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

Diagnosis: Infectious Disease/AIDS/HIV
Treatment: Pharmacy/Prescription Drugs (Rukobia)
The health plan denied the request for Rukobia. 
The health plan's determination is overturned.

This is a treatment-experienced HIV (human immunodeficiency viruses)-infected woman. Other chronic medical conditions include H. pylori, acid reflux, eczema, iron deficiency anemia, and nausea/vomiting. She is on an antiretroviral regimen consisting of Fostemsavir, Emtricitabine/tenofovir Alafenamide, Dolutegravir, Doravirine, and boosted Darunavir. She is tolerating her current regimen without significant side effects.

This patient was previously receiving Fostemsavir through participation in a clinical trial. Her participation in that trial has now ended and her provider wishes to continue prescribing Fostemsavir. As Fostemsavir was only recently approved by the FDA (Food and Drug Administration), it falls under the insurance provider's "non-formulary, new-to-market products policy." According to the policy, Ibalizumab is recommended instead of Fostemsavir.

The health plan's determination is overturned, in whole.

Ibalizumab and Fostemsavir are both relatively newly approved HIV attachment inhibitors. Ibalizumab is a monoclonal antibody that must be given as an intravenous infusion every 2 weeks and is associated with significant adverse reactions (infusion reactions, rash, anemia, nausea, diarrhea, and others) [1]. While Fostemsavir is also associated with numerous side effects [2], this patient has been tolerating Fostemsavir well for many months. Given her very limited treatment options, switching her to a new medication that she may not tolerate and could exacerbate some of her other medical conditions (anemia, eczema/rash) is ill-advised.

In addition, we are currently in the middle of a SARS-CoV-2 pandemic. This patient is significantly immunosuppressed with a most recent reported CD4 count of 95. According to the clinic notes, she has appropriately been staying home due to COVID-19. To switch her to a drug that will require her to come to a health care facility every 2 weeks to receive an infusion will put her at undo risk for SARS-CoV-2 exposure. Further, according to the NIH (National Institutes of Health) HIV Treatment Guidelines, "Persons for whom a regimen switch is planned should consider delaying the switch until close follow-up and monitoring are possible" [3].

The patient has very limited HIV treatment options and is tolerating her current regimen, including Fostemsavir, quite well. To switch her to a new medication (Ibalizumab) with a new side effect profile (some of which could be potentially problematic for this patient as described above) is not warranted. In addition, switching to Ibalizumab would put this patient at increased risk for SARS-CoV-2 exposure. I recommend the authorization of Fostemsavir.

Unfortunately, given how recently Fostemsavir was approved, its role in treating highly treatment-experienced HIV-infected patients is not yet discussed in the NIH HIV Treatment Guidelines (https://clinicalinfo.hiv.gov).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: History of general weakness, hyperglycemia, imbalance, dizziness and confusion. 

Treatment: Continued Subacute rehabilitation center therapy and skilled medical care. 
 
The insurer denied the continued subacute rehabilitation center therapy and skilled medical care. The denial is upheld. 

The patient is a male with history of general weakness, hyperglycemia, imbalance, dizziness and confusion. He has relevant past medical history of abscess of testis, acute kidney failure, BPH (benign prostatic hyperplasia), Diabetes Mellitus, Epididymo-orchitis, hypertension, osteomyelitis right foot, recurrent UTI (urinary tract infection), renal transplant recipient failing, CVA (cerebrovascular accident), etc. 

Prior to admission, the patient was living with his mother in an elevator building with six steps to enter, requiring some assistance with ADLs (activities of daily living) due to limited ability to care for self while ambulating with cane and rolling walker. He had home health aide (HHA) who comes in to help four hours three days per week. 

The patient was ambulating 100 feet (50 feet x 2) using rolling walker with contact-guard, required contact-guard for sit-stand transfers using rolling walker (RW), bed-chair transfers using RW, requiring minimum assistance for dressing, washing, etc. 

No, the continued stay in subacute rehabilitation center therapy and skilled medical care is not medically necessary. 

The patient was ambulating 100 feet (50 feet x 2) using rolling walker with contact-guard, required contact-guard for sit-stand transfers using rolling walker (RW), bed-chair transfers using RW, requiring minimum assistance for dressing, washing, etc. Therefore, continued stay in SNF (skilled nursing facility) was not medically necessary. The patient's ADLs (activities of daily living) level had improved to a level almost back to his pre-admission baseline, and his needs can be met at a lower level of care such as outpatient PT/OT (physical therapy/occupational therapy) or home therapy. 

As stated above, the continued stay in SNF was not medically necessary, with clinical evidence, as stated above, showing improvement that further stay in SNF is not reasonably expected to be health beneficial for the patient, and/or withholding it, in whole or in part, is not reasonably expected to affect the patient's health adversely, as the patient requires mostly contact-guard for most ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CVA (cerebrovascular accident)
Treatment: Skilled Nursing Facility
The insurer denied Skilled Nursing Facility. The health plan's determination is upheld. 

The patient is a male with a past medical history significant for heart failure, cerebrovascular disease, morbid obesity, unstable angina, hemiplegia following cerebral infarction on the left non-dominant side, hyperlipidemia, glaucoma, hypertension and shortness of breath. The patient was admitted to the hospital and subsequently admitted for skilled care. Skilled care consisted of physical therapy and occupational therapy to restore his level of function. Ongoing skilled services were denied stating further inpatient treatment was not medically necessary.

The Skilled Nursing Facility (SNF) Rehabilitation Level of Care from the specified date forward is not medically necessary for this patient.

The patient was admitted to skilled care from the hospital. This occurred following an acute admission to the hospital secondary to shortness of breath. Treatment included physical therapy and occupational therapy. There are no other skilled services noted in the medical record.

Services were denied by the health plan stating the following: Level of function for ambulation/walking has remained stable at 30 feet. Standing with assist in transferring with standby assist has been stable. Occupational Therapy documentation showed no significant progress with bathing, dressing or toileting. Toileting remains at maximal assistance. Services were denied based upon lack of skilled medical therapy needs and gains. Documentation noted that the patient did not make significant progress in therapy the last 2 weeks.

The patient had almost 2 full months of physical therapy. The patient's physical status has plateaued. He is able to ambulate about 30 feet. However, he is unable to transfer to the toilet and requires maximal assistance. This level of care did not change. His level of ambulation also plateaued. There is limited improvement in his other Occupational Therapy services in regards to bathing, and dressing. Since the patient has had limited improvement in his functional status over the last 2 weeks, it is reasonable say that the patient has plateaued in his ability to improve. 

The Progress note states that the patient is making minimal progress in therapy, restorative therapy, and only walking 10-20 feet in therapy. He still requires assistance with toileting. No other skilled needs such as intravenous (IV) fluids/antibiotics or complex wound care was noted in the medical records. Services justifying continued inpatient skilled care included daily physical and occupational therapy. However, since he has plateaued in his functional status. Ongoing inpatient skilled care for the services alone would not be considered medically necessary. He may receive therapy in an alternate location as part of restorative therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic idiopathic constipation.
Treatment:  Amitiza (lubiprostone).

The insurer denied the Amitiza (lubiprostone).  The denial is upheld. 

The patient is a male with chronic idiopathic constipation.  He has failed treatment with Colace, Senokot, Linzess and Lactulose.  His provider is requesting treatment with Amitiza.

No, the treatment with Amitiza (lubiprostone) is not medically necessary.

The patient has chronic idiopathic constipation.  Per the provided plan language and guidelines, Amitiza was denied, as the patient has not tried and failed a bulk fiber, such as Metamucil.  As there is no evidence that the patient has failed a bulk fiber, such as Metamucil, and as there is no medical literature to support that Amitiza is more effective than Metamucil for the treatment of chronic idiopathic constipation, the proposed Amitiza is not medically necessary, and the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient by denying Amitiza.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immunologic Disorders. 
Treatment: Pharmacy/Prescription Drugs (Ilaris). 

The insurer denied Ilaris.  The denial is overturned in whole.

The patient is a female with a diagnosis of periodic fever syndrome.  Genetic testing for periodic fever syndrome was positive.  The patient has been treated with sulfasalazine, Prednisone, minocycline and Plaquenil.  She is unable to taper from steroids and is on anywhere from 20 to 60 milligrams (mg) daily.  The patient is seeing one of the few experts on these diseases who has published on this topic and sees referrals from across the country.  The provider feels the medication prescribed (Ilaris) is appropriate in this case 'given limited options at this juncture.'

Ilaris has been denied by the health plan, as the patient does not have a diagnosis for which the medication is considered necessary.

The subject under review is the medical necessity for the Ilaris.

The health plan's determination is overturned in whole.

The requested health service/treatment of Ilaris is medically necessary for this patient.  The patient has one of the auto-inflammatory diseases, also called periodic fevers syndrome.  These diseases are extremely rare.  Genetic testing for periodic fever syndrome was positive.  The clinical phenotype and genotype of this patient is consistent with a very rare disease called Yao syndrome, formerly called NOD2 (Nucleotide-binding oligomerization domain-containing protein 2)-associated auto-inflammatory disease.  It's very rare and characterized by periodic fevers, dermatitis, arthritis and swelling of the distal extremities as well as gastrointestinal (GI) and sicca-like symptoms.  She has been treated with sulfasalazine (SSz), Prednisone, and minocycline, as well as Plaquenil, with no improvement.  This patient is unable to taper from steroids and is on anywhere from 20 to 60 milligrams (mg) daily.  

Ilaris (also called canakinumab) is an interleukin-1 beta Inhibitor.  It is a monoclonal antibody.  It is indicated in adult onset Still's disease, cryopyrin-associated periodic syndromes (CAPS), as well as various periodic fever syndrome (e.g., Familial Mediterranean fever, hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate kinase deficiency (MKD), tumor necrosis factor receptor associated periodic syndrome (TRAPS), Yao syndrome).  Ilaris reduces inflammation by binding to interleukin-1 beta (IL-1beta) and preventing interaction with cell surface receptors.  The next step for this very rare disease is Ilaris. 
The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatitis C; Cirrhosis; Unintentional weight loss.
Treatment: Computed tomography (CT) scan of abdomen and pelvis.
The insurer denied coverage for CPT 74177 Computed tomography (CT) scan of the abdomen and pelvis.
The denial is upheld. 

This is a male patient with a history of hepatitis C virus (HCV) cirrhosis with a FibroSure level of F4. The patient received treatment for his hepatitis C infection; however, the patient has continued to have unexplained weight loss.  The patient's antinuclear antibody (ANA) level was positive.  The patient's esophagogastroduodenoscopy (EGD) showed normal esophagus and a nodular gastric body mucosa. The pathology was fundic gland polyp pieces, but no dysplasia or carcinoma. The patient's colonoscopy showed 4 millimeter ascending colon polyp, sigmoid colon diverticulosis, and nonbleeding internal and external hemorrhoids. The patient's right upper quadrant (RUQ) ultrasound showed normal hepatic contour and without mass.  The patient's alpha-fetoprotein was normal.  The patient's celiac antibody testing was positive and liver enzymes were normal. The patient was advised that he needs a repeat endoscopy and colonoscopy because there as a concern that he could have celiac disease.  These repeat tests have not yet been performed. A computed tomography (CT) scan of the abdomen and pelvis with contrast due to unintentional weight loss and to evaluate for intra-abdominal pathology

The MCG guidelines for Abdominal/Pelvic Computed Tomography (CT) Scan (A-0013) indicate that the clinical indications for CT scan would include conditions such as cancer staging, jaundice and liver disease with an elevated alpha-fetoprotein, presence of a nodule on a screening ultrasound, a palpable mass, or portal vein thrombosis.  In this case, the patient did not have these clinical conditions for a CT scan evaluation of the abdomen/pelvis areas.  The patient's most recent abdominal ultrasound showed a normal liver with a grade of F2-F3 (FibroSure).

As per an UpToDate article titled "Approach to the patient with unintentional weight loss," the recommended clinical workup for patients with unintentional weight loss includes diagnostic tests such as bloodwork, chest x-ray and age-appropriate cancer screening.  There is no recommendation for a CT scan evaluation. Based on the review of the medical record, the patient does not have evidence of active liver disease that is concerning for a malignancy.  Both the patient's alpha-fetoprotein and ultrasound are unremarkable.  Literature supports that it is medically appropriate to complete the work-up with endoscopy and colonoscopy prior to obtaining the CT scan. Thus, at this time, CT scan 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 CPT (Current Procedural Terminology) 74177- Computed Tomography (CT) of the abdomen and pelvis with contrast should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/gastrointestinal. 
Inpatient hospital. 

Diagnosis: Nausea/Vomiting. 
Treatment: Inpatient Stay. 
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a woman who presented to the hospital with nausea, vomiting and abdominal pain. She had been seen two days earlier with similar symptoms. She denied diarrhea or recent travel. In prior presentations, she had a negative computed tomography (CT) abdomen and pelvis and was also treated with antiemetics. Past history included cannabis use. Labs showed potassium 2.9, sodium 135, and cannabinoids positive. Urine pregnancy test was negative. She received multiple doses of Phenergan without improvement. She was subsequently admitted for cyclic vomiting syndrome and intractable nausea and vomiting. The plan of care included intravenous (IV) fluids, anti-emetics, and supportive care. 

The inpatient stay was medically necessary. The reason is that the patient presented with nausea and vomiting thought to be secondary to chronic marijuana use, and while she had mild hypokalemia, she was persistently nauseous, required continuous intravenous antiemetic therapy, and required ongoing potassium supplementation. In addition, her symptoms were persistent, and gastroenterology recommended an endoscopy, after which she was diagnosed with esophagitis. Because of the severity of her symptoms, and persistence of hypokalemia, inpatient care was reasonable. 

The patient had severe and persistent vomiting with associated hypokalemia that was at least partly attributable to marijuana use and esophagitis. She was treated with IV ondansetron and IV Compazine throughout her hospital stay. Because of the need for intravenous therapy, the presence of electrolyte abnormalities, and the persistence of symptoms and need for gastroenterology consultation, inpatient care was indicated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Osteoporosis.
Treatment:  Formulary Exception for Boniva.

The insurer denied the Formulary Exception for Boniva.  The denial is upheld. 

This is a female with age-related osteoporosis.  The patient's T-score was -2.3 in her spine with ten-year probability of a fracture of eight percent for a major osteoporotic fracture and 0.8% of hip fracture.  She has been on Boniva.

No, the health plan should not cover the proposed formulary exception for Boniva.

The formulary alternatives are alendronate, Fosamax + D, ibandronate, and risedronate.  This patient has been on Boniva, which is the brand name form of ibandronate.  The formulary alternatives, including ibandronate, are expected to have equal efficacy and safety as compared to Boniva in this clinical situation.  The Endocrine Society guidelines on the management of osteoporosis do not recommend the use of Boniva over ibandronate.  Therefore, no, the health plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems.  
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits. 
The denial was overturned in whole. 

The patient is a female with Skeletal Class II malocclusion. She has moderate maxillary spacing and moderate mandibular spacing. The patient has severely proclined incisors, severe overjet, and moderate overbite.

The subject to be determined is the medical necessity for braces and monthly visits.

The health plan's determination is overturned in whole.

The requested service/treatment of braces and monthly visits are medically necessary for this patient.

The patient has a severe overjet of 10mm with severe proclination of the maxillary anterior teeth. With this much proclination of incisors, it is more difficult to speak and chew food and puts more pressure on the maxillary buccal bone, which can lead to bone loss and gingival recession. The patient also has a severe overbite which makes it more difficult to chew foods and can injure or destroy the maxillary palatal gingiva over time.

Considering all these factors and based on the standards of care, braces and monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis: Cardiac/ Circulatory Problems
Diagnosis: Hypertensive Urgency

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was upheld.

This is a male patient with a past medical history of hypertension, vertigo, and gastritis.  The patient presented to the Emergency Department (ED) with complaints of belching after eating and high blood pressure.  The patient was scheduled for an endoscopy on an outpatient basis but was unable to have the procedure because of elevated blood pressure. In the ED, the patient's blood pressure was 213/141.  The patient reported that he was noncompliant with home blood pressure medications. The patient's EKG revealed sinus rhythm with premature atrial complexes, and his troponin level was 0.01 (normal).  The patient's chest x-ray also revealed no significant findings. The patient was given 1 gram of oral Carafate, 20 milligrams of oral of Pepcid, 60 milligrams of oral nifedipine, and 10 milligrams of IV hydralazine, the patient's blood pressure improved. The patient's physical exam was unremarkable with normal cardiovascular, pulmonary and abdominal findings. The patient was admitted for hypertensive urgency. The cardiology and gastroenterology services were consulted. After a period of medical stability, the patient was discharged with outpatient follow up instructions. 

The patient presented to the ED with hypertension and belching.  The patient was noted to have an elevated blood pressure, which favorably responded to medication treatment in the ED, and there was no evidence of end-organ dysfunction. Specifically, the patient exhibited no evidence of acute neurological injury, myocardial ischemia, heart failure, arrhythmias, hemodynamic instability, or other general medical conditions necessitating inpatient admission status.  The patient did not require inpatient admission for his uncomplicated gastritis. Though this patient required an endoscopic evaluation of his gastritis, this procedure could have been done as an outpatient. As per MCG guidelines, the patient's clinical presentation did not meet the criteria for inpatient admission.

As per MCG guidelines, the clinical indications for admission for gastritis (M-560) include hemodynamic instability, gastric outlet obstruction, peritoneal signs, severe vomiting, severe dehydration, ongoing bleeding, and severe anemia.  In this case, the patient did not have these conditions. As per MCG guidelines, the clinical indications for admission for undiagnosed abdominal pain (M-05) include hemodynamic instability, peritoneal signs, bacteremia, and the need for a procedure that could not be performed on an outpatient basis.  In this case, the patient did not have these conditions.

The health plan acted 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 upheld.  The medical necessity is not substantiated.