and allergic reactions to formulary generics. This formulary exception request has been denied by the patient's health plan.

The health plan's determination is overturned in whole.

Based on the patient's documented significant history of intolerances and allergic reactions to generic statin medications, the listed generic statin formulary medications would be poorly tolerated and cause significant adverse reactions. Treatment of this patient's hyperlipidemia with Crestor 40 mg daily is medically necessary and appropriate and supported by evidence-based published medical literature. [1,2]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Type 2.
Treatment: Pharmacy/Prescription Drugs (Tresiba).
The health plan denied the requested prescription medication. The health plan's determination is upheld.

This is a male with type 2 diabetes and insulin deficiency. He has tried and failed Lantus due to poor glucose control. He has been successful with Tresiba. The request for the continuation of Tresiba is under review.

I uphold, in whole, the health plan's determination of medical necessity.

No. the requested Tresiba is not medically necessary.
This patient has type 2 diabetes. The request is for Tresiba. The formulary alternatives are Lantus and Toujeo. The patient has tried and failed Lantus. The documentation does not indicate that the patient has tried and failed Toujeo. There is no documented contraindication to Toujeo. Toujeo is an ultra-long-acting basal insulin in the same class as Tresiba and is indicated for the treatment of type 2 diabetes. The American Diabetes Association clinical guidelines do not recommend the use of Tresiba over Toujeo. Tresiba and Toujeo are expected to be equally safe and effective in this clinical situation. Therefore, no, the requested Tresiba is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Irritable Bowel Syndrome with Constipation (IBS-C). 
Treatment: Linzess. 

The insurer denied coverage for the medication Linzess. 

The denial is upheld. 

This female patient has a history of irritable bowel syndrome with constipation (IBS-C), peptic ulcer disease, an acid reflux. The symptoms improved with proton pump inhibitors (PPI) but were not completely resolved. The patient does not have dysphagia but reports that solid food is slow to go through the esophagus. The patient also has had a work-up for chest pain including endoscopy and esophageal manometry. Her constipation had improved after starting Linzess. The submitted appeal states that Linzess was being requested for esophageal dysmotility difficulty with swallowing pills. 

UpToDate has an article titled "Management of chronic constipation in adults."  There are multiple treatment options given. These include fiber, laxatives, osmotic agents, stimulant laxatives, and Linactolide. 

In this case, the physician has written that the patient is not able to swallow pills due to an esophageal motility disorder. However, there are multiple formulary alternatives for the treatment of constipation. These include fiber preparations, Miralax, and lactulose.  
As per literature review, Linzess is approved for chronic idiopathic constipation and irritable bowel syndrome-constipation (IBS-C). However, the chart does not document which other laxative preparations have been tried and failed by the patient. Since there is no documentation of specific drugs for constipation that have failed, Linzess is not considered medically necessary for this patient at this time. 

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

The medical necessity is not substantiated. The carrier's denial of coverage for Linzess for the treatment of Irritable Bowel Syndrome with Constipation (IBS-C) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental implants. 

The insurer denied coverage for dental implants. 

The denial is upheld. 

This is a male patient who presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants and associated services for teeth areas 6, 8, 9, 11, 21, 22, 24, 26, 27 and 28. The dentist is requesting implants over removable partial dentures presumably due to the patient's limited flexion of the wrists, tenosynovitis and carpal tunnel syndrome for which the patient is receiving physical therapy. The insurer has denied the aforementioned services stating that in their estimation, endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants. The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary; it is considered elective and therefore, no benefit is available, allowing for removable dentures. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph and the medical records and imaging reports, the patient exhibits oligodontia in both the maxilla and mandible. As regards to the endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, as in this patient, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. 
Furthermore, in this case, the documentation provided does not support, justify or substantiate the requested treatment. Although it is clearly and adequately documented that there is a diagnosis of carpal tunnel syndrome, tenosynovitis, and tendonitis that potentially limits flexion of the wrists, nowhere in the medical records submitted is the claim or note that the patient is or would be unable to manipulate removable partial dentures. The patient retains motion in his hands and is receiving physical therapy to aid in restoring full mobility to his hands and wrists. Therefore, as removable dentures remain a standard of care in general dental practice and the medical documentation does not indicate a limitation precluding use or manipulation of partial dentures, the endosteal implants are not considered medically necessary for this patient. 

The request for dental implants is not considered medically necessary for this patient. 

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient. 

The medical necessity for dental implants is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain and dyspnea.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male.  At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN), dyslipidemia, and coronary artery disease (CAD) diagnosed by computed tomography (CT) angiogram, with a finding of severe left anterior descending (LAD) stenosis.  The patient presented to the emergency room (ER) with recurrent chest pain with associated dyspnea. The patient was hemodynamically stable. Given the recent diagnosis of coronary artery disease (CAD), as well as new onset chest pain, the patient was admitted for suspected unstable angina. He was referred for cardiac catheterization and was found to have no obstructive coronary artery disease (CAD). He was diagnosed with pericarditis and was discharged home on anti-inflammatory medical therapy.

Yes, the proposed inpatient admission was medically necessary.

The patient presented with new onset chest pain, suggestive of unstable angina. The patient had multiple risk factors for coronary artery disease (CAD), as well as a known history of coronary artery disease, which was diagnosed by coronary computed tomography (CTA), with a finding of severe left anterior descending (LAD) stenosis and was therefore referred for cardiac catheterization.  Given the presentation, as well as clinical suspicion for an acute coronary syndrome/unstable angina, she would not be an appropriate candidate for an emergency department (ED) chest pain observation unit, and 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: Overturned

Diagnosis: Substance Dependence 
 
Treatment: Inpatient Detoxification

The insurer denied the Inpatient Detoxification. The denial was reversed.   

This is a male patient who was admitted to this inpatient substance detoxification treatment in early 2019.  He was reportedly heavily drinking alcohol and smoking cannabis daily.  He had withdrawal symptoms including sweats, tremors, nausea, and anxiety, and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 12. He reportedly had multiple past inpatient substance detoxification and rehabilitation treatment and could not maintain abstinence. He had past history of blackouts and depression. He lacked coping skills and ability to identify relapse triggers. He was on a Librium protocol during his admission and was discharged several days later. He was referred for inpatient rehabilitation treatment after this detoxification treatment, but refused it.

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.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use large amounts of alcohol daily, continued to use despite past inpatient substance detoxification and rehabilitation treatments, required and needed detoxification medication (Librium) to modify withdrawal and was at risk for worsened severe, complicated, or life threatening withdrawal symptoms if not in this 24 hour setting then

The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis
Treatment: Humira Pen 40MG/0.8mL
The insurer denied the Humira Pen 40MG/0.8mL.
The health plan's determination is overturned.

The patient has a history of seropositive rheumatoid arthritis (RA). Humira was denied by the health plan as not medically necessary and formulary alternatives (methotrexate (MTX), leflunomide, Plaquenil and sulfasalazine (SSz) are recommended. Prior treatments include: many nonsteroidal anti-inflammatory drugs (NSAIDs), prednisone and MTX (stopped due to nausea as well as lack of efficacy per chart review) . She is currently on leflunomide in addition to Humira  and has experienced improvement. At issue is the medical necessity of the Humira.
The requested health service/treatment of Humira pen 40 milligrams (MG)/0.8 milliliters (mL) is medically necessary for this patient. The patient has tried and failed MTX. She is currently on leflunomide, in addition to Humira, which was added as leflunomide monotherapy was not adequate at controlling her RA. She has already tried 2/4 formulary alternatives and is currently on one of them.
If a patient with RA has not achieved remission or low disease activity with a disease-modifying antirheumatic drug (DMARD), the next step in managing their RA is to start a biologic medication, such as Humira (adalimumab). According to UpToDate, 'in patients resistant to MTX after three to six months of treatment at optimal doses and route of administration (usually 25 mg/week), we suggest either the use of DMARD "triple therapy" with MTX plus SSZ and hydroxychloroquine (HCQ), or the combination of continued MTX plus the addition of a tumor necrosis factor (TNF) inhibitor, rather than monotherapy with another nonbiologic DMARD or biological (b) DMARD'. (1) According to a study published in the Journal of Rheumatology, 'addition of adalimumab 40 mg given subcutaneous (SC) every other week to concomitant standard antirheumatic therapy is well tolerated and provides significant improvements in signs and symptoms of RA. The data indicate that adalimumab is a safe and effective therapeutic option in patients with active RA who have an inadequate response to standard antirheumatic therapy, including one or more traditional DMARDs, corticosteroids, NSAID, and analgesics'. (3) In this case, the patient was unable to tolerate MTX due to nausea. She is on lefluonmide (a DMARD) so her provider added a biologic (in this case Humira), which is a reasonable and appropriate next step in the treatment of her RA.
Therefore, the Humira is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia
Treatment: Per oral endoscopic myotomy
The insurer denied the Per oral endoscopic myotomy.
The denial is overturned. 

The patient is a male with obesity, sleep apnea and Achalasia. His provider is requesting treatment with POEM (per oral endoscopic myotomy).

Yes, the health plan should cover the per oral endoscopic myotomy.

POEM (per oral endoscopic myotomy) is safe and effective treatment for achalasia. It is less invasive than Heller myotomy, and as it has a positive effect on health outcomes. It is more likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease, and more likely to be safer in this obese patient with sleep apnea, than a surgical procedure, Heller myotomy.

Therefore, given the above, the health plan should cover the per oral endoscopic myotomy.

Yes the requested per oral endoscopic myotomy is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.
Medical literature supports that POEM (per oral endoscopic myotomy) is safe and effective treatment for achalasia, and has a positive effect on health outcomes.

Per Inoue, H., et al., "Per-oral endoscopic myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used. Adverse events were rare (3.2%), and there were no mortalities. Significant improvements in Eckardt scores and LES (lower esophageal sphincter) pressures were seen at 2 months, 1 year, and 3 years post-POEM (per oral endoscopic myotomy). Based on our large series, POEM (per oral endoscopic myotomy) is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy."

Per Patel, K., et al., "In conclusion, POEM (per oral endoscopic myotomy) is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia-related symptoms. Randomized comparative studies of Laparoscopic Heller Myotomy and POEM (per oral endoscopic myotomy) are required to determine the most effective treatment modality, with additional investigation of more novel metrics such as EndoFLIP and objective measures of reflux (e.g. impedance studies) pre- and post-treatment."

Lastly, per Zaninotto, G., et al., "Recommendations: we conditionally recommend POEM (per oral endoscopic myotomy) as an effective therapy (control of symptoms) for achalasia both in short- and medium-term follow-up with results comparable to Heller myotomy for symptom improvement."

POEM (per oral endoscopic myotomy) is safe and effective treatment for achalasia. It is less invasive than Heller myotomy, and it has a positive effect on health outcomes. It is more likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease, and more likely to be safer in this obese patient with sleep apnea, than a surgical procedure, Heller myotomy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history (PMH) of hypertension (HTN), diabetes mellitus type 2 (DM2), and alcohol dependence and was admitted for alcohol detoxification after being found to have ketonuria and hyperglycemia and was transferred to the medical floor. His vital signs were unremarkable. The physical exam was unremarkable. Lab work was notable for ketonuria, a plasma glucose of 417, carbon dioxide (CO2) 22, negative serum ketones, and potential of hydrogen (pH) of 7.46.A chest x-ray (CXR) showed no acute disease. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with mild diabetic ketoacidosis (DKA) and alcohol dependence, and treated with insulin, fluids, a metabolic work-up, endocrinology consultation, vitamin supplementation, and clinical monitoring. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The inpatient hospital stay was not medically necessary. This patient with a known history of DM2 was admitted for alcohol detoxification without acute withdrawal and was found to have hyperglycemia/mild DKA. The patient was provided with fluids and insulin, in addition to an endocrinology consultation. He was hemodynamically stable, had near-normal CO2 levels, a readily treatable cause of hyperglycemia, the hyperglycemia was not new-onset, there was normal anion gap, no obtundation, no hyperosmolar hyperglycemic state, pH greater than 7.2, no acute mental status changes, end stage renal disease (ESRD), sepsis, hemodynamic instability, acute cerebrovascular accident (CVA), acute myocardial infarction (MI), infections or serious complications. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Evaluation for transient ischemic attack.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned. 

This is a female patient with a medical history of asthma and diabetes mellitus who was brought in by ambulance to Emergency Department (ED) after experiencing syncope while at work.  The patient reported having diarrhea for the prior 2 days after starting new medications, Metformin and Enalapril and experienced left sided weakness and numbness the prior night. She was at work on day of arrival, talking to a coworker, and then she woke up on the floor.  Physical examination was remarkable for left upper weakness and paresthesia.  Chest x-ray showed decreased lung expansion with mild to moderate congestive changes.  Computed tomography (CT) of the head was negative.  The patient received, Aspirin oral and Albuterol inhaler and blood pressure medication was held for permissive hypertension.  The patient was admitted for further evaluation and management of left sided weakness possibly secondary to transient ischemic attack (TIA)/ stroke and syncope possible due to dehydration.  The patient was treated further with intravenous (IV) fluids and continued to receive bronchodilators as needed.  

This patient was admitted to evaluate for a TIA.  She had persistent left-sided weakness/numbness.  This patient had an ABCD2 score of 6 (elevated blood pressure of 170 at presentation, unilateral weakness, diabetes, symptoms lasting over 50 minutes).  

The ABCD2 score is a validated, seven-point, risk-stratification tool to identify patients at high risk of stroke following a TIA.1  

Patients with scores >=5 such as this patient are at high risk of stroke in the period following a TIA, and may potentially require urgent intervention as inpatients, making inpatient admission appropriate.

The admission was medically necessary to evaluate this possible TIA and minimize her risk of subsequent stroke.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.