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

Diagnosis: Rheumatism, unspecified
Treatment: Formulary exception for Zipsor 25mg CAP, Pre-service
The insurer denied the Formulary exception for Zipsor 25mg CAP, Pre-service
The denial is overturned

The patient is a female with history of chronic joint pain. The patient's treatment is complicated by only having one solitary kidney. The patient has been receiving Zipsor 25 mg (milligrams) 4 times daily for several years. She has previously tried and failed naproxen, ibuprofen, diclofenac, etodolac, Celebrex, piroxicam and sulindac. She has had multiple side effects to many non-steroidal anti-inflammatory drugs (NSAIDs) in the past. She has been tolerating Zipsor.

The request for Zipsor was initially denied by the health plan due to the patient not having tried and failed all of the preferred formulary alternatives, which includes topical diclofenac sodium gel 1%, oral ibuprofen, naproxen, etodolac, flurbiprofen, meloxicam, nabumetone, oxaprozin, piroxicam, sulindac, celecoxib and tolmetin. The reason the provider is appealing the determination is because the patient has been on this medication for several years and this is continuation of therapy.

Yes, the health plan should cover the Formulary exception for Zipsor.
It is not known if a formulary drug would be as effective for this patient as the requested non-formulary drug. It is unknown if a formulary medication would have adverse effects for the patient.

The patient has longstanding chronic joint pain and has tried and failed many medications including many formulary alternatives. While the patient has not tried and failed all of the formulary alternatives, the patient has been on the requested medications for several years and overall has been tolerating it well. She has had no side effects to the medication and has controlled her symptoms well. She has had side effects to many of the other alternative medications. There are no clinical studies indicating that the formulary alternatives would be more efficacious or safer for the patient than the requested medication. It is unknown if the patient would have any side effects to the remaining formulary alternatives, but it is known that the patient has no side effects to the requested medication. It is unknown if the patient would respond just as well to the remaining required formulary alternatives but it is known that the patient has a good clinical response to the requested medications. She has had a good clinical response for several years. Clinical studies do show that non-medical switching was more often associated with negative or neutral effects than positive effects on an array of important outcomes. Among patients with stable/well controlled disease, non-medical switching was associated with mostly negative effects.  Therefore, the health plan should cover the requested health service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decreased mobility
Treatment: HHC - Level 2 Personal Care Services: 70 Hours per Week
The insurer denied home care/personal care HHC - level 2 personal care services: 70 hours per week. The health plan's determination is overturned.

The patient is a male with past medical history of dementia, atrial fibrillation, chronic anticoagulation, hypertension, hyperlipidemia, diabetes mellitus type 2, coronary artery disease, glaucoma, hearing loss, osteoarthritis, peripheral vascular disease, and benign prostatic hyperplasia (BPH) who had been assigned PCA (personal care assistant) services. There was a request to increase PCA services and the patient underwent an assessment tool assessing the patient at total assistance with meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing finances, stairs, and transportation. The patient was assessed at extensive assistance with tasks of managing medication, phone use, bathing, dressing lower body, walking, locomotion, and transfer toilet while limited assistance with tasks of personal hygiene and dressing upper body. With tasks of toilet use, bed mobility, and eating, the patient was assessed as independent.

The home care/personal care HHC (home health care) - level 2 personal care services: 70 hours per week is medically necessary for this patient.

There is documentation of increased assistance needs following the death of the patient's spouse and with decline in functional status of the patient. The patient had previously walked with a walker, but was wheelchair dependent at the most recent assessment. The assessment underestimated the patient's care needs as the patient requires at least extensive assistance with walking, locomotion, and transfer toilet. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with medical supplies and adaptive equipment. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, home care/personal care HHC - level 2 personal care services: 70 hours per week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hyperlipidemia, unspecified
Treatment: Formulary exception for Livalo 2mg TAB, Pre-service
The insurer denied the Formulary exception for Livalo 2mg TAB, Pre-service
The denial is overturned

The patient is a female with solitary kidney and hyperlipidemia. The physician note states that she has tried and failed Pravachol, Zocor, Mevacor, Lipitor and Crestor, all due to myalgia. She has been on Livalo for many years. It was stated that she has tried and failed all formulary drugs. The request for continued use of Livalo was denied by the health plan due to lack of documentation of failed use of statins.

Yes, the health plan should cover the Formulary exception for Livalo.
Formulary exception allowed if the patient has documented intolerance to all statins. Initial review did not include that evidence. The follow-up appeal letter from the treating physician did document that history of trial and failure of multiple statins. Thus, the formulary drugs cannot be tolerated. In addition, a history of successful use of Livalo for several years was provided.

The appeal letter does include the information to justify the use of Livalo.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine Fibroids
Treatment: Sonata procedure
The insurer denied the Sonata procedure. 
The health plan's determination is overturned.

This patient is a pre-menopausal female with symptomatic uterine fibroids. She also has a complex medical and surgical history that does not make her a favorable surgical candidate. At issue is the medical necessity for the non-invasive Sonata procedure to treat her fibroids.

The Sonata procedure is medically necessary for this patient. This patient is not a good surgical candidate for myomectomy nor hysterectomy and is 4 years past the average time of menopause. There is evidence that the Sonata procedure has minimal risk and a high enough efficacy to make this treatment medically necessary for this patient in this clinical scenario.
The Sonata procedure has minimal risk and a high enough efficacy to make this treatment medically necessary for this patient in this clinical scenario considering her other co-morbidities.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headache.
Treatment: Nurtec ODT 75mg OR TBDP.

The insurer denied the Nurtec ODT 75mg OR TBDP.
The denial is upheld.

The patient is a female with migraine headache disorder. She has tried and failed triptans for abortive therapy. The provider is requesting Nurtec. The requested medication was denied coverage as the patient has not tried and failed three triptans.

No. The proposed treatment is not medically necessary.
The medical records do not support that the patient has tried and failed three triptan medications for the acute treatment of migraine. There is no documented reason the patient cannot be treated with another triptan. Triptans are FDA (United States Food and Drug Administration)-approved for the acute treatment of migraine headaches and are considered first line, standard of care, abortive agents (Tepper). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Nurtec relative to the preferred agents.

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: Crowding. 
Treatment: Braces. 

The insurer denied the Braces. 
The denial is upheld. 

The patient is a female. The request is for dental services for orthodontic treatment (Braces). 

Per the provider's dental clinical summary, the patient presents with moderate upper and lower arch crowding; normal overbite; upper front teeth are slightly ahead of the lower; upper front teeth bite behind the lower causing gum damage. 

The health plan denied the claim because the patient did not score a 26, the score necessary on the Handicapping Labio-Lingual Deviation (HLD) Index Report needed for the approval of Braces placement. 

No, the Braces are not medically necessary. 

The diagnosis of a crossbite is not supported by the photos and x-rays that were submitted and reviewed. Typically, a crossbite would be an automatic qualifier for braces approval as prescribed on the HLD (Handicapping Labio-Lingual Deviation) Index Report; however this is not supported by the information submitted. 

Braces treatment was not warranted, because the information submitted did not support the criteria for approval.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess, Left Buttock.
Treatment acute inpatient level of care.
The insurer denied coverage for acute inpatient level of care.
The denial is overturned.

The is a patient with a past medical history significant for benign prostatic hyperplasia and hypertension who presented to the emergency department with complaints of progressively worsening pain in his left buttock. The patient underwent an incision and drainage while in emergency department (ED). Vitals on presentation included: Temperature 98.7 Fahrenheit, Blood Pressure 152/87, Pulse 107, Respiratory Rate 20, oxygen (O2) saturation 98% (percent) on Room Air. Laboratory values were notable for the following: white blood cell count (WBC)13.0, Hemoglobin-13.4, Hematocrit-40.8, creatinine-1.1, glucose-93.

The patient was empirically started on broad-spectrum intravenous antibiotics (ceftriaxone and metronidazole). Computed tomography scan showed fluid in the left gluteal fold (3.3 x 1.0 x 3.2 centimeters) compatible with phlegmon or developing abscess. Colorectal surgery evaluated the patient and deemed no surgical intervention was required. The patient remained afebrile, hemodynamically stable and clinically improved. He was discharged to continue oral antibiotics as an outpatient.  

According to the documentation, the patient presented with worsening left buttock abscess despite treatment by his primary care provider with a course of oral antibiotics.  The patient was afebrile, but tachycardic to 107 beats per minute. Laboratory results were notable for elevated WBC (13). Based on above findings, including documented failure of outpatient antibiotics, hospital admission was medically necessary for administration of intravenous antibiotics and surgical incision and drainage.  

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 acute inpatient level of care is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multilevel Degenerative Disc Disease, Lumbar.
Treatment: Out of network admission (OON) at an inpatient level of care.

The insurer denied coverage for out of network admission (OON) at an inpatient level of care.
The denial is overturned.

The patient has a history of sciatica, gastroesophageal reflux disease (GERD), and hyperlipidemia. He presented to the emergency room (ER) via ambulance with complaints of severe lower back pain. He was treated outpatient at an urgent care center and an orthopedic visit. He was currently being treated with non-steroidal anti-inflammatory drugs (NSAID), muscle relaxants and physical therapy. On this day, he bent over to tie his shoes and had severe onset of pain and was unable to ambulate. The ER note states that he had no red flag symptoms or focal neurological deficits. His exam noted mild left paraspinal tenderness and unable to assess gait due to pain. Another note stated that the patient noticed difficulty urinating as well as frequency and urgency but unable to state whether chronic or new after back pain. He had intact rectal tone and a post void residual of 464 ml (milliliter). Laboratory studies and urine tests within normal limits. A lumbar computed tomography (CT) was completed showing a small L [lumbar] 4-5 disc protrusion and Neurosurgery evaluation noted no surgical intervention, pain control in (emergency department) ED, outpatient pain management, physical therapy (PT) outpatient and Neurosurgery follow up. Pain Management was consulted and seen with orders for oxycodone 5 mg (milligrams) every four hours as needed, Tylenol every six hours, Lidoderm patch, Baclofen as needed and NSAIDs.

The requested inpatient stay appears to meet Milliman Care Guidelines (MCG) Back Pain criteria. He had severe pain with inability to walk and bladder dysfunction. 

The inpatient stay is medically necessary as he initially presented with severe back pain that required acute inpatient management with testing, consultations, physical therapy until stable for discharge. He had failed outpatient management prior to admission with medication and physical therapy. He had disc disease at L(lumbar)4-5. His risk for re-admission was high based on the severity of his functional loss and bladder dysfunction. 

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

Based on the above, the medical necessity for the out of network (OON) admission at an inpatient level of care is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a man with past medical history of alcohol abuse and seizure disorder who was non-compliant with medications. He was admitted for two generalized seizures as well as another witnessed by EMS (emergency medical services). He was noted to be postictal. He was given antiseizures and intravenous fluids. Plan was to put on AWS (alcohol withdrawal syndrome) protocol as well as treat with Librium and have a neurological consult. The patient left AMA (against medical advice).

Yes, the Inpatient admission was medically necessary.
The inpatient hospitalization was medically necessary, as the patient was altered to the point where he was nonverbal and was unable to sign consents. There is a risk for non-convulsive status epilepticus which would warrant inpatient admission for further workup including neurology consultation. Furthermore, there was concern for alcohol withdrawal given that patient drinks 1 pack of beer a day. Alcohol withdrawal is potentially life threatening and warrants inpatient hospitalization for treatment and monitoring. The patient left AMA (against medical advice) before workup and treatment could be done.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient was at high risk of non-convulsive status epilepticus and alcohol withdrawal, which can lead to morbidity and mortality.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Heart Attack. 
Treatment: Pharmacy/Prescription Drugs. 

The health plan denied the requested prescription medication, Apixaban. 
The health plan's determination is upheld. 

The patient is a man who suffered an anterior ST segment elevation myocardial infarction. A stent was placed in his left anterior descending coronary artery. A subsequent echocardiogram showed a small apical left ventricular thrombus. Apixaban was prescribed along with Aspirin and Ticagrelor. The Aspirin and Ticagrelor were discontinued. Apixaban was continued and Clopidogrel was substituted for the Ticagrelor.
The medical necessity for Apixaban is at issue. 

I uphold the health plan's determination, in whole. 

This patient is currently being treated with Apixaban for a left ventricular thrombus. Formulary alternatives include Warfarin and Rivaroxaban (Xarelto). 
While Warfarin is currently the standard of care for anticoagulation in patients with left ventricular thrombus, direct oral anticoagulants (DOACs), including Apixaban and Rivaroxaban, are frequently used off-label for this purpose. Multiple published reports, including meta-analyses and observational studies, have shown similar rates of thromboembolism and major bleeding with DOACs, as compared to Warfarin. There are no high-quality data indicating that Apixaban is superior to other DOACs in this situation. Thus, based on the information provided, it cannot be determined that either of the formulary alternatives (Warfarin or Rivaroxaban) would be ineffective or less effective than Apixaban in this instance.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Blood Clot/DVT. 
Treatment: Pharmacy/Prescription Drugs-Eliquis. 

The health plan denied the non-formulary drug because the patient did not try and fail warfarin and Xarelto, the formulary medications. 

The reviewer has overturned in whole the health plan's determination. 

This patient has a history of hyper-coagulable state with recurrent deep vein thrombosis (DVT). She has hereditary thrombophilia with factor V Leiden mutation. Initial history of deep vein thrombosis about 20 years ago which was associated with Epstein-Barr virus infection. Second episode was a form of provoked bilateral deep vein thrombosis after an epidural injection. She was initially treated with Xarelto (rivaroxaban) with a documented progression of deep vein thrombosis while on Xarelto. Her anticoagulant therapy was switched to Eliquis (Apixaban) and since she is maintained on a regimen of Eliquis 5 milligrams (mg) twice daily. 
Eliquis is a non-formulary medication. 

Yes, the formulary drugs warfarin and Xarelto would not be as effective as the non-formulary drug Eliquis or have been ineffective. 

The current medical literature suggests that rivaroxaban and apixaban have similar pharmacology and clinical efficacy; these drugs are interchangeable. Warfarin is also one of the options of treatment in this setting; there are studies reporting superior outcomes with Apixaban and Rivaroxaban compared to Warfarin in many hypercoagulable settings such as atrial fibrillation (A Fib) and DVT. 

However, in this particular case, there is a clear documentation of Xarelto (rivaroxaban) treatment failure. This patient has been receiving Eliquis and she has not experienced any recurrence. She seems to be tolerating this medication very well. Based on the clinical documentation provided, the recommendation would be to continue the current anticoagulation regimen of the non-formulary drug Eliquis (Apixaban). 

Changing this patient's therapy from apixaban to rivaroxaban (or other anticoagulation such as Warfarin) will increase the risk of recurrence of venous thromboembolism and therefore is not clinically advisable. Recurrent venous thromboembolism can lead to serious illness and can be fatal.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease.
Treatment: Home Health Care.

The insurer denied Personal Care Aide Level II PCS (Personal Care Service) Level II 24 hours/7 days Split Shift Services. The health plan's determination is overturned. 

The patient is a  male with past medical history of permanent Foley, benign prostatic hyperplasia (BPH), coronary artery disease (CAD), and chronic anticoagulation who had PCA (personal care aide) services 24 hours/day, live-in, 7 days/week based on an assessment tool that assessed the patient at total assistance with tasks of ordinary housework and shopping while maximum assistance with tasks of meal preparation, managing finances, managing medication, phone use, stairs, transportation, bathing, dressing lower body, and toilet use. With tasks of dressing upper body, walking, locomotion, transfer toilet, and bed mobility, the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene and eating. The patient sustained a fall requiring hospitalization and resultant open reduction internal fixation (ORIF) of the left hip with subsequent transfer to rehabilitation. The patient was discharged to home. There had been a request to increase PCA services to 24 hours/day, split shift, 7 days/week.

Personal Care Aide Level II PCS Level II 24 hours/7 days Split Shift Services are medically necessary for this patient.

The patient has documentation of worsening physical functioning following a fall with hip fracture and subsequent open reduction internal fixation (ORIF) with rehabilitation stay. The assessment documents the patient has 5 bedsores. The denial notice from the insurer incorrectly stated the patient had no skin breakdown or skin ulceration. The patient requires at least maximum assistance with transfer toilet, toilet use, walking, and locomotion. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase for PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs in the overnight hours, specifically, turning and repositioning every 2 hours, would not allow a personal care aide 5 hours of uninterrupted sleep. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide Level II PCS Level II 24 hours/7 days Split Shift Services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.