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


Diagnosis: Infectious Disease-Bacterial Infection
Treatment: Skilled Nursing Facility
The health plan denied the continued Skilled Nursing care as not medically necessary. 
The reviewer has upheld the health plan denial in whole.

The patient was admitted to a skilled nursing facility due to diabetes, constipation, opioid use, bacterial infection of right foot and multiple ulcers. Patient has a past medical history significant for osteomyelitis. Patient also has history of refusing peripherally inserted central catheter (PICC) line for long-term intravenous (IV) antibiotic and for refusal of below knee amputation (BKA). Treatment for the right plantar foot ulcer includes metronidazole gel 1%, clean with normal saline and cover with dry dressing. Metronidazole gel 0.75% apply to right dorsum fourth toe along with Xeroform and calcium alginate after cleaning with normal saline. Patient was on oral antibiotics with doxycycline 100 milligrams (mg) twice a day, previously he was on Augmentin orally twice a day.

Ongoing inpatient skilled medical services are not medically necessary. The patient could be treated at a lower level of care.
This patient has multiple medical problems.
He was diagnosed with acute osteomyelitis of his left shoulder, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, cirrhosis, depression, opioid use disorder, previous osteomyelitis of ankle, right, and sepsis due to Streptococcus. The patient was treated with an acute inpatient hospitalization and subsequently transferred to skilled care for therapeutic services.
The health care facility stated the patient completed physical therapy services with physical therapy (PT) and occupational therapy (OT) but limited response. Patient needed skilled nursing services such as wound care because the patient has nobody who would look after him outside of the facility. The family feels that the patient should have continued skilled care and that it will benefit the patient due to a decrease in level of pain improvement, of gait performance, and improvement of functional mobility.
The patient was receiving wound care. The rest of his medical care would be considered custodial in nature. Services could have been provided in a lower level of care. The services for his wound care are those which can typically be done in a lower level of care facility. Even though the patient had ulcers, the patient did not require inpatient skilled nursing services for the specific wound care treatments. No other services were noted which were medically required which necessitated ongoing inpatient skilled care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Myocardial infarction

Treatment: Automatic Wearable Defibrillator (Procedure code K0606)

The insurer denied coverage for the Automatic Wearable Defibrillator (Procedure code K0606).

The denial is upheld. 

This is a male patient with a history of hypertension, renal transplantation for end-stage renal disease (ESRD), and benign prostatic hypertrophy (BPH). The patient developed substernal chest discomfort radiating to his left arm, called a friend, was found to be diaphoretic, and the emergency medical services (EMS) was called. On arrival, an acute myocardial infarction (MI) was diagnosed by electrocardiogram gram (EKG) and a field ST-elevation myocardial infarction (STEMI) protocol was initiated.  

On arrival to the Emergency Department (ED), the patient developed a pulseless ventricular tachycardia arrest, treated with amiodarone, lidocaine, intubation, and 6 rounds of defibrillation. Emergent coronary angiography revealed a total left anterior coronary artery occlusion, which was treated with two drug eluting stents. The patient's right coronary artery was dominant, with a 50% proximal and 70% mid lesion. The patient's peak troponin I was greater than 83 and his echocardiography revealed left ventricular ejection fraction (LVEF) 35-40%. The patient was treated with aspirin, Brilinta, carvedilol, atorvastatin, losartan and Aldactone, and was continued on tacrolimus, prednisone, and CellCept. A follow-up echocardiography revealed severe anterior, lateral and apical hypokinesis, with LVEF 25-30%. The patient was fitted with a LifeVest automatic wearable defibrillator prior to discharge. Records indicate that the patient was seen by his cardiologist in the office, and medication doses had been lowered due to orthostatic hypotension, with Aldactone discontinued. Nuclear stress testing was planned to determine whether percutaneous intervention was needed for the patient's right coronary artery disease. The cardiologist also discussed the need for an implanted automatic defibrillator, depending on reevaluation of his left ventricular systolic function.   

Scientific evidence in peer reviewed literature does not support use of a Wearable Cardioverter Defibrillator by this patient. Olgin et al. (2018) in a randomized trial found that "among patients with a recent myocardial infarction and an ejection fraction of 35% or less, the wearable cardioverter-defibrillator did not lead to a significantly lower rate of the primary outcome of arrhythmic death than control." 

Based on the review of the medical record and literature, the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for the Automatic Wearable Defibrillator (Procedure code K0606) should be upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine.
Treatment: Aimovig.
The insurer denied the Aimovig.
The denial is upheld. 

The patient is a female with migraine headache disorder. She has tried and failed Aimovig 70 mg/ml (milligrams per milliliter), topiramate, Botox and escitalopram for migraine prevention. 

No. The health plan should not cover the proposed treatment. 

There is no reason the patient cannot be treated with two additional preferred medications for her condition (amitriptyline, propranolol, timolol, amitriptyline, divalproex sodium and venlafaxine). All the preferred agents are considered first line, standard of care, oral migraine preventive agents. 

There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Aimovig relative to the preferred oral agents.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Symptoms Of Depression And Anxiety.
Treatment:  Continued Residential Mental Health Treatment.

The insurer denied the Continued Residential Mental Health Treatment.  The denial is upheld. 

The patient is a male.  He was admitted to this residential treatment program for the treatment of depression and anxiety.  The patient complained of feeling depressed and anxious, with poor sleep and difficulty attending to his activities of daily living.  His formal diagnoses were major depressive disorder, recurrent episodes, severe, avoidant/restrictive food intake disorder, and autism spectrum disorder.  Although the patient reported suicidal ideation, there was no evidence of plan, intent, or history of suicidality.  His problem list included "social skills, measuring success, negative family relationships, and restrictive eating."  The interventions included "motivational interviewing and CBT [cognitive behavioral therapy]."  The only psychotropic medication provided was mirtazapine, 30 mg (milligrams) at bedtime. 

A progress note reports, "patient reports, 'I feel the same as always, but may be a bit better on average.'  He says when he talks to his parents things seem to spiral down.  He remains depressed and anxious but says the anxiety comes and goes.  Gets more anxious in large groups but he is attending career planning, CBT [cognitive behavioral therapy], and DBT [dialectical behavior therapy].  He walks the property most days."  He complained of flashbacks regarding past bullying.  He denied any current thoughts of self -harm, suicide or harm to others.  He denied psychosis.  He discussed a trial of mirtazapine 15 mg (milligrams) at bedtime to target anxiety/depression/eating issues.  There was no evidence of any medical issue regarding his difficulties making food choices, and he was speaking to the chef about food he desired.

No, the Continued Residential Mental Health Treatment was not medically necessary. 

This patient presented no evidence of psychosis, no evidence of imminent danger to self or others, and no evidence of behavioral dyscontrol.  His symptoms were chronic and required ongoing psychotherapy and support.  Nothing in the documentation provided indicates that treatment could not have been continued equally safely and effectively in a less restrictive setting.  Therefore, the Continued Residential Mental Health Treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth Extractions, Fixed Prosthodontics.
Treatment: Bridge On Teeth 4, 5, 6, 11, 12, and 13.

The insurer denied the Bridge On Teeth 4, 5, 6, 11, 12, and 13. The denial is upheld. 

The patient is a female requesting dental benefits for fabrication of Fixed Prosthodontics--Bridge[4,5,6] and [11,12,13]. The patient states that tooth #5 has been extracted and she needs to have tooth #12 extracted as well.

No, the Bridge on teeth (4,5,6) and Bridge on teeth (11,12,13) are not medically necessary.

Fixed Prosthodontics (Bridgework) is a treatment option for replacing missing teeth in some instances. There is no information that shows that other less invasive treatment options were discussed, considered, or contra-indicated in this situation. 

Fixed Prosthodontics bridgework is an invasive procedure that involves reducing healthy tooth structure so that the tooth can act as a support for the bridge. The information presented does not support that the bridges are the only treatment option possible. Given this, the medical necessity of Bridge on teeth (4,5,6) and Bridge on teeth (11,12,13) cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atherosclerotic cardiovascular disease (CVD).
Treatment:  Repatha.

The insurer denied the Repatha.  The denial is upheld. 

The patient is a male with a past medical history of dyslipidemia, hypertension (HTN), coronary artery disease (CAD), status post percutaneous coronary intervention (PCI) x2.  The patient is currently using a combination of Rosuvastatin and ezetimibe with good control of low-density lipoprotein cholesterol (LDL-C), with the most recent LDL (low-density lipoprotein) level of 68 milligrams per deciliter (mg/dL).  Use of Repatha in addition to his regimen was requested for further lowering his LDL ( low-density lipoprotein). 

No, the proposed treatment, Repatha, is not medically necessary.

Repatha is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low-density lipoprotein cholesterol (LDL-C).  This patient with a history of coronary artery disease (CAD) status post prior percutaneous coronary intervention (PCI) x2, is currently managed with a high intensity statin (rosuvastatin) and Zetia with an excellent control of LDL-C (low-density lipoprotein cholesterol), below the level of 70 milligrams per deciliter (mg/dL).  As per attending physician statement, the patient was previously not controlled on lower dose of rosuvastatin.  As his LDL (low-density lipoprotein) level is at goal on the current dose, the medical necessity of adding Repatha to his regimen could not be established and would not be consistent with the currently accepted American College of Cardiology (ACC) / American Heart Association (AHA) guidelines and standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Migraine Headaches.
Treatment:  Botox.

The insurer denied the Botox.  The denial is upheld. 

The patient is a female with chronic migraine headache disorder.  She is treated with Emgality and Botox (abobotulinumtoxinA) to prevent migraine. 

No, the treatment with Botox (abobotulinumtoxinA) is not medically necessary.

There are no high-quality clinical studies or standard-of-care guidelines demonstrating that Botox (abobotulinumtoxinA) is safe or effective when used with a CGRP (calcitonin gene-related peptide) inhibitor, as requested here.  The pivotal trial leading to the FDA (Food and Drug Administration) approval of Emgality for migraine prevention excluded persons who were treated with Botox (abobotulinumtoxinA) at study commencement. Therefore, the safety and efficacy of Botox (abobotulinumtoxinA) combined with Emgality remains undetermined.  A recent review article (Pellesi et al.) concluded that the there is no clinical evidence to support using both agents concurrently and that, "Rigorous studies evaluating clinical efficacy, safety...are needed."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: LV (left ventricle) dysfunction
Treatment: LifeVest (automatic wearable automatic cardiac defibrillator) 
The insurer denied the Life Vest (automatic wearable automatic cardiac defibrillator).
The denial is overturned. 

The patient is a woman. She presented with dyspnea over a six-week period and was diagnosed with severe LV (left ventricle) dysfunction and an LV ejection fraction of 10% with severe mitral regurgitation. Echocardiogram also revealed severe tricuspid valve regurgitation and severe pulmonary hypertension with an estimated RVSP (right ventricular systolic pressure) of 62 mmHg (millimeters of mercury). Cardiac catheterization was performed and revealed normal coronary arteries without obstruction. Telemetry monitor revealed non-sustained ventricular tachycardia. 

The patient was treated with guideline directed anti-congestive therapy and an external LifeVest defibrillator. Plans were made to reassess left ventricular ejection fraction following three months of medical therapy.

Yes, the LifeVest is medically necessary.

An external LifeVest defibrillator for a patient presenting with newly diagnosed congestive heart failure with a severely reduced LVEF (left ventricle ejection fraction) (10%) is medically necessary and in the best interest of the patient. Such therapy is both safe and efficacious. 

The SCD HFT (Sudden Cardiac Death in Heart Failure Trial) clearly demonstrated that such patients have a significant risk of sudden cardiac death and benefit from ICD (implantable cardioverter defibrillator) therapy (Reference 1). Prior to implanting an ICD, patients must be treated with guideline directed medical therapy for at least three months in an attempt to allow for ventricular remodeling and improve LVEF.  If medical therapy is effective, then patients often do not require device implantation (Reference 2).  During this period of treatment, patients are at risk for sudden cardiac death and must be protected. External LifeVest defibrillator therapy provides such protection. 

Guideline statements from the Heart Rhythm Society/American Heart Association and the American College of Cardiology specify that external LifeVest defibrillator therapy should be utilized during periods when patients are at risk of sudden cardiac death and require further cardiac workup/treatment (References 3-5). In a real-world study of patients treated with external LifeVest defibrillators, almost 5% of subjects received lifesaving therapy (Reference 6).  

This patient was at high risk for sudden cardiac death due to a severely depressed LVEF, severe pulmonary hypertension, and nonsustained VT (ventricular tachycardia) noted on telemetry monitor. In conclusion, the wearable LifeVest defibrillator is in the best interest of the patient and is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, urinary incontinence, chronic pain syndrome, gait ataxia and frequent falls.
Treatment: Personal Care Assistance Services Level II, 24 Hours Per Day 7 Days Per Week (Monday through Sunday), Split Shift or Live-In.
The insurer denied the Personal Care Assistance Services Level II, 24 Hours Per Day 7 Days Per Week (Monday through Sunday), Split Shift or Live-In.
The denial is overturned.

The patient is a female with a history of hypertension, urinary incontinence, chronic pain syndrome, gait ataxia and frequent falls. 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 24 hours per day, seven days per week (split shift or live-in) Personal Assistance Services to offer increased activities of daily living (ADL) support.
The proposed treatment of 24 hours per day, seven days per week, live-in, Personal Assistance Services is deemed medically necessary.
This is a female with a history of hypertension, urinary incontinence, chronic pain syndrome, gait ataxia and frequent falls. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to worsening gait ataxia, generalized weakness and chronic pain symptoms, the patient is no longer able to walk on her own, bathe independently or toilet independently. For these reasons, the currently approved plan of 70 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 24 hours per day, seven days per week, live-in, Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myasthenia gravis

Treatment: Rituxan for the treatment of myasthenia gravis

The insurer denied coverage for Rituxan for the treatment of myasthenia gravis.

The denial is upheld. 

This is a male with refractory myasthenia gravis. The patient has had very frequent hospitalizations for his myasthenia gravis condition and associated complications despite treatment with plasma exchange, intravenous immunoglobulin (IVIG), thymectomy, prednisone, Cellcept, and Mestinon. The patient's neuromuscular specialist believes that Rituxan is the best therapy for the patient and has requested approval for this medication.  

As per literature review, Rituxan or a biosimilar drug is medically necessary to treat this patient's refractory myasthenia gravis condition.  In this case, the patient's insurer is offering a biosimilar medication, Ruxience which is an appropriate alternative medication for this patient. There is no meaningful difference between the two drugs, Rituxan and Ruxience. Since the patient's plan is offering a biosimilar medication to Rituxan, i.e. Ruxience, Rituxan is not considered 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 Rituxan for the treatment of myasthenia gravis should be upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Alopecia. 
Treatment: Pharmacy/Prescription Drugs. 
The health plan denied the requested prescription drug (Xeljanz). 
The health plan's determination is overturned. 

The patient is a male with alopecia areata (AA), treated with topical and intralesional steroids. The provider is requesting Xeljanz. 

The health plan's determination regarding the proposed health service or treatment is overturned, in whole. 

Yes. A wide range of treatments have been used for the management of alopecia areata, most of which are not highly effective. Treatments include topical or intralesional corticosteroids, topical Minoxidil (2% or 5%), topical Anthralin, systemic corticosteroids, Cyclosporine, and other immunosuppressants. A dependable and safe treatment for extensive disease (totalis or universalis) has yet to be found. Given the rarity of the disease, large randomized controlled trials are extremely difficult. These other "standard" treatments are largely not beneficial in AA. 

Tofacitinib first demonstrated efficacy in alopecia areata in the article published in 2014. A patient with concomitant psoriasis and alopecia areata was treated with the medication and serendipitously his alopecia areata reversed. Since then further case reports have emerged documenting its efficacy, which has led to the very recently published retrospective studies involving adults and adolescents, as well as others, summarized below: Published in January 2017, the adult study involved 65 patients, defined as those with alopecia totalis or alopecia universalis. 77% achieved a clinical response, with 58% of patients achieving greater than 50% change in SALT (severity of alopecia) score over 4 to 18 months of treatment. Patients with AA experienced a higher percent change in SALT score than did patients with alopecia totalis or alopecia universalis (81.9% vs 59.0%). Tofacitinib was well tolerated, and there were no serious adverse events. 

Alopecia areata and its variants are an extremely distressing disease. With further case reports of "off-label" uses of medications such as Xeljanz, more treatment options can become available. Xeljanz is currently Food and Drug Administration (FDA) -approved for rheumatoid arthritis and undergoing approval trials for psoriasis and psoriatic arthritis. It is known to be safe and effective in the conditions for which it is FDA approved. Biologic medications as a whole have many off label uses, leading to better outcomes in rare diseases for which large, randomized trials are not readily available.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, depression and diabetes mellitus
Treatment: Increase Personal Care Services To 24 Hours A Day, 7 Days A Week (split-shift)
The insurer denied the  Increase Personal Care Services To 24 Hours A Day, 7 Days A Week (split-shift).
The denial is overturned. 

The patient is a male with a history of Alzheimer's dementia, depression and diabetes mellitus. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review requested for potential approval of 24 hours a day, 7 days a week (split-shift) Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the Increase of Personal Care Services to 24 hours a day, 7 days a week (split-shift) is deemed medically necessary. 

This is a male with a history of Alzheimer's dementia, depression and diabetes mellitus. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to worsening functional decline, the patient now requires continuous supervision for ADLs (activities of daily living) and safety. For these reasons, the currently approved plan of Personal Assistance Services is insufficient to meet the patient's current needs. Hence, the proposed treatment 24 hours a day, 7 days a week (split-shift) Personal Assistance Services is deemed medically necessary.