Persius/hicric huggingface dataset:
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurativa.
Treatment: Humira 80mg Weekly.
The insurer denied the Humira 80mg Weekly.
The denial is overturned. 

The patient is a woman with severe hidradenitis suppurativa for whom Humira injections 80 mg (milligrams) per week are requested. She is allergic to Remicade and is currently on topical chlorhexidine and clindamycin, oral rifampin, clindamycin and spironolactone, as well as Humira injections 40 mg (milligrams) a week. A recent flare resulted in an emergency room visit where her lesions were incised and drained. She also undergoes intralesional Kenalog injections and has had surgical treatment of the hidradenitis in the past. She also had radiation treatment of some lesions.

Yes, the Humira 80mg Weekly is medically necessary.
The patient has severe, refractory hidradenitis suppurativa poorly responsive to multiple therapies. Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the terminal hair follicle that usually occurs after puberty and presents as painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal, and anogenital regions. Due to chronic pain, drainage, and malodor associated with HS (hidradenitis suppurativa) lesions, this condition imposes a significant burden on patients' quality of life and psychological well-being.

Adalimumab is the only approved compound for the treatment of adult patients with moderate-to-severe hidradenitis suppurativa (HS) who did not respond to a systemic classical treatment. Adalimumab is administered as a 160-mg (milligrams) loading dose injected subcutaneously at week 0, followed by an 80-mg (milligrams) subcutaneous injection at week 2, and 40-mg (milligrams) subcutaneous injections weekly thereafter. Despite its significant short- and long-term efficacy, a percentage of patients do not respond sufficiently. Moreover, some primary responders experience a response loss with time. In a recent study, an enhanced level of effectiveness was assessed in the majority of the HS (hidradenitis suppurativa) patients treated with adalimumab dose intensification (80 mg [milligrams]/week). This, high dosage, has been used for other indications, such as rheumatoid arthritis, when the standard dosing failed.

Therefore, given the above, the Humira 80mg Weekly is medically necessary.

This patient has severe, refractory hidradenitis that has failed multiple therapies. She's currently on multiple oral and topical medications as well as standard Humira dosing of 40 mg (milligrams) a week. Although she has had some improvement with the injections, she still develops flares requiring incision, drainage, and intralesional injections of steroids. It is medically appropriate to increase the dose to 80 mg (milligrams) weekly in an attempt to control her disease.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Testicular Hypofunction. 
Treatment: Testosterone Gel, Pre-service. 

The insurer denied the Testosterone Gel. 
The denial is upheld. 

This male has requested coverage for testosterone 1% gel for continued use.  He has tried only testosterone 1% gel/Androgel.  The AP (attending physician) requests use based on continuation of care. 

No, the health plan should not cover the proposed Testosterone Gel. 

The formulary agents are acceptable treatment alternatives with a low risk of potentially risky destabilization.  The patient's Plan requires a trial of a all three formulary alternative--testosterone 1.62% gel, a testosterone solution or Androderm. 

Per AUA Guidelines, 
"28. Commercially manufactured testosterone products should be prescribed rather than compounded testosterone, when possible. (Conditional Recommendation; Evidence Level: Grade C)" 

"In contrast to commercial pharmaceutical manufacturing, which is regulated by the FDA (Food and Drug Administration), compounded medications are regulated by state laws and, therefore, vary significantly from one region to another.405 While testosterone gels and creams are the most commonly used forms of compounded testosterone therapies and are routinely less expensive than branded forms of testosterone, these preparations by individual pharmacies occur without direct FDA (Food and Drug Administration) oversight and approval. Considerable variation in dosages and in ingredients results."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Giant unrepaired omphalocele.
Treatment: Home Health Care For 24 Hours x 7 Days (LPN hours).
The insurer denied the Home Health Care For 24 Hours x 7 Days (LPN hours).
The denial is overturned.

The patient is a male child with complex medical history significant for giant unrepaired omphalocele with anticipated placement of tissue expanders, pulmonary hypoplasia with eventration of the right hemidiaphragm, severe pulmonary hypertension, chronic respiratory failure status post tracheostomy with ventilator dependence, and oral aversion/feeding intolerance with continuous transpyloric tube feedings. He has been weaning his pulmonary hypertension medications in anticipation of surgery. He has been able to wean mechanical ventilation to CPAP (continuous positive airway pressure) while awake and full mechanical ventilation during naps and nighttime. He does not tolerate nasogastric tube feedings because of his pulmonary hypertension, necessitating close attention to placement of his transpyloric nasoduodenal feeding tube. He is not a candidate for gastrostomy tube placement. His care team includes pediatric surgery, plastic surgery, otolaryngology, pulmonology, and gastroenterology. The anticipated surgical intervention is expected to result in prolonged recovery due to his medically fragile state. He is currently receiving speech and language therapy services for delays in speech and language acquisition.

Skilled nursing needs include the following: tracheostomy care, monitoring of respiratory status and need for mechanical ventilation, mechanical ventilation when sleeping, medication administration and monitoring of effect (e.g. weaning medications for pulmonary hypertension), maintenance of transpyloric feeding tube with administration of continuous feeds, management of giant omphalocele (currently with placement of a compression dressing, soon to have tissue expanders inserted), maintenance of reflux and aspiration precautions, and maintenance of skin integrity. He must be actively evaluated every one to two hours to determine best course of therapy and intervention.

Yes, the proposed treatment is medically necessary.

Skilled nursing services 24 hours a day 7 days a week remain medically necessary and appropriate for this very complicated and medically fragile child. This child requires the expertise of skilled nursing with round the clock frequent evaluations, need for intervention (with feedings, with ventilator), active participation with the medical teams to wean ventilatory support and medications in anticipation of future surgery. The care that this child requires is consistent with intensive care at home. It is neither safe nor reasonable to expect his family to independently care for him, although their assistance is appropriate. The requested skilled nursing services 24 hours a day 7 days a week remains medically necessary to foster a safe and stable clinical environment without requiring return to the hospital.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis

Treatment: Otezla 30 milligram (mg)

The insurer denied coverage for Otezla 30 milligram (mg).

The denial is upheld.

The patient is a female with a history of Psoriasis, currently affecting 5% (percent) total body surface area (TBSA).  The patient has failed topical steroid therapy.  The provider is requesting Otezla.  

Based on the submitted documentation, Otezla is not medically necessary for the patient's condition.  There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Otezla for this patient's condition as an accepted standard of practice over available alternatives. There are no comparative, controlled studies showing that Otezla has a superior efficacy and safety profile to the formulary alternatives such as phototherapy and methotrexate. 

According to the "national physician specialty society recommendations" for psoriasis- the American Academy of Dermatology Psoriasis Guidelines - and dermatology literature, phototherapy and methotrexate are effective treatments for the management of psoriasis (1-3).   Within the peer-reviewed literature, Racz et al. writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (4).  Mehta et al writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with >10 % affected body surface area who have not responded to topical treatments... narrow band - ultraviolet B (NB-UVB) effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile" (5).
 
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not necessary. There is no documentation provided that the patient has tried and/or failed phototherapy or methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Otezla medically more appropriate than the other options.  Finally, in a Cochrane network analysis they noted that "There was no significant difference between tofacitinib or apremilast and between two conventional drugs: ciclosporin and methotrexate". 

Therefore, the administration of Otezla (7) is not supported for this patient, and Otezla is not medically necessary for this patient based on the current evidence-based medical literature. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the Otezla 30 milligram (mg) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscesses, Right Arm
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

The patient had no significant past medical history and presented to the emergency department with complaints of right arm abscesses following a new tattoo placement.

Vitals on presentation included: Temperature 98.4 Fahrenheit, Blood Pressure - 113/56, Pulse - 98, Respiratory Rate - 17, Oxygen (O2) saturations - 97% (percent) on room air. Laboratory results included the following: white blood count (WBC) - 12.6, hemoglobin (HGB) - 12.6, hematocrit (HCT) - 40.7, creatinine - 0.96, glucose - 103.

The patient was admitted to the hospital for abscesses of his right arm. He was empirically started on antibiotics (vancomycin and nafcillin). Chest x-ray (CXR) and x-ray of right humerus were negative. The patient underwent an incision and drainage procedure. Cultures grew methicillin-resistant staphylococcus aureus (MRSA). Plastic Surgery consulted and recommended local wound care. 

The patient remained afebrile and hemodynamically stable. He was discharged to continue oral antibiotics (Bactrim) as an outpatient.

According to documentation, patient presented with multiple abscesses of the right arm. Although he was afebrile, laboratory results were notable for an elevated WBC. Physical exam revealed several skin abscesses on the arm that had recent tattoos. The patient required an incision and drainage procedure. Based on above findings, the patient required inpatient admission for intravenous antibiotics and surgical intervention.  

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

Prior determination of denial of coverage for inpatient hospital services is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis. 
Treatment: Prolia. 

The insurer denied the Prolia. 
The denial is overturned. 

The patient is an adult female with systemic lupus erythematosus and osteoporosis, who was treated with Prolia.  Her bone density scan a few years ago revealed a T-score of -1.8 at the lumbar spine, -2.3 at the left femoral neck and -2.5 at the left total hip.  The appeal is for continuation of Prolia for the treatment of osteoporosis. 

Continuation of Prolia was denied by the insurer due to lack of demonstration of improvement in her bone density scan since a few years ago.  The patient submitted an appeal letter along with her more recent repeat bone density scan results which demonstrated a T score of -1.5 at the lumbar spine, -2.2 at the left femoral neck and -1.9 at the left total hip, consistent with improvement on Prolia therapy. 

Yes, the requested Prolia is medically necessary. 

Prolia is FDA (United States Food and Drug Administration)-approved for the treatment of osteoporosis, as diagnosed in this patient.  Per attached documentation, this patient has been treated with Prolia.  Her bone density improved on Prolia, as evidenced by the recent bone density scan.  With the submission of her most recent improved bone density scan, this patient has evidenced a positive clinical response, and the requested Prolia dosing is in accordance with the United States Food and Drug Administration approved labeling.  As such, continuation of Prolia in this patient is clinically appropriate and in accordance with standard of care in the medical community, and is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Renal Failure

Treatment: Acute inpatient hospitalization

The insurer denied coverage for acute inpatient hospitalization.

The denial is overturned.

This case involves an adult male with a past history of multiple myeloma status post bone marrow biopsy as well as a prior history of hypertension, chronic kidney disease stage IV (4) and hypothyroidism. The documentation indicated the patient was sent to the Emergency Department (ED) from his primary care physician's office due to elevated creatinine which was greater than 15 and a blood urea nitrogen (BUN) of 92. The documentation indicated the patient had been receiving dialysis for a year however he has discontinued dialysis. He stated he felt fine and did not want any procedures because he did not feel sick. The physician indicated per physical examination blood pressure was 152/84 with a pulse of 78 beats per minute. The physician recommended laboratory diagnostic studies. An electrocardiogram (EKG) revealed a normal study. The patient's creatinine was 18.37. Calcium was 7.5 and venous Ph (potential hydrogen) was 7.27. Hemoglobin was 7.2 and hematocrit was 21.8. A stool guaiac was negative. There were also documented red blood cells in the urinalysis. The physician indicated the patient was found to be in acute renal failure. The patient refused admission initially; however, he agreed after discussion with his son. The plan was to transfer the patient. The documentation indicated he was seen and reevaluated and admitted for likely dialysis catheter placement. The documentation detailed he did undergo placement. He then received his first hemodialysis session. An arteriovenous (AV) fistula was created and he continued treatment. The documentation detailed throughout the remainder of the admission there was no further significant abnormalities noted. No adverse events occurred, and he was discharged with instruction to follow-up.

This adult male has chronic renal failure (CRF) due to multiple myeloma (MM). He attempted suicide by discontinuing his hemodialysis, but his son intervened. He was readmitted for dialysis and AV fistula to ease catheter insertion and discharged to continue out-patient dialysis. It was the right decision and he benefited from a major medical intervention. All his lab studies are consistent with CRF. He must either continue with dialysis or be transplanted. Therefore, the requested inpatient admission was medically necessary.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interests of the patient. 

The insurer's denial of coverage for acute inpatient hospitalization is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Systemic Lupus Erythematosus (SLE)

Treatment: Benlysta 200 mg/ml (milligram per milliliter) autoinjector

The insurer denied coverage for Benlysta 200 mg/ml autoinjector.

The denial is overturned.

This case involves an adult female who has a diagnosis of systemic lupus erythematosus (SLE). The documentation indicated the patient was seen for a follow-up regarding joint pain and osteoporosis. The documentation indicated she complained of 10/10 pain. The physical examination revealed muscle spasm and painful range of motion to the cervical spine. Additionally, there was muscle spasm and painful range of motion with the lumbar spine and hands. The bilateral knees had crepitus and pain with range of motion. The bilateral feet also had pain with range of motion. The physician indicated upon examination of the joints there was no swelling. There was tenderness to the bilateral hips. The patient did undergo an injection of Depo-Medrol and Prolia. The documentation indicated she was recommended to continue multiple medications. The physician recommended trialing Benlysta for SLE. It is noted she felt worse after her last rituximab injection. She had gastrointestinal (GI) issues with abdominal pain and constipation, as well. 

According to appeal documentation, the requested medication has been recommended due to a failure of Rituxan and the need for a biologic. The patient also failed colchicine, azathioprine, and hydroxychloroquine. She has been recommended to utilize the requested Benlysta for lupus.

This individual has a diagnosis of SLE with arthritis and arthralgias. She had already tried Rituxan with no success. She could not tolerate Plaquenil. Given this scenario, the requested Benlysta is an appropriate therapeutic option in this case.

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

The insurer's denial of coverage for Benlysta 200 milligrams/milliliter (mg/ml) autoinjector is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite with severe soft tissue damage

Treatment: D8080 braces and D8670 monthly visits x (times) 12

The insurer denied coverage for D8080 braces and D8670 monthly visits x 12.

The denial is upheld. 

This female patient has a history of deep impinging overbite with severe soft tissue damage

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a handicapping labio-lingual deviation (HLD) index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used, utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 13 points (4 points overjet, 6 points overbite, and 3 points labio-lingual spread).

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

The carrier's denial of coverage for the D8080 braces and D8670 monthly visits x 12 is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left-sided neck pain radiating to her left shoulder and chest

Treatment: Inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld. 

This female patient has a history of hypertension (HTN), type 2 diabetes, gastritis, seizure disorder, major depressive disorder, hypothyroidism, substance abuse, fibromyalgia, and colon cancer.

The patient presented with complaints of chest pain. Her symptoms were concerning for a cardiac etiology and further evaluation was warranted based on her clinical presentation. The patient underwent appropriate initial evaluation in the emergency room (ER). This included an unremarkable physical exam, a non-diagnostic electrocardiogram (EKG), and abnormal cardiac troponin which was down-trending from the day prior when she was evaluated at the same institution. There were no other high-risk symptoms present to suggest acute coronary syndrome. As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance. The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. Cardiac troponins remained non-diagnostic for acute coronary syndrome.

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

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.