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

Diagnosis: Atrial Fibrillation

Treatment: Eliquis (apixaban)

The insurer denied coverage for Eliquis (apixaban).

The denial is upheld.

This is a patient with a history of atrial fibrillation that is treated with Eliquis requesting approval for formulary exception. An alternative agent is Xarelto. No evidence was submitted to support intolerance to Xarelto or other formulary alternatives.

The formulary drug, rivaroxaban/Xarelto is not likely to cause the patient an adverse reaction. The formulary drug has not been ineffective, and no documentation is provided to support that the patient has ever been treated with rivaroxaban. Both Eliquis and Xarelto therapies have been found to be non-inferior to warfarin. The American Heart Association and American College of Cardiology and Heart Rhythm Society Guidelines provide a Class I (level of evidence A) recommendation for treatment with novel oral anticoagulant regimen instead of warfarin. This recommendation was based on several randomized clinical trials that enrolled thousands of patients. The direct thrombin inhibitor medications and the Factor Xa inhibitor medications (including Xarelto/Rivaroxaban) were at least non-inferior and in some cases superior to warfarin therapy. When Xarelto was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated non-inferiority to warfarin in preventing stroke or systemic embolism (Reference 2). In conclusion, the patient should be treated with Xarelto. There is no evidence provided to demonstrate intolerance to the formulary medications. The requested drug would not be more effective than the formulary drug.

The insurer's denial of coverage for Formulary Exception for Eliquis (apixaban) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: tricompartmental osteoarthritis, knee

Treatment: durable medical equipment (DME) knee brace

The insurer denied coverage for durable medical equipment (DME) knee brace

The denial is upheld

The patient is a female with a history of a left uni-compartmental replacement. The request is for a knee orthosis. She has tricompartmental osteoarthritis on the right side. The request is for a medial off loader brace for the right knee. She has chronic low back pain and fibromyalgia. She reported improved pain after physical therapy. 

The durable medical equipment (DME) knee brace is not considered medically necessary for this patient.

The majority of braces available are unicomparmental unloading braces with minimal efficacy; however, this patient tricompartmental arthritis and this is unlikely to benefit from such a brace. At her age, she is not considered too young for a knee replacement. She reported improved pain after physical therapy. In conclusion, the durable medical equipment (DME) knee brace is not considered medically necessary for this patient.

Kemker, B. P., 3rd, Kankaria, R., Patel, N., & Golladay, G. (2021), "Knee brace indications range from mild arthralgias to instability and osteoarthritis. Although braces are routinely used clinically, high-level evidence is sparse for their use. With this review, the different types and uses of hip and knee braces have been defined, and their indications exemplified in hopes of spurring future research."

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

The insurer's denial of coverage for durable medical equipment (DME) knee brace is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pain Swelling and Redness of Left Leg.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is overturned.

The patient is a man with a history of morbid obesity status post bariatric surgery and venous stasis dermatitis, whose inpatient Hospital Admission is under review. The patient presented with LLE (left lower extremity) pain and swelling for one day.

In the ER (emergency room), the patient's vitals were as follows: T (temperature) - 98.0, BP (blood pressure) - 167/98, P (pulse) 100. On general examination, the patient was noted to be NAD (no acute distress). Examinations of the chest, CVS (cardiovascular system) and abdomen were normal. Examination of the extremities revealed left lower extremity swelling (to knee), pain, erythema.

The patient's labs were as follows: WBC (white blood count) - 16.3 (high) Hg (hemoglobin) - 10.7 Hct (hematocrit) - 37.4 Plt (platelets) - 523 Na (sodium) - 136 K (potassium) - 4.2, Cl (chloride) - 101 CO2 (carbon dioxide) - 28 BUN (blood urea nitrogen) - 11 Cr (creatinine)  0.8. Left lower extremity duplex showed no evidence of DVT (deep vein thrombosis).

In the ER (emergency room), the patient was thought to have cellulitis and sepsis. The patient was admitted and started on IV (intravenous) vancomycin.  During the hospitalization, he was noted to have diabetes mellitus for which they started metformin. He improved and was discharged on PO (oral) augmentin and clindamycin.

Yes, the Inpatient Hospital Admission is medically necessary.

The treatment was medically necessary as according to the Infectious Diseases Society of America (IDSA), the patient met criteria for inpatient admission and IV (intravenous) treatment, as he had signs of systemic illness including tachycardia and leucocytosis (1).

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient as the patient met criteria for admission, and failure to admit could lead to loss of function, septic shock, or death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left foot arthrodesis with nonunion and recurrence deformity

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission 
The denial is overturned

This is the case of an adult female with a history of arthritis, diabetes mellitus, endocarditis, hypertension, left ankle Charcot deformity and status post left foot arthrodesis with nonunion and recurrence deformity. The patient was admitted for elective left tibiotalocalcaneal (TTC) nail revision. She was admitted to the floor for pain management and physical therapy. The patient received intravenous antibiotics and deep vein thrombosis prophylaxis. 

The records show the patient underwent an extremely complex and difficult procedure. She had several associated comorbidities which would have great influence on outcome and level of service. These included: 1. Morbid obesity with BMI (body mass index) over 48. 2. The procedure was a revision which would entail increased difficulty., 3. There was concern for blood loss as eBL (estimated blood loss) was over 500cc (cubic centimeters). The physician recommended the admission to monitor hematocrit. The hematocrit had dropped from 28 to 23. This by itself would be appropriate for continued length of stay. 

The inpatient admission is considered medically necessary for this patient.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic hepatitis C virus infection with genotype 1a.
Treatment:  Harvoni.

The insurer denied the Harvoni.  The denial is overturned.

This is a female. She has been diagnosed with chronic hepatitis C virus infection with genotype 1a. Her doctor requested treatment with Harvoni. The reason for prior denial was that the patient has not tried preferred drugs.

The consensus guidelines for hepatitis C virus treatment recommend that IFN (Interferon) regimens are the best options in hepatitis C virus infected adolescents (> [greater than] 12 years of age, weight > [greater than] 35 kg [kilograms]) independently of the stage of liver disease and of comorbidities (C1) and PEG IFN (Polyethylene glycol Interferon) and ribavirin are presently no more recommended for treatment of hepatitis C virus-infected adolescents. The multi-center clinical studies showed safety and effectiveness of Sofosbuvir/ledipasvir (Harvoni) in young children 3-11 years of age with hepatitis C virus infection (Murray et al.; Schwarz et al.). Currently, sofosbuvir/ledipasvir (Harvoni) has become the choice of single-tablet regimen in the treatment of chronic hepatitis C in children, including young children 3-11 years of age (Indolfi et al.; Kim et al.; Murray et al.; Schwarz et al.). 

As documented, this patient has had chronic hepatitis C virus infection with abnormal labs. Antiviral treatment would be indicated. Per current treatment guidelines and literature, Sofosbuvir/ledipasvir (Harvoni) would be the choice of treatment options. The requested Harvoni is medically necessary.

The multi-center clinical studies showed safety and effectiveness of Sofosbuvir/ledipasvir (Harvoni) in young children 3-11 years of age with hepatitis C virus infection (Murray et al.; Schwarz et al.). Currently, Sofosbuvir/ledipasvir (Harvoni) has been become the choice of single-tablet regimen in the treatment of chronic hepatitis C in children, including young children 3-11 years of age (Indolfi et al.; Kim et al.; Murray et al.; Schwarz et al.). Even though recent pediatric studies showed that Mavyret (glecaprevir/pibrentasvir) was safe and effective in children but providers has had more experience with Harvoni. In addition, this patient cannot swallow Mavyret tablets. Generic sofosbuvir/ledipasvir has just became available, and there has not been much clinical experience in children. Thus, Harvoni would be the choice of treatment for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gynecological - fibroids. 
Treatment: Surgical Services. 
The insurer denied outpatient services. 
The denial is overturned.

The patient is a female with a history of uterine fibroids. She had a uterine artery embolization (UAE) performed. A magnetic resonance imaging (MRI) of the pelvis with contrast confirms multiple enlarged fibroids after ultrasound previously identified.
The patient's past medical history was reviewed. Pertinent past medical records note symptoms including back pain, pelvic pain and distention. Her past surgery history reviewed including previous fibroid surgery about 15 years prior to presentation. The patient's medications are noted.
The subject under review is the medical necessity for the uterine artery embolization.

The health plan's determination is overturned.

The proposed/requested health service or treatment of office/outpatient medical services, are medically necessary for this patient with this condition. This patient met all criteria for a uterine artery embolization (UAE). Menstrual or vaginal bleeding is not the only acceptable reason for UAE performance. MRI is acceptable testing for her presenting symptoms which noted uterine fibroids. Her symptoms are the type caused by fibroids. Other etiologies for her symptoms were ruled out by the imaging. The performed treatment of embolization is safe, effective, with little risk or morbidity and is cost effective. The benefit would be to control the patient's symptoms and allow for shrinkage of the fibroids. The treatment is likely to be beneficial to the patient and would be expected to provide a positive effect on this her condition and well-being.
This patient meets accepted criteria in the literature. Embolization therapy is appropriate for patients with uterine fibroids even peri-menopausal and without significant vaginal bleeding.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal - Diarrhea. Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Colesevelam. 
The denial is overturned.

The patient is a female with bile acid diarrhea following a cholecystectomy. She has previously tried and failed cholestyramine and Colestipol. Therefore, the attending provider would like to use Welchol (Colesevelam) to treat this bile acid diarrhea. The subject under review is the medical necessity for the use of Colesevelam in this patient.

The health plan's determination is overturned.

The requested treatment with Colesevelam is medically necessary for this patient. The patient has failed treatment with the alternative plan medications.
Approximately 20% of patients develop diarrhea post cholecystectomy. The cause of diarrhea after gallbladder removal is not clear. Some experts believe that it results from an increase in bile, especially bile acids, entering the large intestine which acts as a laxative. A sizable proportion of patients with chronic functional diarrhea diagnosed as irritable bowel syndrome-diarrhea (IBS-D) in fact have bile acid diarrhea. A systemic review of studies of these patients who had 23-seleno-25-homotaurocholic acid, selenium homocholic acid taurine (SeHCAT) tests found that about 30% had moderate or large increases in fecal bile acid loss, and these patients had responses to bile acid sequestrants which increased with the severity of the bile acid loss. First-line treatment is with bile acid sequestrants, primarily cholestyramine. These medications are primarily licensed for use as cholesterol-lowering agents and are therefore used off-label to reduce diarrhea in patients with bile acid diarrhea.
The mainstay of treatment for bile acid diarrhea has been the use of anion exchange resins to bind bile acids with high affinity. Cholestyramine is poorly tolerated, often because of the poor texture and taste of the resin powder. Fortunately, another bile acid sequestrant, colesevelam, is available in tablet form, being used initially for hyperlipidemia. There is now experience in the use of colesevelam in bile acid malabsorption and IBS-D. It has a greater affinity for binding bile acids, which may be an advantage. Colesevelam was shown to be effective at doses between 1.25 and 3.75 grams/day and was well tolerated. Patients who had failed to tolerate cholestyramine were able to accept colesevelam, with the majority of them continuing with colesevelam long term. A study by Camilleri and colleagues showed that Colesevelam increases delivery of bile acids to stool while improving stool consistency, and increases hepatic bile acid synthesis, avoiding steatorrhea in patients with IBS-D. Overall effects are consistent with luminal bile acid sequestration by colesevelam.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left lower quadrant pain - Diverticulitis. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female who presented to the emergency room with left lower quadrant pain. The patient was completing a course of Augmentin at that time. The patient was sent into the emergency room (ER) by her colorectal surgeon to obtain a new computed tomography (CT) of the abdomen/pelvis for continued abdominal pain. On presentation her heart rate was 110. Her white blood cell (WBC) count was 11.8. The patient had lower abdominal tenderness on exam. The CT scan demonstrated mid-ascending and proximal transverse colon diverticulitis. The patient's tachycardia resolved in the emergency department. Patient received Zosyn and intravenous (IV) fluids in the ER. The patient was hospitalized overnight.
The next day the patient was noted to complain of minor pain that was well controlled by medication. The patient was kept nothing by mouth (NPO) status and on IV Fluids. The Zosyn was continued. Her heart rate was 94. The WBC count was 7.1.
The following day the patient was noted to be feeling better. She was passing gas and having bowel movements. The patient had tolerated clear liquid diet (CLD). The patient was advanced to a soft mechanical diet. Zosyn was continued. They began planning for discharge. The WBC count was 6.7.
The subject under review is the medical necessity for the inpatient stay.

The inpatient medical stay was not medically necessary, the patient could have been safely managed at a lower level of care status. The patient did not have clinically active comorbidities. The patient did not experience ileus. The patient did not experience complications or conditions such as anemia, arrhythmia, electrolyte disorder, fever, gastrointestinal (GI) bleed, Hyperglycemia or complicated diabetes control, mental status change, psychiatric disorders, respiratory insufficiency, urinary complications, thrombotic complications or wound and skin care complications. There is no evidence that a complicating event occurred before, or during the hospitalization that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lung adenocarcinoma

Treatment: Procedure codes 81406, 81406 ,81405, 81405, 81404, 81401, 81318, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 81173, 81121, and 81120 (panel of gene tests) (circulating tumor DNA (Deoxyribonucleic acid) testing)

The insurer denied coverage for procedure codes 81406, 81406 ,81405, 81405, 81404, 81401, 81318, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 81173, 81121, and 81120 (panel of gene tests) (circulating tumor DNA testing)

The denial is overturned

This is a female. The treating provider has diagnosed the patient with lung adenocarcinoma and she has had a right lower lobe (RLL) lobectomy. The treating provider ordered the Guardant 360 test from the blood. The treating provider stated the patient has been treated, but has progressed, and has not responded to chemotherapy. 

"Genotyping tumor tissue in search of somatic genetic alterations for actionable information has become routine practice in clinical oncology. Although these sequence alterations are highly informative, sampling tumor tissue has significant inherent limitations; tumor tissue is a single snapshot in time, is subject to selection bias resulting from tumor heterogeneity, and can be difficult to obtain. Cell-free fragments of DNA are shed into the bloodstream by cells undergoing apoptosis or necrosis, and the
load of circulating cell-free DNA (cfDNA) correlates with tumor staging and prognosis. Moreover, recent advances in the sensitivity and accuracy of DNA analysis have allowed for genotyping of cfDNA for somatic genomic alterations found in tumors. The ability to detect and quantify tumor mutations has proven effective in tracking tumor dynamics in real time as well as serving as a liquid biopsy that can be used for a variety of clinical and investigational applications not previously possible." (Diaz, et al., 2014).

"Liquid biopsy in lung cancer is evolving as an important added tool for screening, early detection, monitoring, and even prognostication of lung cancer. Guidelines and expert recommendations for its use in practice are available and there are specific scenarios in which liquid biopsy is actively being adopted. Several biomarkers, from which important tumor genomic information is obtained, are currently the subject of ongoing investigation. In this review, we summarize the available data on each specific biomarker and provide an overview on how they play a role in current clinical practice." (Revelo, et al., 2019).

The carrier's denial of procedure codes 81406, 81406 ,81405, 81405, 81404, 81401, 81318, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 81173, 81121, 81120 (panel of gene tests) (circulating tumor DNA testing) should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope

Treatment is an inpatient admission 	

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

According to the medical records, the patient was admitted for nausea, diarrhea, vomiting, syncope, mild kidney dysfunction, thrombocytopenia (platelet count 10), and autoimmune hemolytic anemia Hb (hemoglobin) 8.7). She was transfused and treated with an oral steroid 100mg (milligrams) daily and Rituxan. She was hypotensive and diagnosed with Covid a few days previously.

The denial is on the basis that MCG (Milliman Care Guidelines) considers a full hospital admission for syncope to be medically necessary when severe problems exist, but considers only a heart attack, difficulty breathing or stroke as such severe problems. The denial was because these three conditions weren't present. In fact, severe medical problems were present: Covid, hypotension, anemia, and severe thrombocytopenia. MCG would support hospitalizations in this case.      

She had hypotension and required hydration, very low platelet counts, anemia, diarrhea with probable fluid depletion, and the background of recently acquired Covid. These factors justify an admission.

"Conclusion: In COVID-19 patients, standardized ICU (intensive care unit) admission criteria appeared to safely reduce ICU overload. In the absence of dyspnea and/or confusion, a SpO2 (serum pressure of oxygen) cutoff up to 85% for an ICU admission was not burdened by negative outcomes. In a pandemic context, the SpO2 cutoff of 92%, as a threshold for ICU admission, needs critical re-evaluation." (Ceruti, S. et al. 2021).

"Conclusion: Hospital admissions due to syncope and orthostatic hypotension occur in 3% of older individuals and increase with age and comorbidities. Admissions due to syncope are associated with prevalent hypertension, whereas those due to orthostatic hypotension overlap with diabetes and previously identified orthostatic hypotension. Syncope-related admissions predict higher all-cause mortality, whereas orthostatic hypotension-related admissions herald increased cardiovascular mortality." (Ricci, F. et al. 2017).

"Conclusions: Patients discharged with the diagnosis of unexplained syncope or OH (orthostatic hypotension) show higher incidence of cardiovascular disease and mortality with only partial overlap between these two conditions." (Yasa, E. et al. 2018).                                                         

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.