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

Diagnosis: Left leg varicose veins.
Endoluminal Albation Of Varicose Veins (procedure code 36475 and 36478).
The insurer denied the Endoluminal Albation Of Varicose Veins (procedure code 36475 and 36478).
The denial is overturned. 

The patient is a female. She presents with left leg varicose veins and symptoms of leg achiness, fatigue, heaviness and swelling. She has worn compression stocking with minimal relief. Duplex demonstrates marked enlargement and severe reflux of the left greater saphenous vein. The provider has recommended endovenous ablation.

Yes, the Endoluminal Albation Of Varicose Veins (procedure code 36475 and 36478) is medically necessary.
In order to determine the medical necessity of the procedure, widely accepted criteria will be applied.

Under widely accepted criteria [1-7], endovenous ablation of an axial saphenous vein is medically necessary when the patient meets the following:

The patient has venous insufficiency symptoms severe enough to affect normal function.

The patient has failed a trial of prescription compression stockings.

The patient has duplex-proven reflux affecting the vein in question, and the reflux can be reasonably construed as a cause of the patient's symptoms.

Requirement 1 has been met. The office notes state that the patient had leg pain, aching, fatigue, swelling and heaviness. These symptoms can reasonably be expected to impair normal function. The patient's occupation requires long periods of standing, which is known to exacerbate symptoms of venous insufficiency.

Requirement 2 has been met. The patient reported that she had minimal benefit after using compression stockings and other conservative modalities.

Requirement 3 has been met. The venous reflux study showed severe enlargement (10 mm [millimeters] at junction; 7.3 mm [millimeters] below) and severe reflux (well over 500 msec [milliseconds]) in the left greater saphenous vein.

Therefore, the patient meets published, well-accepted criteria for the proposed ablation therapy. As such, it is medically necessary.

Coverage was denied on the basis that the patient did not have impairment of normal function. However, the medical records describe symptoms that can be inevitably impair normal function.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Migraine.
Treatment:  Botox Injection.

The insurer denied the Botox injection.  The denial is upheld. 

The patient is a female with history of migraines, which progressively worsened to 15 or more headaches per month lasting at least four hours at a time.  The headaches woke her from sleep and were also associated with nausea, fatigue, anxiety, irritability, and she had difficulty concentrating. She missed a lot of school due to her headaches.

The patient has tried and failed multiple medications including Nurtec, Effexor, hydroxyzine, gabapentin, and Topamax, as well as DHE (dihydroergotamine) infusions. She also tried Maxalt, but this was not effective in aborting her headaches either, and it caused side effects of a burning sensation in her mouth.  Nurtec was only effective in reducing her 10/10 headache severity down to 8/10 in severity.  Her neurologist recommended Botox injection therapy. Crowded airway and obesity were noted, and polysomnogram was recommended as well.

No, the treatment with Botox is not medically necessary.

This treatment is not appropriate for the patient's age. The patient was tried on only one FDA (Food and Drug Administration)-approved preventative medicine for migraine, namely Topamax. There are multiple other medications that can be tried. Botox is not approved by FDA (Food and Drug Administration) for pediatric age for migraine prevention. Additionally, the patient has crowded airway and obesity, which are risk factors for obstructive sleep apnea - known to worsen chronic migraines.

Botox injections are not medically necessary in the patient's case. Standard of care would dictate that patients that are at risk for obstructive sleep apnea, such as this patient, first be checked for this condition. Additionally, the patient has only tried on one preventative medicine approved by FDA (Food and Drug Administration), and there are several other medications which are effective in pediatric age, including Depakote, propranolol and amitriptyline. Therefore, the treatment with Botox is not medically necessary, and the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumobilia.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a female patient who presented to the Emergency Department (ED) complaining of nausea as well as vomiting and abdominal pain. The patient's past medical history was significant for diabetes and hyperlipidemia. The patient's physical examination revealed abdominal tenderness to the epigastric area. The patient's blood pressure was 145/81. The patient's pulse was 77 and her oxygen saturation was 100%. The physician indicated that the patient should undergo laboratory diagnostic studies. Multiple laboratory and diagnostic studies were done; the patient was found to have COVID-19 [Coronavirus Disease 2019] polymerase chain reaction (PCR) test positive. The patient's computed tomography (CT) scan of the abdomen and pelvis showed sigmoid diverticulosis without evidence of diverticulitis. The patient was status post cholecystectomy with a dilated common bile duct (CBD) to 1.2 centimeters in pneumobilia. The patient's chest X-ray revealed no acute pulmonary disease. The patient's ultrasound of the abdomen indicated intrahepatic pneumobilia. The patient's laboratory studies showed: sodium of 120 with calcium at 7.9; blood urea nitrogen (BUN) < 4. The physician indicated that the patient should be admitted due to the patient's clinical presentation. The admission note does not list the COVID test as a reason for admission. The infectious disease consult, when the result of COVID test was positive, stated that there was no need for therapy related to COVID unless there was a change in the patient's clinical condition. The patient was evaluated by the surgical team and they recommended magnetic resonance cholangiopancreatography (MRCP) for the patient. The patient's MRCP noted a dilated CBD which was likely related to her post cholecystectomy state.  The patient's hyponatremia resolved with intravenous (IV) fluids. There were no further significant adverse events during this patient's inpatient stay. 

Based on the review of the medical record, the patient had no evidence of concerning clinical features suggestive of systemic inflammatory response syndrome (SIRS). The patient's labs are unremarkable except for severe hyponatremia which warranted observation. The patient was tested positive for COVID but the patient presented with no respiratory issues and her chest X-ray did not reveal pneumonia. As per this patient's CT scan and MRCP, this patient with a history of cholecystectomy presented with pneumobilia. As per literature, pneumobilia after cholecystectomy is common and does not warrant admission. Overall, based on the clinical description, imaging studies and labs, the patient could have been managed under observation.

Inpatient hospital admission was not medically necessary for this patient.

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

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

Diagnosis: Respiratory Failure
Treatment: Custodial Care
The health plan denied the request for custodial care. 
The health plan's determination is upheld.

The patient is a female with a history of morbid obesity, falls, congestive heart failure, hypertension, diabetes, and peripheral neuropathy who is currently in a rehabilitation center.  A request has been made by the treating physician for custodial care at a skilled nursing facility.

The health plan's determination of medical necessity is upheld, in whole.

The requested health service of custodial care is not medically necessary for this patient.
Based on the documentation provided, this patient has been in the rehabilitation facility for >90 days with significant gains with improvement in functional status. Most of the initial goals that were set by her therapist were met, such as improvement in muscle strength in the upper and the lower extremity, improvement in dynamic sitting balance ( improved 95%), improved functional transfers with modified independence. She was noted to need assistance with some activities of daily living (ADLs), notably with toileting. She was initially totally dependent on admission, now she is noted to be able to perform some ADLs but needing some assistance with set up. It is clear that she was not yet at an independent functional level, and requires some assistance with ADLs, however this can also be achieved at a home setting with set up for assistance at home. It did state that the discharge plan was for her to go home with support from others which is feasible based on level of function.
The patient still requires assistance with ADLs as well as continued skilled therapy as per therapists she is improving and expected to reach prior level of function and making consistent progress towards goals and good rehabilitation potential. Ongoing physical therapy (PT) skilled services are recommended which is medically necessary for her to achieve functionality and progress to baseline. This can also be achieved at a home setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sarcoidosis.
Treatment: Humira.
The insurer denied coverage for Humira for Sarcoidosis.
The denial is overturned. 

This is a male patient with a history of sarcoidosis. The diagnosis was made from a biopsy of the lung, and positron emission tomography (PET) scan signals in the heart and lung. The patient has tried high dose steroids with a partial response. The patient was also placed on mycophenolate mofetil (MMF). While the patient's cardiac inflammation decreased with MMF treatment, the patient developed life-threatening Herpes Zoster in the eyes; the patient's infection responded to valacyclovir treatment. The patient cannot resume MMF treatment because of this complication. The physician is requesting Humira to treat this patient's sarcoidosis. In a visit note, the provider indicates that anti-tumor necrosis factor (TNF) therapy is recommended for this patient.    

As per UpToDate article on "Management and prognosis of cardiac sarcoidosis", cardiac involvement is a poor prognostic indicator for patients with sarcoidosis. It is an uncommon manifestation of an already rare disease.  Given these considerations and the lack of Food and Drug Administration (FDA)-approved treatments, treatment decisions have to be made on limited data. Humira is an alternative therapy in steroid-resistant cardiac sarcoid. In a study in the Journal of the American Heart Association (JAHA) September 17, 2019 Vol 8, Issue 18 "Long-Term Corticosteroid-Sparing Immunosuppression for Cardiac Sarcoidosis," Rosenthal et al. (2019) states that there are no good trials of immunosuppression in cardiac sarcoid. This particular retrospective study looked at methotrexate with and without Humira, and found methotrexate alone and methotrexate plus Humira worked. 

As per literature review, there is no standard of care for choice of steroid-sparing agent in cardiac sarcoid where high-dose steroids have not worked well and the patient cannot tolerate Cellcept. Treatments are off-label. There is limited data for Humira as well as other alternatives such as methotrexate. There are no comparative trials. Any recommendation that is made has limited clinical support. There is little expectation for large, double-blind, randomized or comparative trials given the rarity of this patient's condition. As there is some literature that supports the use of Humira (and its analogue Remicade) in general and in cardiac sarcoid in particular, it is a reasonable choice for this patient.

Based on the review of the medical record and literature, Humira is considered medically necessary for this patient's treatment.

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

The carrier's denial of coverage for Humira for Sarcoidosis should be overturned. The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Osteoarthritis and Gastric ulcer.

Treatment: Formulary Exception for Naproxen-Esomeprazole Magnesium 500-20mg [milligrams] tab [tablet] (Vimovo).

The insurer denied coverage for the Formulary Exception for Naproxen-Esomeprazole Magnesium 500-20mg [milligrams] tab [tablet] (Vimovo).

The denial is upheld.

This is a female patient with a history of gastric ulcer and osteoarthritis. She was complaining of gastrointestinal side effects from non-steroidal anti-inflammatory drugs (NSAIDS). She has requested a combination medication, Vimovo, which contains Naproxen and Esomeprazole. The insurance company has denied Vimovo but has suggested using separate prescriptions for Naproxen and Esomeprazole. 

The Up-To-Date article titled "Proton Pump Inhibitors: Overview of use and adverse effects in the Treatment of acid related disorders" indicates, Peptic ulcer disease is an indication for proton pump inhibitor (PPI) use. However, the article states that there is no consistent difference in relation to symptom resolution between various PPI. The magnitude of pharmacological differences is small and the clinical relevance of these has not been established.

It is appropriate for this patient to be given a PPI and Naproxen. However, both of these medications can be given separately. There is no scientific data that giving both medications in one formulation is superior to giving two individual prescriptions. The formulary drugs of Naproxen and Esomeprazole are not more likely to cause an adverse reaction. Giving the drugs as two separate prescriptions would not make it less effective. The requested drug is equivalent to prescribing Esomeprazole and Naproxen separately and would not be more effective.

The carrier's denial of Request for Formulary Exception for Naproxen-Esomeprazole Magnesium 500-20mg [milligrams] tab [tablet] (Vimovo) is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  H pylori (Helicobacter pylori) gastritis.
Treatment:  Formulary exception for Pylera.

The insurer denied the Formulary exception for Pylera.  The denial is upheld. 

The patient is a female with H pylori (Helicobacter pylori) gastritis. Her provider is requesting treatment with Pylera.

No, the health plan should not cover the Formulary exception for Pylera.

The patient has H pylori (Helicobacter pylori) gastritis. The plan preference that three preferred alternatives be tried before Pylera can be covered is not unreasonable. The patient has not tried and failed preferred formulary alternatives. There is no medical literature to support that Pylera is more effective than clarithromycin and amoxicillin with proton pump inhibitor (omeprazole, lansoprazole, esomeprazole, pantoprazole, or rabeprazole); or metronidazole and tetracycline with proton pump inhibitor (omeprazole, lansoprazole, esomeprazole, pantoprazole, or rabeprazole), for the treatment of H pylori (Helicobacter pylori). Therefore, the health plan should not cover the formulary exception for Pylera.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced dementia with associated cognitive impairment, gait ataxia, fecal and urinary incontinence. 
Treatment: Increase Personal Care Services 12 Hours per Day, 7 Days per Week, 84 Hours Total. 

The insurer denied the Increase Personal Care Services 12 Hours per Day, 7 Days per Week, 84 Hours Total. 

The denial is overturned. 

The patient is a female with a history of advanced dementia with associated cognitive impairment, gait ataxia, fecal and urinary incontinence. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 84 hours per week Personal Assistance Services to offer increased activities of daily living support. 

Yes, the proposed treatment of 84 hours per week Personal Assistance Services is deemed medically necessary. 

This is a female with a history of advanced dementia with associated cognitive impairment, gait ataxia, fecal and urinary incontinence. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living. 

Recent correspondence from the patient's medical provider indicates that due to progressively worsening functional decline, the patient is chronically wheelchair bound, maximum assist for all forms of ambulation and maximum assist for completion of all of her activities of daily living. Hence, the currently approved plan of 56 hours per week Personal Assistance Services is not sufficient to meet the patient's current needs. For these reasons, the proposed treatment 84 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ruptured arteriovenous malformation. 
Treatment: Consumer Direct Live-in 7 Days per Week, 1 Client (Health Plan approved 35 hours/week). 

The insurer denied the Consumer Direct Live-in 7 Days per Week, 1 Client (Health Plan approved 35 hours/week). 
The denial is overturned. 

The patient is a female with history of ruptured arteriovenous (AV) malformation. She has continued neurological impairments affecting her ability to perform Activities of Daily Living (ADLs), ambulate & mobilize independently, along with associated truncal instability, motor paresis/left hemiparesis, visual deficits, balance & coordination deficits, speech & language deficits that includes dysarthria, oropharyngeal dysphagia and dysphonia. She requires continuous physical, occupational and speech therapies towards helping her improve her independence in self-care, mobilization and ambulation. 

The patient had a period on rehabilitation at home that was interrupted due to the COVID (Coronavirus disease) lock down, and also because she was infected with COVID-19. 

The treating physician is requesting 24-hour supervision along with assistance with all ADLs (activities of daily living) along with instrumental activities of daily living, as the patient is slow in progression and it is unsafe for her to perform those activities without direct supervision. 

Yes, the Consumer Direct Live-in 7 Days Per Week, 1 Client is medically necessary. 

After brain injury, the patient has not adequately gone through the rehabilitation process due to the COVID lockdown and unfortunately due to her being infected with the COVID virus. She requires cognitive rehabilitation, medication with cerebral stimulants, maximizing neuromuscular stimulation/function in view of SLP (speech-language pathology), OT (occupational therapy) and PT (physical therapy) rehabilitation, all of which will not be available except in a long-term continuous home comprehensive and coordinated therapy sessions. In the interim, she will also require health aid assistance on a more regular basis while she continues with the rehabilitation therapies. 

Based on the above rationale, this patient with history of Non-traumatic brain injury is more than likely to benefit from a continued comprehensive home rehabilitation program and also home aid assistance, which is more than likely to better help her towards greater recovery as compared with what is receiving the moment. 

For the reasons outlined above, the health plan's currently approved regimen of 35 hours/week of consumer direct service is not adequate to meet the patient's needs. Therefore, the increase to Consumer Direct Live-in 7 Days Per Week is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Multiple sclerosis, urinary polyuria and urinary
urgency
Treatment: Formulary exception for Myrbetriq 50mg, Pre-service
The insurer denied the Formulary exception for Myrbetriq 50mg, Pre-service.
The denial is upheld. 

The patient is a male with multiple sclerosis, urinary polyuria and urinary urgency.  He has tried and could not tolerate oxybutynin IR (immediate release), oxybutynin XL (extended release), and Tolterodine. His provider has requested Myrbetriq.

No, the health plan should not cover the Formulary exception for Myrbetriq.

There is no documented reason as to why the patient cannot be treated with remaining preferred agents for his condition (solifenacin, tolterodine ER [extended release], Toviaz, trospium, trospium ER [extended release]). All of these agents are considered to be standard-of-care treatment options for his condition. There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Myrbetriq relative to the preferred agents.