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

Diagnosis: ADHD (attention-deficit/hyperactivity disorder) 
Treatment: Quillivant XR (extended release)
The insurer denied Quillivant XR.
The denial is overturned.

This case involves a young male with ADHD (attention-deficit/hyperactivity disorder) who is requesting Quillivant XR (extended release) 24-hour suspension 5 mg (milligrams) PO QAM (orally, every day before noon). The patient is also treated with methylphenidate 5 mg tablet one daily at 2 PM. The provider indicates the patient has been on this medication for several years and has shown good response to this medication and would like to continue this medication. Note from the provider indicates the patient has failed multiple trials of other formulary medication's however the names of these medications are not provided.

Per the health plan denial:
"Formulary alternatives are: amphetamine-dextroamphetamine mixed salts ext-rel [extended release], dexmethylphenidate ext-rel, dextroamphetamine ext-rel, methylphenidate ext-rel, Azstarys, Jornay PM, Mydayis, Vyvanse. Requirement: 3 in a class with 3 or more alternatives, 2 in a class with 2 alternatives, or 1 in a class 1 alternative. Note: Formulary alternatives may require a prior authorization. Your prescriber will be responsible for determining what alternative is appropriate for you."

The health plan should cover the proposed treatment.

Information from the provider states that patient has failed trials of covered medications and has been managed successfully on Quillivant for several years. As patient has been managed successfully on this medication for several years, this reviewer would recommend continuation of same medications to maintain clinical benefits. Therefore, the health plan should cover the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, osteoarthritis, and dizziness
Treatment: Increase Personal Care Aide (PCA) Services Level II: 12 Hours/Day, 4 Days/Week; 12 Hours/Day, 4 Days/Week; 16 Hours/Day, 1 Day/Week; 18 Hours/Day, 1 Day/Week; 22 Hours/Day, 1 Day/Week - a Total Amount of 152 Hours/Week
The insurer denied an increase in PCA services level II: 12 hours/day, 4 days/week; 12 hours/day, 4 days/week; 16 hours/day, 1 day/week; 18 hours/day, 1 day/week; 22 hours/day, 1 day/week - a total amount of 152 hours/week.
The denial is overturned.

This elderly female has conditions including Alzheimer's disease, osteoarthritis, and dizziness. She was hospitalized last year with non-ST-elevation myocardial infarction (NSTEMI), hypotension, colitis, and urinary tract infection. She was discharged with a 
recommendation for 24/7 home aide. She is appealing denial of increase in personal care aide (PCA) services for a total amount of 152 hours/week. The health plan approved 128 hours/week. Additional hours were requested because a family friend can no longer assist. Uniform Assessment System (UAS) evaluation completed recently shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, and locomotion; maximal assistance with managing medications, phone use, bathing, personal hygiene, dressing, walking, and toilet transfer; and extensive assistance with bed mobility and eating. Compared to UAS evaluation completed last year, there has been a decline in cognition, toilet use, and locomotion. She is incontinent of bowel and bladder. Appeal statements note the patient is unable to care for herself and requires constant supervision to sustain activities of daily living (ADLs).

The proposed treatment is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with ADLs, health maintenance activities, and routine support services. This patient has multiple chronic conditions, including recent hospitalization a couple of months ago. She is appealing denial of increase in PCA services for a total amount of 152 hours/week. The health plan approved 128 hours/week. UAS evaluation completed recently shows severely impaired cognition and the patient requires extensive assistance to total dependence with all ADLs. Compared to UAS evaluation completed last year, there has been a decline in cognition, toilet use, and locomotion. She is incontinent of bowel and bladder. The appeal statements support the patient has multiple chronic medical conditions and needs assistance with all ADLs. The patient is losing informal support. The information provided shows that this patient has significant limitations in functioning. She is unable to function without assistance. In addition, there has been a significant decline in the patient's level of functioning resulting in need for total assistance with toilet use and locomotion. The patient's needs cannot be met with the approved PCA 128 hours/week. The proposed PCA 152 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease
Treatment: Nexium 40MG (milligrams) Capsule
The insurer denied: Nexium 40MG (milligrams) Capsule
The denial is overturned.

The patient is an adult male with gastroesophageal reflux disease (GERD). He has failed pantoprazole, Dexilant and esomeprazole, and has done well on Nexium 40 milligrams daily. 

The physician (MD) is requesting to continue Nexium 40 milligrams daily.

The proposed treatment is medically necessary.

Nexium was denied, as the patient has not failed a four-week course of esomeprazole or did not have an allergic reaction to or a life-threatening allergy to esomeprazole. However, per the note by the physician assistant (PA), the patient has failed generic esomeprazole. Therefore, treatment with the proposed brand Nexium is clinically appropriate, accepted standard of care and medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Myelin oligodendrocyte glycoprotein antibody 
disorder (MOGAD)
Treatment: IVIG (Privigen)
The insurer denied: IVIG (Privigen)
The denial is overturned

The patient is an adult male. He carries a diagnosis of anti-Myelin Oligo Glycoprotein Associated Disorder (MOGAD) for which authorization of coverage for treatment with IVIG (intravenous immunoglobulin) is sought. The health plan's prior denial of coverage was made on the grounds of ambiguity of the indication for treatment. The denial is being appealed.

The health plan should cover the requested Privigen.

The patient carries the diagnosis that serves as indication for treatment. The requested Privigen is standard of care for the prevention of disease exacerbation in patients with MOGAD (Myelin Oligodendrocyte Glycoprotein Antibody Disease).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Myelin oligodendrocyte glycoprotein antibody 
disorder (MOGAD)
Treatment: IVIG (Privigen)
The insurer denied: IVIG (Privigen)
The denial is overturned

The patient is an adult male with MOGAD (myelin oligodendrocyte glycoprotein antibody disorder). This has manifested in bilateral optic neuritis. The provider wishes to start the patient on Privigen (IVIG intravenous immunoglobulin). The request was previously denied coverage by the health plan, as it was considered to be experimental/investigative. The denial is being appealed.

The health plan should cover the requested Privigen.

The requested is not experimental/investigative. MOGAD (Myelin Oligodendrocyte Glycoprotein Antibody Disease) is a rare disease with no FDA (United States Food and Drug Administration)-approved medications. IVIG (intravenous immunoglobulin) has data including most recently from a 
retrospective cohort study showing that IVIG (intravenous immunoglobulin) is safe and effective for treating MOGAD (Myelin Oligodendrocyte Glycoprotein Antibody Disease). For this reason, it is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Myelin oligodendrocyte glycoprotein antibody 
disorder (MOGAD)
Treatment: IVIG (Privigen)
The insurer denied: IVIG (Privigen)
The denial is overturned

The patient is an adult male with MOG (myelin oligodendrocyte glycoprotein) antibody-positive demyelinating disease presenting as bilateral optic neuritis. The provider has requested IVIG (intravenous immunoglobulin). This was denied coverage by the health plan as being experimental for this indication. The denial is being appealed.

The health plan should cover the requested Privigen.

The patient has a rare condition, and there are no established maintenance treatments for this diagnosis. However, there is a clinical trial to support that IVIG (intravenous immunoglobulin) is effective when used as a maintenance treatment for MOG (myelin oligodendrocyte glycoprotein) antibody-positive demyelinating disease (Chen et al., 2022). Its use is supported by standard-of-care guidelines and expert opinion (Wynford-Thomas et al., 2019). Therefore, Privigen (IVIG intravenous immunoglobulin) is an appropriate treatment option here.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Dementia
Treatment: Increase in personal care services from 42 hours to 56 hours per week 
The insurer denied: Increase in personal care services from 42 hours to 56 hours per week

The denial is Overturned.

The patient is a female with medical history notable for dementia, diabetes, hypertension, and chronic kidney disease. The patient is currently approved for 42 hours per week of personal care services. The patient and her care team requested an increase to 56 hours per week, and this request was denied by the insurance company. This denial is the subject under review.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to have moderately impaired cognition; she is alert to familiar faces only and requires verbal cueing and repetition. From a functional standpoint, she requires total dependence for housework, meal preparation, managing finances and medications, shopping, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing, hygiene, dressing upper/lower body, and toilet use. She requires limited assistance for toilet transfer and eating. She requires supervision for walking and locomotion. She is frequently incontinent of urine and infrequently incontinent of stool. She requires changing from incontinence episodes 2-3 times per day. Compared with a prior assessment, the patient showed a decline in functional status across most Instrumental activities of daily living (IADLs) and requires additional assistance with toileting, hygiene, and dressing. She also had worsening frequency of her urine and stool incontinence. A task tool associated with the assessment recommended 39.3 hours per week to address her personal care needs, an increase from 38 hours noted on prior assessment.

The health plan's determination is overturned.

The requested health service of increase in personal care services from 42 hours to 56 hours per week is medically necessary for this patient.
The patient has had a decline in functional status as reflected in her UAS. She requires more assistance for numerous IADL's and ADL's than she did in prior assessments. Her urinary and stool incontinence has worsened. Her dementia is more advanced. It is reasonable that she would require additional hours dedicated to personal care tasks to meet her functional needs. This medical necessity was also certified by the patient's physician. The task tool associated with the UAS can be useful as a baseline for number of personal care hours per week, but if she has unmet personal care needs at the current level it becomes medically necessary to increase her hours commensurate with her functional needs.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease. 
Treatment: Repatha. 

The insurer denied: Repatha. 
The denial is upheld. 

The patient is an adult male with documented history of CAD (coronary artery disease) including multi vessel CABG (coronary artery bypass graft) and PCI (percutaneous coronary intervention). He has PMH (past medical history) of diabetes and hyperlipidemia. His family history is positive for CAD (coronary artery disease). The patient's lipid panel showed an LDL (low-density lipoprotein) of 38, HDL (high-density lipoprotein) of 46; total cholesterol of 118, TG (triglyceride) of 170 and lipoprotein (a) of 83. The patient is on and tolerates rovastatin 20 mg (milligrams)/day. The use of PCSK9 (proprotein convertase subtilisin kexin 9) Repatha in this clinical situation was 
denied coverage by the health plan and is being appealed. Eligibility for inclusion included an LDL (low-density lipoprotein) greater than 70, and the patient did not meet that criterion. 

The requested PCSK9 (proprotein convertase subtilisin kexin 9) Repatha is not medically necessary. 

PCSK9 (proprotein convertase subtilisin kexin 9) medications are a relativity new class of medications that are effective in lowering LDL (low-density lipoprotein), often to very low levels. The FOURIER study is a well-performed published study and is cited by the appeal. The FOURIER trial was a randomized, double-blind, placebo-controlled clinical trial that enrolled 27,564 patients aged 40 to 85 years with clinically evident atherosclerotic cardiovascular disease (prior myocardial infarction, prior non-hemorrhagic stroke, or symptomatic peripheral arterial disease) and additional risk. The conclusion was that it was beneficial in the patients that met the inclusion criteria. 

However, this patient does not meet the inclusion criteria for the study. His LDL (low-density lipoprotein) is already very low at 38. There is no evidence to support adding a PCSK9 (proprotein convertase subtilisin kexin 9) to this regimen would improve outcome. It is inappropriate to use the results of FOURIER as a justification for its use in this clinical situation. Community practice and most guidelines would not recommend PCSK9 (proprotein convertase subtilisin kexin 9) treatment in a patient with a LDL (low-density lipoprotein) of 38. Therefore, given the above, the requested Repatha is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a male who presented to the hospital with a history of progressively worsening abdominal pain of 1-day duration. Past medical history included hypertension and seizures. Evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. The heart rate was 87/minute in the emergency department (ED). Lab data identified an elevated white blood cell (WBC) count of 15.6 thousand (K). Computed tomography (CT) scan yielded the diagnosis of appendicitis (thickened appendix with moderate to severe adjacent stranding/phlegmonous changes). Treatment was initiated with intravenous (IV) fluid and antibiotics.

The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. He was provided IV fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without fever. Diet was advanced and pain management was converted to oral medications. He was discharged home.
The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

Inpatient hospital admission was not medically necessary as the care and treatment provided could have appropriately rendered with a lower level of care. The patient was clinically stable at the time of presentation and remained so during the course of care. This patient presented to the ED with abdominal pain. The evaluation with examination, lab data, and CT scan established the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and appendectomy performed. The early post-surgical course was uncomplicated, and the patient was clinically stable for discharge from the hospital on the first post-surgical day.
The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient presented with abdominal pain and underwent uncomplicated appendectomy. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, stroke, and dementia.

Treatment: Personal care assistance (PCA) for a total of 40 hours per week.

The insurer denied coverage for PCA for a total of 40 hours per week.

The denial is overturned.

This is an elderly patient with multiple medical problems including hypertension, stroke, and dementia. She lives in a private home with her sister. The insurer approved PCA 33 hours/week, and the request is for an increase to 40 hours per week.

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "modified independent." However, she requires extensive assistance for bathing, dressing, and toilet transfer/use. She is frequently incontinent of bladder and infrequently incontinent of bowel. She requires limited assistance for personal hygiene. The patient is independent with bed mobility and eating. She uses a walker for ambulation and requires extensive assistance. The patient's functional ability has declined compared to the prior UAS report; particularly for upper body dressing, toilet transfer/use and ambulation. The patient's condition and functional deficits are at a level and unpredictable as to require the requested PCA of 40 hours/week. Based on the enclosed documents reviewed, the patient's health and safety can be more appropriately provided and maintained by the increasing PCA services to 40 hours/week.  

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations. All decisions are evidence-based.   

From a physical medicine and rehabilitation perspective, the requested increase in PCA services to 40 hours/week is medically necessary.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care assistance (PCA) for a total of 40 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders
Inpatient Hospital

Diagnosis: Cellulitis
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

The patient is a female who presented to the emergency department with concerns of right lower extremity pain. Pertinent history is diabetes mellitus, bilateral lower extremity peripheral neuropathy, liver cirrhosis, and chronic diastolic congestive heart failure. The admitting physician had an impression of recurrent right lower extremity cellulitis, liver cirrhosis, and uncontrolled diabetes mellitus. Treatment plan included empiric antibiotics, upper endoscopy for variceal screening, subcutaneous insulin, and consultations. Gastroenterology consulted and recommended an outpatient esophagogastroduodenoscopy (EGD). Infectious disease consulted who had an impression of right lower extremity cellulitis. Empiric antibiotics were continued. The next day there were no new issues. The patient continued to make clinical improvement. Antibiotics were continued. The following day the patient was discharged on oral antibiotics.

The health plan's determination is upheld.

the inpatient admission was not medically necessary for this patient.
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
Ramakrishnan et al. note inpatient treatment is necessary for patients who have uncontrolled infection despite adequate outpatient antimicrobial therapy or who cannot tolerate oral antibiotics. Hospitalization is also indicated for patients who initially present with severe or complicated infections, unstable comorbid illnesses, or signs of systemic sepsis. Broad-spectrum antibiotics with proven effectiveness against gram-positive and gram-negative organisms and anaerobes should be used until pathogen-specific sensitivities are available; coverage can then be narrowed. Intravenous antibiotics should be continued until the clinical picture improves, the patient can tolerate oral intake, and drainage or debridement is completed.[1]
The patient had a history of bilateral peripheral lower extremity, liver cirrhosis, and diabetes mellitus who presented with right lower extremity pain. Initial evaluation to be afebrile, hemodynamically stable, and without elevated inflammatory markers. Her A1C was 9.4%. Treatment plan included empiric antibiotics and clinical improvement was achieved. No other issues or complications were documented.