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

Diagnosis: Paroxysmal atrial fibrillation.
Treatment: Eliquis (apixaban).
The insurer denied coverage for Eliquis (apixaban).
The denial is upheld.

Asked to review the case of a gentleman previously treated with Eliquis appealing his insurers decision to transition therapy to a formulary alternative - rivaroxaban (Xarelto).  No clinical reason or contraindication is provided with documentation.  
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 in treatment of thromboembolism. The 2019 American Heart Association, 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 (coagulation factor) 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 health plan acted reasonably with sound medical judgment in the best interest of the patient. 

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

Diagnosis: Synovial sarcoma
Treatment: Proton Beam Radiation Therapy
The insurer denied the Proton Beam Radiation Therapy
The denial is overturned

The paring is a male with a diagnosis of synovial sarcoma involving the right supraclavicular region.  The plan is neoadjuvant chemotherapy followed by surgical resection and adjuvant radiation therapy, and proton therapy was requested.

The initial proton therapy request was denied because it does not meet eviCore criteria for coverage and is not considered medically necessary.

Yes, the proposed treatment with proton beam radiation therapy is medically necessary.
The requested proton therapy is medically necessary because it is consistent with generally accepted standards of good medical practice in the United States, is clinically appropriate and considered effective for patient's illness and is not for the personal comfort or convenience of the patient, family or provider.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
A photon/proton comparison plan was done. The Dmax spinal cord dose (spinal cord point maximum doses) was 55 gray (Gy) with photon (which exceeded tolerance) and 1.5 gray (Gy) with proton therapy (within tolerance).  The brachial plexus Dmax (spinal cord point maximum doses) was 114 gray (Gy) with photon therapy (exceeded tolerance) and 59.1 gray (Gy) with proton therapy (within tolerance).   If photon based radiation was utilized, there is a significantly high risk of spinal cord and brachial plexus injury.  The proton plan was able to reduce the radiation dose to those structures with acceptable levels.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Radiation Therapy.
The insurer denied Proton Beam Therapy. 
The denial is upheld. 

This is the case of a male patient who presented with T2N1 right (R) base of tongue cancer. The patient is being evaluated by his provider for curative radiation using Proton beam therapy.
At issue is the medical necessity of Proton Beam Therapy.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Proton Beam Therapy is not medically necessary for this patient.
Medically necessary treatment is defined as those which are in accordance with the generally accepted treatment in USA. The generally accepted treatment for head and neck cancer in the United States is intensity modulated radiation therapy (IMRT). Proton beam therapy is currently being evaluated under National Cancer Institute (NCI) sponsored trials.
Currently, there is no clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for head and neck cancer. In this setting, there is no published literature that compares clinical outcomes of proton beam radiotherapy compared to standard photon techniques. In the majority of cases the standard approach to treat this malignancy is with standard photon techniques. In addition, the American Society for Radiation Oncology (ASTRO) emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials. Although with IMRT, dose to certain critical structures may be higher, it is still considered acceptable to use IMRT in this setting and the difference between the two plans is not considered clinically significant.
Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in this setting. Consensus group guidelines do not support the use of proton therapy in this setting and there is no level one (I) evidence to support the use of proton therapy for the treatment of head and neck cancer.
Therefore, the requested health service/treatment of Proton Beam Therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis
Treatment: Vumerity 231MG (milligrams) OR (oral) CPDR (capsule delayed release), pre-service
The insurer denied the Vumerity 231MG OR CPDR, pre-service.
The denial is upheld.

The member is a female with multiple sclerosis (MS). She has tried and could not tolerate generic dimethyl fumarate. The provider is requesting Vumerity. This was denied coverage as the member has not tried and failed the preferred agents. The provider has indicated that none of the preferred agents are appropriate.

No, the proposed treatment, Vumerity, is not medically necessary.

There is no reason the member cannot be treated with the preferred formulary agents for her condition. Anticipatory side effects such as future neuropathy do not preclude the use of any of these medications. To complete an eye examination and laboratory studies before initiating a medication does not represent a significant burden, is not a realistic reason for significant delay, and therefore does not preclude the use of any of these medications. Anticipatory non-compliance due to the member's unwillingness to inject a medication does not preclude using the preferred medications. Co-morbid depression is not an absolute contraindication to using any of the preferred medications. All of the preferred agents are FDA (Food And Drug Administration) approved for her condition based on high quality clinical trials published in the peer reviewed medical literature (McGinley, et al). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Vumerity relative to the preferred agents. There is no evidence that switching to a preferred agent would jeopardize her clinical stability.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Hizentra. 
The denial is upheld. 

The patient is a female diagnosed with autoimmune autonomic neuropathy. The patient has been recommended for treatment with Hizentra, which has been denied by the health plan for medical necessity. The provider has appealed the determination.
At issue is the medical necessity of Hizentra.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Hizentra is not medically necessary for this patient.
Hizentra is subcutaneous immunoglobulin. The drug has been shown to be safe and effective for primary immunodeficiency and chronic inflammatory demyelinating polyneuropathy. The drug is United States Food and Drug Administration (FDA) approved and compendia supported for these indications.
In this instance, the drug is requested for treatment of autoimmune autonomic neuropathy. The diagnosis is based on low-level antibody titers on a specialized panel from the Mayo Clinic Laboratories. The patient does not clearly have dysautonomia and the provider notes that the significance "of this is unclear." The physician further notes that the main symptoms are downbeat nystagmus which was first noted several years ago.  In this instance, Hizentra is not medically necessary as there are no controlled studies or cohort studies from more than one institution to show that the specific treatment (Hizentra or subcutaneous immunoglobulin) is safe or effective for treatment of this condition. Further studies are needed. There is no literature provided by the physician to show that this specific drug, Hizentra, has been shown to be safe and effective for this condition.
Therefore, the requested health service/treatment of Hizentra is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse.
Treatment: Inpatient admission substance rehabilitation.
The insurer denied coverage for inpatient admission substance rehabilitation.
The denial is overturned.

This patient is a male who reportedly was admitted to this inpatient substance rehabilitation treatment for substance rehabilitation. He reportedly had a positive toxicology for cocaine and THC (tetrahydrocannabinol). He reportedly had a diagnosis of Cocaine Use Disorder, Sedative Hypnotic Use Disorder, and Cannabis Use Disorder. He reportedly had past inpatient substance detoxification and rehabilitation treatment. He reportedly could not maintain abstinence and lacked sober support as he was homeless and unemployed. He also reportedly lacked coping skills and ability to identify relapse triggers. He reportedly was accepted into a step down inpatient residential treatment.

According to the LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) determination) he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of substances daily putting him at risk medically and for severe withdrawal despite past inpatient rehabilitation and detoxification treatment. He reportedly lacked coping skills to maintain abstinence outside of this 24-hour substance rehabilitation treatment and needed to better identify relapse triggers and to learn relapse prevention skills as well as increase sober supports. It was reported that his use of substances was unmanageable and interfering with his quality of his life. He still reportedly had intense cravings for substances, difficulty maintaining housing and employment, and was spending more time and money on using substances. He reportedly could not be managed at a less restrictive level of care as he could not even maintain abstinence after being treated in a past inpatient substance rehabilitation treatment so it was not likely that he could effectively be treated in a less restrictive level of care then. He reportedly could not stop multiple substances of use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting then. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed quickly as evidenced by relapses after other inpatient substance treatment settings. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient substance rehabilitation treatment.

It did not appear that the health care plan acted reasonably or with sound medical judgment or in the best interests of the individual then.

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

Diagnosis: Gastroenteritis.
Treatment: Inpatient emergency admission.

The insurer denied coverage for inpatient emergency admission.
The denial is upheld.

The patient presented to the emergency room (ER) with epigastric pain, nausea, and vomiting. By the time of admission her symptoms had improved. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The renal function was normal. The lipase was 314 but a computed tomography (CT) scan was negative for acute pancreatitis. Intravenous (IV) hydration, proton pump inhibitor (PPI) therapy, and antiemetics were given and her symptoms improved.

Clinical indications for admission for Gastroenteritis (MCG [Milliman Care Guidelines] M-170) include having as suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting that is not responsive to antiemetic therapy, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

Clinical indications for admission for Vomiting (MCG M-370) include having a significant metabolic derangement, hemodynamic instability, severe electrolyte abnormalities, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had symptoms that were consistent with a gastroenteritis. IV hydration, PPI therapy, and antiemetics could have been given in the ER with observation status. She improved with the treatment. 

The patient did not meet MCG criteria for admission for either Gastroenteritis or Vomiting. 

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

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

Diagnosis: COVID (Coronavirus Disease)  
Treatment: Inpatient Admission. 

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

The patient is a female with history of asthma. She presented to emergency room with cough, fever, shortness of breath. Patient was diagnosed with COVID-19 pneumonia. Patient was started on supplemental oxygen and IV (intravenous) remdesivir and decadron. The patient was admitted to acute inpatient level care. The patient's symptoms improved within 24 hours and was discharged home. 

No, the Inpatient admission was not medically necessary. 

The patient had COVID-19 infection with pulmonary manifestations. However, at the time of admission, the patient's oxygen levels were above 90% (percent) on room air. The patient's breathing had improved. Within 24 hours, the patient's symptoms had significantly improved. The patient was hemodynamically stable. The patient was tolerating diet and was ambulating. The acute inpatient level of care is not medically necessary, as the patient could have been safely and effectively treated at a lower level of care. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Left knee pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is partially overturned.

The patient is a male with left knee pain. He was diagnosed with osteoarthritis and was admitted to hospital for an elective total knee replacement. His post-operative course was complicated by continued pain and requirement of hemovac. 

The inpatient admission was medically necessary, in part.
Specifically, the inpatient admission was medically necessary until the hemovac was removed.

The records show ongoing pain that did not respond to oral medications. He was provided with Morphine on several occasions on POD (post-operative day) #1. He also was found to need a hemovac. The hemovac was not removed until POD (post-operative day) #2. A patient after arthroplasty would be at risk for hemarthrosis. The use of the hemovac indicated ongoing drainage. A person would not be discharged with the hemovac present. Monitoring of drainage would be important.

Therefore, given the above, the initial inpatient admission was medically necessary, but the patient could have been discharged two days prior.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.
The records show post surgical problems of continued pain despite oral medications. The records also showed presence of hemovac until POD (post-operative day)  #2. Medical reasons were provided to substantiate the inpatient hospitalization. However, the patient could have been discharged two days prior.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated Blood Pressure

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a female who presented 6 days postpartum with complaints of headache and elevated blood pressure (highest 162/126)). Evaluation in the ED (emergency department) showed a blood pressure of 160/98. Repeat blood pressure was 128/84. Headache resolved on Fioricet. Laboratory evaluation was normal except for minimally elevated LDH (lactate dehydrogenase). She was admitted for magnesium prophylaxis and was started on nifedipine 30 mg (milligrams). Her blood pressures were in the low mild range. The patient left against medical advice.

This patient presented 8 days after delivery with elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery. The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman: systolic blood pressure greater than or equal to 140 mmHg (millimeters of mercury) or diastolic blood pressure greater than or equal to 90 mmHg, and proteinuria greater than or equal to 0.3 grams in a 24-hour urine specimen or protein to creatinine ratio greater than or equal to 0.3, or signs of end-organ dysfunction (platelet count 100,000/microliter, serum creatinine greater than 1/1 mg/dL [milligrams per deciliter] or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had elevated blood pressure that normalized without treatment, no protein in the urine was documented, no significantly elevated LFTs (liver function tests), and no end organ dysfunction. This patient did not have a diagnosis of preeclampsia. She had elevation in her blood pressure. Ideally, this patient would have been observed in the ED. Once her blood pressure was controlled, the patient could have been discharged home on home blood pressure monitoring and to return if any worsening of her blood pressure. Admission to the hospital was not medically necessary. 

The health care 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 admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess Skin.
Treatment: Abdominoplasty.
The insurer denied the abdominoplasty.
The determination is upheld.

The patient lost 100 pounds with a keto diet. She developed a large pannus and was treated with a panniculectomy and abdominoplasty. The procedure was performed and 4.3 pounds of abdominal skin and fat was removed. She had rashes that occurred once per month. She treated the rashes with Nystatin and topical antifungal medications. The review of systems on the office notes indicates that the patient denies rashes. At issue is the medical necessity of an abdominoplasty.

No. The abdominoplasty was not medically necessary. The medical records do not provide documentation in the form of primary care physician (or provider) (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. Supervised medical management for rashes is not documented in any of the progress notes. The review of systems on the office notes indicates that the patient denies rashes. The patient has a history of incontinence but the records do not document a urology work-up. She has back pain but the records do not document a work-up for back pain. In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi et al. the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2%. In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines.
Treatment: Formulary exception for Nurtec 75mg OR TBDP (orally disintegrating tablets).
The insurer denied the Formulary exception for Nurtec 75mg OR TBDP (orally disintegrating tablets).

The denial is upheld.

The patient is a female with migraines as well as cerebral aneurysm. Her provider wishes to start her on Nurtec to abort migraines.

The request was previously denied coverage by the health plan, as the patient has not tried and failed or demonstrated intolerance to at least two triptans. The provider states that triptans are contraindicated in people with cerebral aneurysms.

No, the health plan should not cover the Formulary exception for Nurtec.
There is no evidence that the formulary drug would be or has been ineffective for the patient. The American Headache Society recommends anti-CGRP (calcitonin gene-related peptide) medication after a trial and failure of at least 8 weeks of at least two agents or intolerance. Furthermore, there is no evidence that Nurtec is any more effective than triptans. There is lack of data in the literature that triptans would have adverse effects. It has been noted that the concerns surrounding unruptured cerebral aneurysms is "excessive and unwarranted."