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

Diagnosis: Blood Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Eliquis. 
The denial is upheld.

The patient is a male with a past medical history significant for chronic systolic heart rate due to non-ischemic cardiomyopathy (premature ventricular contraction [PVC] mediated), chronic right lower lobe pulmonary embolus, obstructive sleep apnea, chronic kidney disease, paroxysmal atrial fibrillation anticoagulated with apixaban for stroke prevention. The patient's health plan has denied coverage for apixaban (Eliquis) as prescription benefit exception on the grounds that documentation provided does not meet established criteria for prescription benefit exception stating there are alternative formulary anticoagulants, warfarin and Xarelto, that would be appropriate for this patient. The patient's treating cardiologist is requesting an appeal of the patient's health plan denial of prescription benefit plan exception for apixaban for the ongoing treatment of atrial fibrillation and pulmonary embolus. 

The health plan's determination is upheld.

There is no clear documentation provided for review of this case that indicates that all of the formulary anticoagulants would be contraindicated or be less effective than apixaban for the treatment of atrial fibrillation and pulmonary embolism in this case. Current published medical literature and expert consensus guideline statements on venous thromboembolism (VTE) and the management of stroke prevention in atrial fibrillation as demonstrated that both warfarin and Xarelto would be medically appropriate anticoagulants in his case. Furthermore, clinical trial data has demonstrated Xarelto to be non-inferior to warfarin for prevention of stroke with an associated lower risk of major bleeding events in patients with atrial fibrillation making this medication preferable over warfarin as an appropriate formulary alternative for this patient (1-3).

Given that documentation provided for review of this case does not demonstrate patient intolerance, treatment failure, or contraindication of any of the alternative formulary anticoagulants, the health plan's determination is upheld in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis with Perforation

Treatment: Inpatient level of care

The insurer denied coverage for inpatient level of care.

The denial is upheld.

This case involves a patient who presented to the emergency department with complaints of right flank pain.  He also had complaints of chills.  He does not have any past medical history.  The physical examination revealed a temperature 98.7 with a blood pressure 128/82.  Heart rate was 72.  The patient did have right flank pain on examination of the abdomen and was recommended he undergo laboratory diagnostic studies.  The patient did undergo a computed tomography (CT) scan showing acute appendicitis without perforation.  He was recommended to be admitted to undergo surgical intervention.  The documentation detailed he did undergo surgical intervention the following morning without complication.  The documentation indicated he tolerated the procedure well and postoperatively was tolerating his diet.  The documentation detailed he was discharged.

This patient presented to the emergency department (ED) complaining of right flank pain and chills.  Work up including labs and CT scan of the abdomen revealed acute non perforated appendicitis.  The patient was admitted for preoperative IV (intravenous) hydration, antibiotics and pain management.  Later on, he was taken to the operating room where he underwent laparoscopic appendectomy.  His postoperative course was uneventful and he was discharged later.

This patient underwent uncomplicated appendectomy for acute appendicitis.  The management of such cases does not require acute inpatient management and is successfully done either ambulatory or during a period of observation. 

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

Based on the above, the medical necessity for the inpatient level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth
Treatment: D8080 Braces, Pre-service
The insurer denied the D8080 braces, pre-service.
The denial is overturned.

The patient is a female. The request is for dental benefits for orthodontic treatment (braces).

Per the provider's clinical findings, the patient presents with a class III molar relationship, lateral open bite, impacted teeth, moderate crowding, and straight profile.

The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) index report, the score necessary for orthodontic treatment approval. The denial of the claim was denied based on the diagnosis and the condition of the teeth, namely the impacted teeth.

Yes, the braces are medically necessary.

As evident on the x-rays, the impacted canines do not have enough space to naturally erupt due to the position and the position of the adjacent teeth.

Under these circumstances, surgical exposure of these teeth coupled with orthodontic treatment is indicated as a corrective measure.

No, the health plan did not act reasonably, with sound medical judgement, or in the best interest of the patient.

An untreated canine impaction can damage adjacent teeth and lead to eventual tooth loss. Additionally, proper alignment and position of this tooth in the mouth is essential for chewing, functional guidance and aesthetics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis.
Treatment: Tecfidera DR 240mg.
The insurer denied the Tecfidera DR 240mg.
The denial is upheld.

The patient is a woman with relapsing remitting multiple sclerosis who is currently taking Tecfidera. She was previously on Copaxone and switched to Tecfidera due to breakthrough disease. She is currently stable on Tecfidera. The request for continued Tecfidera was previously denied as brand name Tecfidera is not in the plan formulary and it has not been documented that patient has tried and is intolerant of generic dimethyl fumarate.

No, the Tecfidera is not medically necessary.

The Tecfidera is not medically necessary, as no justification or rationale is provided as to why there is a medical exception for continuation of Tecfidera without trying generic dimethyl fumarate, which has been approved by the FDA (United States Food and Drug Administration). There is no available data comparing Tecfidera and generic dimethyl fumarate in regards to efficacy and safety.

Therefore, the Tecfidera is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Dimethyl fumarate in the generic form is the same ingredient as Tecfidera, and there is no evidence in the medical literature that supports the use of Tecfidera over generic dimethyl fumarate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ileitis
Treatment: Inpatient hospital stay
The insurer denied coverage for inpatient hospital stay.
The denial is upheld.

This case involves a male who presented to the emergency department complaining of diffuse abdominal pain with diarrhea and vomiting since the prior night. He indicated since receiving his first COVID (Coronavirus)-19 vaccination 2 weeks before and he has been having generalized fatigue. He denied fever, chills. The patient had a heart rate of 115 beats per minute (bpm) on physical examination with a blood pressure of 148/115, temperature of 97. He was well appearing, in no apparent distress. Physical exam revealed normal bowel sounds to all 4 quadrants. There was no rebound, no guarding and abdomen was nontender. He was alert and oriented with no significant deficits. It was recommended he undergo laboratory diagnostic studies. His white blood cell (WBC) count was 12.2 with hemoglobin (Hgb) at 17.1. A computed tomography (CT) scan revealed fibrofatty intramural deposition within the terminal ileum. There was mild wall thickening and inflammatory changes of the ileum. It was recommended he be admitted for intravenous (IV) fluids, in addition to pain medications and a gastrointestinal evaluation. The documentation detailed the patient was admitted, as he was noted he had likely infectious ileitis. He was recommended to undergo stool studies and a colonoscopy as an outpatient. The patient continued with treatment and denied any further significant adverse events. He was on oral fluids. By the next day, vital signs were normal and exam remained unremarkable with WBC 9.5 and Hgb of 16.8. He was discharged with instruction to follow-up.

As per MCG (Milliman Care Guidelines), to justify acute inpatient admission, the patient would have to have suspected severe infection, severe abdominal pain, peritoneal signs, toxic megacolon, hemodynamic instability, persistent severe vomiting, dehydration that was severe or persistent, severe electrolyte abnormality, inability to take oral hydration after a period of observation. None of these issues was present. The patient on evaluation was suspected to have acute gastroenteritis with a plan for outpatient colonoscopy for possible Ileitis. This does not justify acute inpatient admission. 

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

The insurer's denial of coverage for the inpatient hospital stay is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient presented to the emergency room with vertigo. The patient's medical history is significant for a left posterior cerebral artery infarction and then cerebellar infarction. These strokes were attributed to dissection of the vertebral arteries. The patient presented back to the emergency room with vertigo. Given his recent admissions for stroke, the patient was re-admitted to the hospital with concern for a repeat stroke. The patient underwent a magnetic resonance imaging (MRI) scan of the brain that did not show a new stroke. The patient had magnetic resonance angiography (MRA) of the brain and neck that demonstrated the prior dissections. The patient was subsequently discharged. 

At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient stay is not medically necessary for this patient. 

The patient presented to the hospital with vertigo. He did not have new focal neurologic deficits. The patient was not treated with a tissue plasminogen activator. He was not treated with parenteral anticoagulation. The patient did not have a new cardiac arrhythmia. Other vital signs and laboratory work were within normal limits. The patient underwent an MRI of the brain that re-demonstrated the prior posterior cerebral and cerebellar strokes. The MRA of the head and neck re-demonstrated the known vertebral artery dissections. There was not a new stroke. There were no new management strategies. The patient did not undergo an invasive procedure. Inpatient admission is not warranted for obtaining an MRI of the brain or MRA of the head/neck. The patient was discharged from the hospital after the study. Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Hypoxic Respiratory Failure
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission.
The denial is upheld.

The patient is a male with history of primary lateral sclerosis (PLS) and chronic obstructive pulmonary disease (COPD), who presented to the emergency department (ED) with complaint of weakness and shortness of breath (SOB). The patient had been seen in ED for chronic back pain. He was discharged home on oral (PO) pain meds. The patient had fallen from his bed and was not able to get up. He denied any fever or cough. The patient was on Baclofen and Nuedexta for PLS. 

Vital signs at presentation included temperature 97.6 Fahrenheit, heart rate (HR) 77, respiratory rate (RR) 18, blood pressure (BP) 123/71 mm Hg (millimeters of mercury), and oxygen (O2) saturation 95% (percent) on 2L (liters) nasal cannula (NC). The patient was in no acute distress (NAD). Lungs were clear, cardiovascular system (CVS) had normal S1 (first heart sound), S2 (second heart sound) heart sounds. The patient was alert and oriented to person, place, and time. He had weakness in lower extremities (LE). Motor strength of upper extremities (UE) was 5/5. LE 3/5. White blood cell (WBC) count was 8.7, hemoglobin (Hgb) was 12, electrolytes were within normal limits (WNL), blood urea nitrogen (BUN)/Creatinine (Cr) 37/1.1. Imaging studies revealed infiltrates/atelectasis in left lobe. The patient was admitted for pneumonia and started on Rocephin and Azithromycin.

Repeat vital signs were temperature 98.8, HR 78, RR 18, BP 142/97 mm Hg, and O2 saturations 98%. The patient was in NAD. Lungs were clear. WBC 9, BUN/Cr 28/1.0. The patient was tolerating PO (oral).

The patient remained stable after admission and was discharged home on PO medications.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. Observation period could be for up to 48 hours. This patient remained afebrile and hemodynamically stable. The patient was requiring minimal O2 if any. He was tolerating PO. WBC was normal.

The patient's pneumonia was mild. The patient's pneumonia severity index (PSI) was low. CURB65 (confusion, uremia, respiratory rate, BP, age > [greater then] 65 years) score was 1. The patient's BUN improved after hydration. The patient was able to hydrate PO.

This patient was stable to be discharged home on PO antibiotics, pain meds and his maintenance medications for PLS after a period in observation.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: peripheral vascular disease
Treatment: Outpatient Vein Procedures 
The insurer denied Outpatient Vein Procedures. 
The health plan's determination is overturned. 

The patient is a male who continues to actively smoke with hypertension (HTN), diabetes and hyperlipidemia who presented with bilateral lower extremity claudication for 6 months that progressed to rest pain in both feet with bilateral lower extremity ABI (ankle brachial index) of 0.5. He underwent bilateral lower extremity angiogram and right leg endovascular intervention with treatment of right superficial femoral artery occlusion with stent. Per the notes, right leg symptoms resolved after the right leg endovascular intervention. Angiogram of the left lower extremity revealed left superficial femoral artery occlusion.
Under review is the medical necessity of outpatient vein procedures.

The requested procedure is medically necessary for this patient.
The patient has a documented significantly reduced arterial blood flow to the left leg with an ABI of 0.5 in the left leg. He has documented symptoms in the left leg with rest pain in the leg and has documented arterial blockages in the left leg on arteriogram performed. Based on these 3 findings, the standard of care would be for endovascular intervention in the left leg, and this is what is appropriately requested by the provider.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Home health care. 
The insurer denied consumer directed personal assistance services 7 days per week, 24 hours per day/live in. 
The denial is overturned.

The patient is a female with a past medical history significant for Dementia, supraventricular tachycardia, obesity, syncope, hypertension, hyperlipidemia, hypothyroidism, breast cancer, sleep apnea, osteoarthritis of knees and osteoporosis, and depression. This review is for the medical necessity of Consumer Directed Personal Assistance Services, 7 days a week 24 hours per day live-in medically necessary for this patient. Currently the patient is approved for 56 hours a week.

The requested health service is medically necessary for this patient.
The patient has additional needs during nocturnal hours which are not predictable and/or assisted by a Personal Care Aide (PCA). This was noted in the log that was provided. The patient has incontinence needs.
Services were denied by her insurance stating the following: Any additional hours would be for stand-alone safety supervision as there is no additional taps required based upon her functional needs. New York State regulations do not require personal care assistant services for safety supervision alone, such as may be clinically necessary for someone with cognitive dysfunction. These services are not a covered benefit under your plan.
Uniform Assessment System (UAS) State of New York were reviewed. The tasking tool was also noted
The patient had informal help from family members however are unable to provide ongoing informal care.
Her son is a personal care assistant Sunday through Thursday however states he is unable to be there at night with the patient. She needs care at night. Son reported he will be leaving to go out of state and will not be available to be the PCA for the patient. The patient's daughter comes in once a week to check on the patient.
The patient has Alzheimer's disease with dementia and worsening symptoms both cognitive and physical. This was outlined through her UAS which were provided from February and June. It appears from the information provided that the patient has no informal caregivers, or at least limited, stating that the daughter stops by once a week. It is reasonable that the patient does need more care than this. It is not reasonable to leave the patient alone for these nocturnal needs without assistance. The requested services are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Home health care. 
The insurer denied consumer directed personal assistance services 7 days per week, 24 hours per day/live in. 
The denial is overturned.

The patient is a female with a past medical history significant for Dementia, supraventricular tachycardia, obesity, syncope, hypertension, hyperlipidemia, hypothyroidism, breast cancer, sleep apnea, osteoarthritis of knees and osteoporosis, and depression. This review is for the medical necessity of Consumer Directed Personal Assistance Services, 7 days a week 24 hours per day live-in medically necessary for this patient. Currently the patient is approved for 56 hours a week.

The requested health service is medically necessary for this patient.
The patient has additional needs during nocturnal hours which are not predictable and/or assisted by a Personal Care Aide (PCA). This was noted in the log that was provided. The patient has incontinence needs.
Services were denied by her insurance stating the following: Any additional hours would be for stand-alone safety supervision as there is no additional taps required based upon her functional needs. New York State regulations do not require personal care assistant services for safety supervision alone, such may be clinically necessary for someone with cognitive dysfunction. These services are not a covered benefit under your plan.
Uniform Assessment System (UAS) State of New York were reviewed. The tasking tool was also noted
The patient had informal help from family members however are unable to provide ongoing informal care.
Her son is a personal care assistant Sunday through Thursday however states he is unable to be there at night with the patient. She needs care at night. Son reported he will be leaving to go out of state and will not be available to be the PCA for the patient. The patient's comes in once a week to check on the patient.

The patient has Alzheimer's disease with dementia and worsening symptoms both cognitive and physical. This was outlined through her UAS which were provided from February and June. It appears from the information provided that the patient has no informal caregivers, or at least limited, stating that the daughter stops by once a week. It is reasonable that the patient does need more care than this. It is not reasonable to leave the patient alone for these nocturnal needs without assistance. The requested services are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease

Treatment: Entyvio 300 mg (milligrams) every 4 weeks

The insurer denied coverage for Entyvio 300 mg every 4 weeks

The denial is overturned. 

The patient has Crohn's disease and has failed multiple previous treatments including Budesonide and Remicade. After developing antibodies to Remicade he was switched to Entyvio. He was initially on Entyvio at 6 and 8 week intervals but for the last two cycles he has been receiving the Entyvio every 4 weeks. He has had improvement on the every 4 week regimen. He did not have Entyvio antibodies and has had good Entyvio levels.

The Journal of Crohns and Colitis article titled "Vedolizumab dose escalation in patients with inflammatory bowel disease experiencing loss of response: A systematic review and meta-analysis of real world evidence concludes that more than half of inflammatory bowel disease (IBD) patients who experienced loss of response during the maintenance phase, after initially responding to vedolizumab every 8 weeks, regained response on an every 4 week regimen. This data supports the use of vedolizumab dose escalation to every 4 weeks in patients who lost response to the every 8 week dosing.

This patient has moderate to severe Crohn's disease and has failed multiple previous regimens. He has lost response to the vedolizumab every 8-week dose and has improved on the vedolizumab 4-week dosing. The medical literature supports the use of dose escalation of biologic therapy in patients when the 8-week dose is no longer having a satisfactory response. Giving vedolizumab 300 mg every 4 weeks is a medically necessary treatment. 

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 Entyvio 300 mg every 4 weeks is overturned. Medical Necessity is substantiated.