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

High Cholesterol
Pharmacy/Prescription Drugs

The patient is a man with a history of hypertension, hyperlipidemia, prediabetes and a family history of premature atherosclerotic cardiovascular disease. His coronary calcium score is 1124, placing him in the 94th percentile for his age and gender. Cardiac catheterization revealed a 60% right coronary artery stenosis. On Praluent, rosuvastatin 40 milligrams (mg) daily and ezetimibe 10 mg daily, his low density lipoprotein (LDL) cholesterol level was 13 mg/dl. From the records provided, it is not clear how long he has been taking Praluent or what his LDL cholesterol was prior to starting Praluent. Coverage for Praluent is at issue.

The health plan's determination is upheld. Praluent is not medically necessary for this patient. Praluent is a member of a class of lipid-lowering drugs called PCSK9 inhibitors. These drugs have been shown to be superior to other lipid lowering agents and have been demonstrated to have salutary effects on cardiovascular health outcomes. Current guidelines support their use in patients with clinical ASCVD whose LDL cholesterol levels remain above goal despite treatment with maximally tolerated statin therapy. The patient's most recent LDL cholesterol level was below his National Lipid Association recommended goal level of less than 70 mg/dl. However, the records provided in this instance do not indicate what the patient's level was prior to starting Praluent. Without documentation that the level was above goal prior to starting therapy, Praluent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Depression
Mental Health: Inpatient

The patient is a woman with diagnoses of Major Depressive Disorder (MDD) without psychosis and Polysubstance abuse (PSA). Case notes document that the patient was referred to hospital after an overdose. She was experiencing multiple high stress situations at the time of the overdose, including going through a divorce and being unemployed. She had a recent history of failing rehabilitation treatment three weeks prior to the admission under review. Her admission mental status documented low mood, low energy, low motivation, poor concentration, insomnia, anergia, anhedonia, and poor impulse control.

The health plan's determination is overturned. The PIHS level of care until discharge is medically necessary for several reasons. This patient suffers from chronic and severe MDD complicated by polysubstance abuse. She had recently relapsed after substance rehabilitation with a positive urine drug screen. She was undergoing high stress life situations. She had made a prior suicide attempt, She was described as very needy and medication seeking during her PIHS. Premature discharge had a high likelihood of her needing to return to hospital or taking another overdose or resuming substance use.
Case notes document the need for PIHS: she was still depressed and anxious with continued insomnia which out of hospital would most likely cause her to see substance use. However, she was still medication seeking, with decreased but still present anxiety and depressive symptoms. Poor social attachment is associated with increased suicide risk. She became more cooperative, but still anxious, drug seeking, isolative, depressed and anxious. Only on dischargewas she described as being without depressive symptoms or irritability or paranoia. Her mood appeared to be normal without suicidal ideation or homicidal ideation, and without any psychosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteogenic Sarcoma
 
Treatment: Computed Imaging (CT) Scan of the Chest

The insurer denied the Computed Imaging (CT) Scan of the Chest The denial was reversed.

This is a male patient with a medical history of left proximal femoral osteogenic sarcoma status post resection over a decade ago with an intercalary segmental replacement and vascularized fibular graft, L5 disk bulge with epidural injections treatment. The patient underwent a computed tomography (CT) of the chest to evaluate his osteogenic sarcoma; there were no changes noted from his prior CT several years ago. 
Based on the National Comprehensive Cancer Network (NCCN) (2020) surveillance guidelines, the NCCN recommends imaging of the primary site yearly after years 4 and 5 in this clinical scenario. 

Per Prater, S. and McKeon, B. (2019), "OSTEO-4 (Follow-up & surveillance) Surveillance schedule:

1)	Every three months for post-op years 1 and 2
2)	Every four months in post-op year 3
3)	Every six months in post-op years 4 and 5
4)	Yearly for post-op years six and beyond

Surveillance visit should include:

1)	Physical exam with assessment of function
2)	Imaging of post-op site and chest
3)	Consider Positron Emission Tomography/Computed Tomography [PET/CT] or Bone scan
4)	Complete blood count [CBC] +/- additional laboratory tests as clinically indicated (e.g., alkaline phosphatase levels)

If a relapse is detected, the following are the guidelines to follow:

1)	Chemotherapy +/- resection (if possible)
2)	Response to these treatments should have an evaluation via:
3)	Radiographs of the original tumor site
4)	CT or MRI (both with contrast) of the site of relapse
5)	CT of the chest to assess for pulmonary lesions"

Per Cipriano, C., Griffin, A. M., Ferguson, P. C., & Wunder, J. S. (2017), "With the numbers available for study, the overall local recurrence-free survival did not differ between sarcoma grades at any time points (p = 0.864).  Metastasis-free survival curves differed between sarcoma grades (p < 0.001), and the pattern of Grade 2 osteosarcoma [OSA] metastasis was more consistent with other Grade 3 sarcomas, so it was subsequently classified as high grade.  No metastases of Grade 1 sarcomas occurred after 3 years, whereas Grade 2 and 3 sarcomas continued to metastasize until 10 years and rarely thereafter.  According to the number of new pulmonary metastatic events per patient-year in each group, we propose that chest surveillance be performed according to the following schedule: annually only until 5 years for low-grade sarcomas; every 3 months for 2 years and annually from 2 to 10 years for intermediate-grade sarcomas; and every 3 months for 2 years, every 6 months from 2 to 5 years, and annually from 5 to 10 years for high-grade sarcomas."          
   
Therefore, the health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The computed tomography scan of the chest was considered medically necessary for this patient.

The carrier's denial of coverage for the computed tomography scan of the chest is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis 
Treatment: Continued inpatient admission 
The continued inpatient admission was medically necessary. 

The patient is a male whose continued inpatient admission is under review. The patient has a history of DM (diabetes mellitus), COPD (chronic obstructive pulmonary disease), CAD (coronary artery disease), obesity, HTN (hypertension), a-fib (atrial fibrillation), and L BKA (left below-knee amputation). He presented with fever, rigors and confusion. He was found to have cellulitis, sepsis (leucocytosis, bandemia), and metabolic encephalopathy. He was started on IV cefepime and vancomycin, and admitted. He improved over the next two days. IV antibiotics were changed to cefazolin, and then to PO (oral) antibiotics on the first day under review. He was then discharged the next day. 

The patient presented with a severe infection that met criteria for admission for cellulitis according to the Infectious Diseases Society of America (1). Of particular concern, the patient had systemic signs of infection with a high WBC (white blood cell) count, bandemia, lactic acidosis, and confusion. Although the patient did have improvement by the first day under review, standard of care would have required continued observation for the following reasons: 1) Continued inpatient monitoring because of sepsis with encephalopathy, lactic acidosis, and bandemia, 2) Following up blood culture results, and
3) Ensuring continued improvement of leg cellulitis. 

Thus, this admission was warranted, supported by IDSA guidelines, and continued admission was supported by standard of care. Failure to treat such as a patient as an inpatient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet, overbite, crowding
 
Treatment: D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit. The denial is upheld. 

This patient is a female child who it appears that this patient presented for evaluation for orthodontic care. The Orthodontist identified several clinical findings including overjet, overbite, crowding and has recommended orthodontics. The orthodontist has completed the HLD index attaining 27 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 21 points on the HLD index.

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 27 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 21 points on the HLD index (8 overjet, 5 overbite, 5 anterior crowding and 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

In this case the HLD index total score of 21 points remains below the threshold of 26 points to justify orthodontic care. The D8080 braces and D8670 monthly visit is not considered medically necessary for this patient.

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

Based on the above, the medical necessity for D8080 braces and D8670 braces is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with age related osteoporosis as well as degenerative joint disease (DJD) in her knees and stage 2 chronic kidney disease (CKD). She was on alendronate without any improvement and then Prolia  She was due for Prolia again but it was denied by her health plan as the following critera was not met: 'there has been inadequate information provided with this prior authorization request. Please have your doctor submit the following information for further review: bone density scan results after at least 2 years of treatment with Prolia'. Per chart review and a note from her provider dual-energy x-ray absorptiometry (DEXA)  with osteoporosis. There was another DEXA done that also showed osteoporosis. At issue is the medical necessity of Prolia.
The health plan's determination is upheld.
The requested service, treatment with Prolia, is not medically necessary at this time.
According to the National Osteoporosis Foundation (NOF), a bone density scan should be done every 1-2 years in people taking osteoporosis medications. This should be done to monitor their disease to see whether their osteoporosis is stable, improving or progressing.  Although the patient is tolerating Prolia injections well, the last DEXA scan is from over 2 years ago.
Therefore, without the results of a recent DEXA scan the Prolia cannot be determined medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems - Coronary artery disease/CAD
Pharmacy/Prescription Drugs

The patient is a morbidly obese male with hypertension, prediabetes, heterozygous familial hypercholesterolemia and atherosclerotic coronary artery disease. He has been intolerant to multiple statins, including rosuvastatin, atorvastatin and simvastatin. He is currently taking lovastatin 80 milligrams (mg) daily and Praluent, which he has been on for two years. The patient had a prior trial of Repatha and had an adverse dermatologic reaction. The patient's low density lipoprotein (LDL) cholesterol level was 68 milligrams per deciliter (mg/dl). The subject under review is the medical necessity for Praluent; the preferred formulary option is Repatha.

The health plan's determination is overturned.

Praluent (alirocumab), like Repatha (evolocumab), is a member of a class of lipid lowering agents called proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. These drugs have proven superior to other classes of drugs in reducing LDL cholesterol levels. Both also have been shown to improve cardiovascular outcomes. Current guidelines endorse the use of a PCSK9 inhibitor for patients with heterozygous familial hypercholesterolemia or atherosclerotic cardiovascular disease whose LDL cholesterol levels remain above goal despite maximally tolerated statin therapy. There are no data demonstrating that either PCSK9 inhibitor is clearly superior to the other.
In this instance, the Plan's preferred PCSK9 inhibitor is Repatha. However, the patient has a history of an adverse reaction to Repatha. He meets accepted criteria for use of a PCSK9 inhibitor. Given his inability to tolerate Repatha, Praluent is medically necessary in this instance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Poor visual acuity; hypertensive cardiovascular disease
Treatment:  Increase in consumer directed personal assistance services from 53 hours/week to five days/week, 24 hours/day live-in

The proposed treatment of an increase in consumer directed personal assistance services from 53 hours/week to five days/week, 24 hours/day live-in is deemed medically necessary. 

This is a female with a history of poor visual acuity/legal blindness, hearing loss, depression and hypertensive cardiovascular disease.  Due to impairments related to these conditions, she requires assistance with the majority of her activities of daily living (ADLs).  Per documentation from the patient's Attending Physician, the patient's heart condition results in chronic fatigue, dyspnea and generalized weakness, resulting in the need for 24 hr assistance for bed mobility, transfers, ambulating, toileting and fall prevention.  For these reasons, the currently approved plan of 53 hours/week consumer directed personal assistance services is insufficient to meet the patient's current medical needs.  Hence, the proposed treatment of an increase in consumer directed personal assistance services from 53 hours/week to five days/week, 24 hours/day live-in is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diabetes
Inpatient hospital

The patient is a male with diabetes and hepatitis B (with viral clearance) who was sent to the hospital by his primary care physician for glucose levels in the 600s. The patient noted urinary frequency, decreased appetite, weight loss, lower extremity weakness, low back pain, and lower extremity pain. Labs demonstrated a white blood cell count 9.0, potassium 4.9, bicarbonate 29, creatinine 1.35, and glucose 387. Lower extremity Dopplers demonstrated no deep venous thrombosis. It was noted that an outpatient line antibody was positive; Lyme titers were ordered. Intravenous fluids and subcutaneous insulin were administered, and metformin dosing was adjusted. Serial glucose levels were followed and demonstrated improved glycemic control. The creatinine dropped to 1.2.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had hyperglycemia but did not have nonketotic hyperosmolar state or diabetic ketoacidosis. There was no evidence of ketonuria, severe acute kidney injury, acidemia, vomiting, severe persistent dehydration, mental status change, or seizure activity. Glycemic control improved with subcutaneous insulin and metformin; an insulin infusion was not required. The patient remained hemodynamically stable and afebrile. The inpatient hospital admission was not medically necessary for this patient. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Major Depressive Disorder, Substance Use Disorder

Treatment:  Outpatient Mental Health Treatment

The insurer denied the outpatient mental health treatment.  The denial was reversed. 

This is a female patient with a history of substance abuse.  She presented to a facility for intense outpatient mental health program.  It was reported that she had just participated in a partial hospital program.  She was noted to have depressed and anxious mood, social isolation, low energy and motivation, and increased sleep.  The patient's polysubstance abuse included use of stimulants, benzodiazepines, LSD, cannabis, cocaine, and alcohol.  Despite multiple medication changes and multiple therapies that included individual, group and family, she continued to struggle with her symptoms of depression and anxiety. 

The American Psychiatric Association (APA) Practice Guidelines for the treatment of Patients with Major Depressive Disorders reports that the determination of an appropriate setting for treatment should include consideration of the patient's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning. The APA guidelines indicate that the determination of a treatment setting should also include consideration of the patient's ability to adequately care for him- or herself, to provide reliable feedback to the psychiatrist, and to cooperate with treatment of the major depressive disorder. 

Based on the this review of the medical notes, this patient continued to struggled with symptoms of depression and anxiety despite medication adjustments and was socially withdrawn and had difficulty coping with her mood.  The patient was also noted to have low awareness of her issues, and showed apathy towards maintaining sobriety.  The severity of this patient's unstable mental and behavioral health initially required treatment at the partial hospital program.  It was consistent with the American Psychiatric Association (APA) guidelines and standard of care to transition the patient to this next, least restrictive level of care and to provide further support until the patient's symptoms were well-controlled on a stable medication regimen, and the patient's care could be safely and effectively provided at a less intensive outpatient program or plan.

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

The carrier denial of coverage for intensive outpatient mental health treatment is reversed.  The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 1 Diabetes

Treatment: Afrezza 4 & 8 & 12UNIT IN POWD

The insurer denied Afrezza 4 & 8 & 12UNIT IN POWD. The denial was upheld.   

This is a male patient with a history Type 1 diabetes mellitus (DM), and hypothyroidism.
He consulted an endocrinologist as he was interested in switching his current insulin medication Humalog to inhaled insulin called Afrezza. It was reported that the patient is using Omnipod insulin pump for his insulin administration and that he has not tried formulary alternatives yet.

The patient is using an Omnipod insulin pump. There is no additional support for the need for inhaled insulin on any kind.

The formulary drug is not likely to cause any adverse reactions. Inhaled insulin Afrezza is the only other ultra-fast-acting mealtime insulin. Afrezza and Fiasp have not been compared in a head-to-head study.      

The formulary drug has not been ineffective based on the patient's clinical history. The patient's most recent A1c of 7.1 indicates good control of his blood sugars.     

The requested drug is not expected to be more effective that the formulary drug. The patient's most recent A1c of 7.1 indicates good control of his blood sugars.

Ranamukha, S. et al. (2018), "Fiasp (insulin aspart, Novo Nordisk) is a faster-acting injectable insulin formulation that is administered subcutaneously (SC) for blood glucose management. We hypothesized that intradermal (ID) administration could improve the pharmacokinetic profile of Fiasp when compared to traditional SC injection."

The carrier's denial of Formulary Exception for Afrezza 4 & 8 & 12UNIT IN POWD is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis 

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was upheld. 

This is a male patient who presented to the Emergency Department (ED) with complaints of abdominal pain with vomiting.  Laboratory workup was performed revealing leukocytosis. A computed tomography (CT) scan was done that showed appendicolith at the base of a moderately distended appendix measuring up to 10 mm with no abscess; there was suspicion for acute appendicitis.  The patient was made nothing by mouth (NPO). Intravenous (IV) fluids and antibiotics were administered and IV morphine for pain management. The patient underwent a laparoscopic appendectomy without complications. The patient's diet was advanced as tolerated.  He was medically stable and was discharged home with outpatient follow up instructions.

MCG notes that for patients with appendicitis, without abscess or peritonitis, the patient should undergo an appendectomy as an ambulatory procedure.  They further indicate that an inpatient is reserved for patients over 65 years of age or patients with toxicity, active comorbidities or an inability to arrange adequate outpatient support. The patient presented at the hospital and was found to have appendicitis.  The patient underwent a laparoscopic appendectomy.  The patient could have undergone the appendectomy as an ambulatory procedure and could have been discharged from the Post-Anesthesia Care Unit (PACU) post procedurally or been observed overnight if complications were noted. The patient had no complications noted.  The postoperative recovery was normal.  Therefore, the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The hospital admission was not medically necessary.

Based on the above, the medical necessity for the hospital admission is not substantiated.  The insurer's denial is upheld.