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

Diagnosis: Progressive dementia, diabetes mellitus,
hypertension, hypothyroidism, vertigo and
incontinence
Treatment: Increase of Personal Care Aide hours from seven days ,12 hours, per week to seven days, 24 hours per day (Live-In)
The insurer denied the Increase of Personal Care Aide hours from seven days ,12 hours, per week to seven days, 24 hours per day (Live-In).
The denial is overturned. 

The patient is a female with a history of progressive dementia, diabetes mellitus, hypertension, hypothyroidism, vertigo and 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 168 hours/week Personal Assistance Services to offer increased ADL support.

Yes, the proposed treatment of seven days, 24 hours per day (Live-In) Personal Care Services is deemed medically necessary. 

This patient is a female with a history of progressive dementia, diabetes mellitus, hypertension, hypothyroidism, vertigo and incontinence. 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 physician indicates that due to progressive functional decline, the patient has demonstrated progressively worsening balance, more frequent falls and now requires constant supervision and assistance with bed mobility, transfers and ambulation. Hence, the currently approved plan of 84 hours per week Personal Assistance Services is no longer sufficient to meet the patient's current needs. For these reasons, the proposed treatment of seven days 24 hours a day (Live-In) Personal Assistance Services is deemed medically necessary.
Appeal type: Step Therapy
Decision: Overturned


Diagnosis: Hyperlipidemia.
Treatment: Vascepa 1 mg Capsule.
The insurer is denied coverage for Vascepa 1 mg Capsule.
The denial is overturned.

This is a female patient who was seen for pre-operative clearance prior to bariatric surgery for morbid obesity. The patient's past medical history also included diabetes mellitus, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), chronic cervical radiculopathy treated with prednisone, and osteoarthritis, and seasonal allergies. The patient's medications also included aspirin, atorvastatin, azelastine, celecoxib, levocetirizine, losartan, metformin, methocarbamol, montelukast, naproxen, omeprazole, prednisone, and proair. The patient's vital signs during this office visit included blood pressure 120/80, heart rate 102, and oxygen saturation on room air 99%. The only laboratory test result submitted was the triglyceride level of 257 for which Vescepa was prescribed.

According to literature review, studies have shown improved cardiovascular disease outcomes in patients with hypertriglyceridemia and diabetes with this drug compared to placebo. This drug is a highly purified form of omega 3 fatty acid and previous studies about other omega 3 fatty acids, fenofibrate, gemfibrozil or nicacin have not shown similar results. However, it should be noted that this patient was on prednisone. Therefore prior to initiating Vascepa, it needs to be determined that her triglyceride level remains elevated off prednisone therapy.

Although there is no evidence submitted that insurer preferred alternatives to treat
hypertriglyceridemia had been tried, caused adverse events, or were contraindicated, they are less likely to achieve the therapeutic benefit of decreasing risk for future adverse cardiovascular events in this patient with diabetes mellitus. Subclinical coronary artery disease is likely in patients with diabetes mellitus, and although the patient was stable on statin therapy and lifestyle modifications, the addition of Vascepa to her regimen is more likely to be effective than any of the drugs currently on formulary for management of her hypertriglyceridemia. (Up to Date). Thus, Vascepa 1mg Capsule is considered medically necessary for this patient.

Based on the above, the medical necessity for Vascepa 1 mg Capsule is substantiated. The insurer's denial should be overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus

Treatment: metformin ER (generic Glumetza)

The insurer denied coverage for metformin ER (generic Glumetza).  

The denial is upheld.

This is a male patient with type 2 diabetes mellitus and worsening of HgbA1c to 8.7%. The patient is on Jardiance. Recommendations were for starting metformin, better diet, exercise and better compliance. The provider is requesting authorization for metformin HCL ER (Mod).
In the www.uptodate.com Chapter "Initial management of blood glucose in adults with type 2 diabetes mellitus" metformin is recommended as initial therapy. Specific brands are not preferred over others in a case such as this. The Attending MD has not submitted any documentation clarifying why a specific brand is needed. 
Although it is documented in literature that with metformin ER there are less gastrointestinal side effects, in term of effectiveness in reduction of A1C and Glycemic control there is no statistical difference. 
Based on the available information, the patient is at no increased risk from a formulary drug over the requested drug. The patient has no contraindication for use of the formulary drug. There is no documentation submitted that would indicate that the requested drug would work better than a formulary drug.

The carrier's denial of Request for Formulary Exception for metformin ER (generic Glumetza) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder/Urinary tract infection /UTI.
Treatment: Inpatient Hospital. 
The insurer denied the inpatient hospital stay 
The denial is upheld in whole 

The patient has a history of being post-partum who presented to the hospital with fevers associated with suprapubic pain, dysuria, left-sided flank pain, and chills. The patient denied abdominal pain, nausea, vomiting, headache, dizziness, vaginal pain/discharge, or blurred vision.
No, the inpatient medical admission was not medically necessary in this case based on the documentation provided. The patient presented with tachycardia and fever with signs and symptoms of a urinary tract infection. The patient was considered hemodynamically stable as the tachycardia resolved within 12-24 hours with IV fluids and antibiotic therapy. The patient did not have persistent or severe nausea or changes in mental status. The patient did not have positive blood cultures. The patient did not have a resistant organism necessitating prolonged IV antibiotic usage. The patient did not have a urologic complication requiring an inpatient surgery or procedure, such as a perinephric abscess. The patient was not pregnant or immunosuppressed. There was no other documented indication for inpatient admission.
The majority of patients with acute pyelonephritis can be treated at a lower level of care without inpatient admission.  Exceptions include patients with signs/symptoms of septic shock, patients with positive blood cultures, patients who are pregnant or immunosuppressed, patients who have severe pain or are unable to take adequate oral fluids, or who require an urgent inpatient urologic procedure. The patient, in this case, did not exhibit any of these higher-risk characteristics or findings.   
A study looking at a similar group of non-pregnant patients without immunosuppression, serious underlying disease or septic shock were successfully treated with emergency department observation and subsequent outpatient follow rather than inpatient admission in over 97% of cases.   
Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Fever/Wheezing.
Treatment:  Inpatient stay.
The insurer denied the inpatient stay.  The health plan's determination is overturned in part.  The first two days of the inpatient stay were medically necessary. 

The patient is a boy brought by ambulance to the emergency department (ED) with fever for two days and wheezing since the morning.  He received racemic epinephrine and solumedrol en route to the ED with Emergency Medical Services (EMS).  At triage, He was noted to have stridor, but was otherwise well appearing to the triage RN.  Temperature was 101.7, heart rate (HR) 139, respiratory rate (RR) 25, blood pressure (BP) 103/53, and oxygen saturation 99% on room air.  He was admitted to the hospital.

The inpatient stay for 2 days was medically necessary.  This previously healthy boy presented with fever, respiratory distress and signs and symptoms of upper airway obstruction from infectious cause (stridor, croupy cough, posterior pharyngeal erythema, radiographic soft tissue swelling, pus seen in trachea by ENT on scope).  His influenza swab was positive for Influenza B and given the pus seen on scope, the treating providers reasonably concluded that he had a bacterial superinfection of the trachea.  He did not have hypoxemia, but did have significant respiratory distress documented.  Bacterial tracheitis is a potentially serious infection, even life threatening, if not managed promptly and properly with antibiotics (e.g. ceftriaxone and vancomycin as in this case), anti-inflammatories (steroids given in this case), upper airway dilators (e.g. racemic epinephrine inhalation treatments) and, if necessary, advanced airway management up to and including mechanical ventilation.  He did not have hypoxemia or severe and progressive distress; his disease responded to the initial therapies in the ED and PICU: antibiotics, antiviral, steroids, racemic epinephrine, heliox.  On the first hospital day, the trajectory of his illness was uncertain, and it was appropriate that he be managed in a setting that could not only treat his condition as it was, but also rescue his airway if he worsened.  So, the first hospital day was medically necessary.  

By the second hospital day, he had improved significantly.  It was reasonable to continue the intravenous antibiotics until his blood cultures were negative at 48 hours.  On this day, the heliox and racemic epinephrine were stopped and he began to eat.  By the middle of the second hospital day, further care was medically necessary in the form of IV antibiotics, and the inpatient stay on this day was indicated.

The third hospital day was not medically necessary.  By hospital day three, he was drinking and eating, breathing comfortably without any respiratory distress or hypoxemia, and off IV antibiotics because his cultures were negatives at 48 hours.  He could have been safely discharged home on oral antibiotics and not have spent another night in the hospital.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chron's Disease. 
Treatment: Stelara (ustekinumab). 
The insurer denied the Stelara (ustekinumab). 
The denial is upheld. 

The patient is a female with ileocolonic Crohn's. She has failed treatment with 
sulfasalazine, 6-MP (mercaptopurine), Methotrexate, Remicade and Humira. Her MD is requesting treatment with Stelara. 

No, the treatment with Stelara (ustekinumab) is not medically necessary. 

The patient has Crohn's, and she has failed Remicade and Humira. Per plan guideline, in order for criteria for Stelara to be met, the patient must have tried and failed Entyvio. As Entyvio is safe and effective treatment in patients with Crohn's who have failed an anti-TNF (tumor necrosis factor), and as there is no consensus in the literature supporting that Stelara is more effective than Entyvio for the treatment of Crohn's, the proposed Stelara is not medically necessary over the plan-preferred Entyvio, and the health plan did act reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces
The insurer denied the braces. 
The denial is overturned. 

The patient is a female.  The request is for orthodontic benefits.

Yes, the proposed braces are medically necessary. 

The patient has a deep, impinging overbite with soft tissue damage to the palate. This is an automatic qualifier according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Precordial Pain. 
Treatment: Myocardial perfusion imaging test. 
The insurer denied coverage for a myocardial perfusion imaging test. 
The denial is overturned. 

This is a male patient who was evaluated by his cardiologist due to complaints of intermittent left sided chest pain. He had no associated dyspnea, nausea or diaphoresis. He was diagnosed with precordial pain, and his treating physician ordered a stress test with nuclear perfusion imaging. The treating physician documented that the patient reported "current bout of bursitis" which prevented him from walking on a treadmill. The patient underwent a myocardial perfusion imaging test for a cardiac evaluation. 

Based on the review of the medical record and literature, the nuclear perfusion stress testing was appropriate and medically necessary for this patient. The patient had a documented contraindication to exercise stress testing, namely active bursitis. In such instances when a patient is unable to perform exercise stress testing due to non-cardiac comorbidities, the use of noninvasive and non-exercise based stress testing is appropriate and indicated. Given this patient's intermediate pre-test probability for having obstructive coronary artery disease, further evaluation was appropriate and indicated. The sensitivity of perfusion imaging over exercise stress testing alone has improved, with a sensitivity of 88-90% for nuclear perfusion stress testing vs 75-80% for exercise electrocardiogram (EKG) stress testing, in detecting the presence of obstructive coronary artery disease. Given this patient's risk profile and symptoms, and intermediate pre-test probability for obstructive coronary artery disease, nuclear perfusion stress testing is considered medically necessary and appropriate in this particular clinical scenario. 

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

The medical necessity for the myocardial perfusion imaging test is substantiated. The insurer's denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male diagnosed with Stage II colon cancer. The pathology showed moderately differentiated adenocarcinoma, a tumor size of 3.7 centimeter (cm), T3, N0 and M0. Surgical margins were clear. 25 lymph nodes were examined and all negative. There was no lymphovascular or perineurial invasion. No evidence of perforation or obstruction was noted. The OncotypeDX colon cancer assay was ordered and is under review.

The health plan's determination is upheld. The Oncotype Dx colon cancer assay is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This patient had no high-risk features of stage II disease such as poorly differentiated histology, lymphovascular invasion, bowel obstruction or perforation, < 12 lymph nodes examined, perineurial invasion, or close margins. According to National Comprehensive Cancer Network (NCCN) Guidelines, there are insufficient data to recommend the use of multi-gene assay panels to determine adjuvant therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

The case involves a male patient with stage II colon cancer whose oncologist ordered the Oncotype Dx colon assay to assist with risk stratification and treatment recommendations. The patient's health care plan has denied coverage of this test citing it to be experimental and investigational.

The health plan's determination is upheld. The Oncotype Dx assay is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
While the adjuvant therapy benefit for patients with stage III colon cancer has been solidified, the benefit of adjuvant chemotherapy in stage II colon cancer has remained the subject of debate. The OncotypeDX colon assay is a quantitative multi-gene, real-time polymerase chain reaction (RT-PCR) gene expression profile assay that measures gene expression in paraffin-embedded tumor tissues in patients with stage II colon cancer. At this time, such testing is not endorsed by the National Cancer Care Network or the American Society of Clinical Oncology.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a male with a resected stage II colon cancer. The Oncotype DX Colon Cancer assay was obtained and is under review.

The health plan's determination is upheld. The Oncotype Dx colon cancer assay is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The ASCO guidelines do not address use of this assay. The National Comprehensive Cancer Network (NCCN) guidelines state that there are insufficient data to recommend the use of multi-gene assays, such as the Oncotype DX assay to determine adjuvant therapy.
For these reasons, the routine use of this assay in this clinical scenario is not likely to be more beneficial than basing treatment recommendations on the patient's cancer pathology and current data.
Appeal type: Medical necessity
Decision: Upheld

Endocrine. 
Inpatient hospital. 

Diagnosis: Hyperglycemia. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman who presented to the hospital. She presented complaining of high blood sugar. Her husband also reported recent confusion in the patient. She reported weakness and stated she had not been taking her metformin recently. She denied fevers, chills, chest pain and shortness of breath. Social history was notable for the recent loss of her mother in law. Vital signs showed temperature 98.1 Fahrenheit, heart rate 97, blood pressure 135/79, and respiratory rate 18. On physical examination, heart was regular, breath sounds were normal, abdomen was soft and nontender. There was no neurologic deficit. Labs showed Sodium 127, potassium 4.0, creatinine 0.723, glucose 555, calcium 9.0, white blood cell (WBC) 7.86, hemoglobin 14.3, and platelets 277. The patient was admitted for hyperglycemia/uncontrolled diabetes. 

The inpatient stay is not medically necessary. The patient had a short hospital stay because she presented with hyperglycemia and nonspecific symptoms but had negative cardiac enzymes, largely unremarkable electrolytes, no evidence of infection, no evidence of acute stroke, and no other acute abnormalities. She improved with supportive care and was referred to endocrine at the time of discharge. Her care could have been provided safely and effectively at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Immunologic Disorder 
Pharmacy/Prescription Drugs 

Diagnosis: Psoriasis 
Treatment: Tremfya 

The insurer denied Tremfya. The health plan's determination is overturned. 

The patient is a male with moderate to severe psoriasis. The patient has tried and failed Stelara, Humira, Cosentyx, and Taltz. The patient has received approval for coverage of Tremfya with his previous health plan and has already received the loading dose. However, the correspondence reports denial of Taltz and no treatment failure with Taltz prior to starting Tremfya. 

Guselkumab (Tremfya) 100MG/ML Syringe is medically necessary for this patient. The patient has not to date used a biologic agent with a different mechanism of action (Interleukin-23 inhibition) such as Tremfya. Skyrizi and Ilumya have anti-Interleukin-23 mechanisms of action, but they are not formulary alternatives. 

Accordingly, with current medical literature supporting use of a biologic agent with a different mechanism of action than those previously utilized, Tremfya is most appropriate for this patient at this time, and particularly so because it has already been started. Continuation of Tremfya is medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Purulent Skin Abscess
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial was overturned.

This is a male patient with past medical history of hypertension, diabetes mellitus, hyperlipidemia, and anxiety. He presented to the Emergency Department (ED) with complaints of a neck abscess. The patient's vital signs on ED presentation included: Temperature 98.3 F, Blood Pressure 148/87, and Pulse 105, Respiratory Rate 20, and Oxygen (O2) saturation 99% on Room Air. The patient's laboratory results included the following: white blood cell (WBC) count 18.5, hemoglobin (HGB) 15.2, hematocrit (HCT) 48, creatinine 0.8, glucose 488, lactic acid 3.0, and HbA1c 14.8. The patient was empirically treated with intravenous (IV) antibiotics; vancomycin, ceftriaxone, and metronidazole).  A computed tomography (CT) scan of the thoracic spine was performed that revealed a large 14 x 14 x 4cm phlegmon in the posterior subcutaneous fat in the lower and mid-thoracic level.  General surgery was consulted and deemed no operative intervention was required.  Endocrinology was also consulted for diabetic management.  The patient remained afebrile, hemodynamically stable, and clinically improved. Infectious Diseases recommended discharge on oral antibiotics as an outpatient.  

According to documentation, the patient was admitted with a large abscess to his back. The patient's computed tomography (CT) scan revealed a large collection of unclear etiology, possibly infectious. The patient also had multiple laboratory abnormalities including leukocytosis of 18.5, elevated lactic acid of 3, and uncontrolled hyperglycemia (glucose of 488 and HbA1c of 14.8) in the setting of an active infection. Based on these clinical findings in a high-risk patient with multiple co-morbid conditions including poorly controlled diabetes, the hospital admission for intravenous antibiotics and surgical evaluation was medically necessary. 

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 the full hospital admission should be overturned.  The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type One Diabetes Mellitus.
Treatment: Apidra - Humalog KwikPen (Insulin lispro [human]).
The insurer denied the Apidra - Humalog KwikPen (Insulin lispro [human]).
The denial is overturned. 

This is a male with type one diabetes on insulin pump therapy. He has tried and failed Novolog. When using U-100 insulin, he had to change the cartridge daily. His A1C is 8.3%. He tried and failed U-500 insulin. Request for Humalog U-200 is under review. 

Yes, the proposed Apidra - Humalog KwikPen (Insulin lispro [human]) is medically necessary.

Humalog U-200 is FDA-approved for the management of type one diabetes and is accepted as standard medical treatment of type one diabetes. 

This patient has type one diabetes. He has tried and failed Novolog. Fiasp insulin, like Novolog, is a form of aspart insulin, which is not appropriate in this clinical situation as he has tried and failed Novolog. This patient has marked insulin resistance. The use of concentrated insulin, such as Humalog U-200 insulin, is supported by the American Diabetes Association clinical guidelines in the setting of insulin resistance. Novolog and Fiasp insulin are U-100 formulations, not U-200 formulations. Without Humalog U-200, this patient is at risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore the requested Humalog U-200 is medically necessary as this request is essential to, consistent with, and provided for the treatment of the diagnosis (in this case type one diabetes), and is in accordance with generally accepted standards of medical practice, not primarily for convenience, and is the most economical supply that is appropriate for the safe and effective treatment of the patient.