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

Diagnosis: Dementia, Parkinson's Disease, unsteady gait, spinal stenosis, CHF (congestive heart failure), and type 2 diabetes mellitus
Treatment: Personal Care Aide (PCA) two 12-hour split shifts per day, 7 days a week
The insurer denied coverage for Personal Care Aide (PCA) two 12-hour split shifts per day, 7 days a week
The denial is overturned

 
This is an elderly patient with medical problems that include Parkinson's disease, congestive heart failure and dementia. He lives alone in a private residence. The insurer approved personal care aide (PCA) 24 hours/day, 7 days/week (live-in) and the request is for two 12-hour split shifts/day, 7 days a week was denied.  

According to the Uniform Assessment System (UAS) report, the patient's cognitive skills are "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times."  He is totally dependent to maximal assistance for performing Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is also totally dependent for bathing, lower body dressing and toilet use. Maximal assistance is needed for personal hygiene, upper body dressing, bed mobility, locomotion, eating and toilet transfer. He is frequently incontinent of bladder and occasionally incontinent of bowel. He is also non-ambulatory. His functional ability has declined compared to the previous UAS report. This patient is an elderly adult who is essentially totally dependent to maximal assistance for IADL/activities of daily living (ADL) and incontinent. Based on the records reviewed, the approved live-in PCA is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. His clinical condition, limited functional ability, and severely impaired mobility support the medical necessity of the requested PCA services 24 hours/day, 7 days/week, split shift. The patient's health and safety are more appropriately provided and maintained at home with the requested PCA services 24 hours/day, 7 days/week split shift.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Aide (PCA) two 12-hour split shifts per day, 7 days a week is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Formulary Exception for Dulera (mometasone furoate-formoterol fumarate). 

The insurer denied coverage for Formulary Exception for Dulera (mometasone furoate-formoterol fumarate). 

The denial is upheld. 

The patient is a young adult with a history of asthma. The patient is receiving Xolair injections. The treating provider prescribed Dulera (mometasone furoate-formoterol fumarate) for management of the patient's asthma. The patient was seen for follow up. The patient was feeling better but still had significant cough which kept the patient up at night. The patient was afebrile, pulse 65, oxygen saturation 98%. No other exam notes were provided. The patient was on Asmanex Twisthaler 220 1 inhalation twice a day (Dulera had not been approved). In addition, the patient was on Spiriva Respimat once a day. 

The treating provider documentation noted having tried Breo, but the patient had some hoarseness secondary to not being capable of tolerating Dry Powder Inhaler (DPI). No other details were provided. The patient had tried Symbicort but had an "emotional reaction " to it. It is unclear as to what it was as no further details were provided. The patient had tried Advair, but it was ineffective. The patient does not want to try Advair Diskus as it is a DPI. As per the treating provider's note, the patient has hoarseness to all DPIs and cannot tolerate anything other than Asmanex; further details were not provided. The patient has not tried Advair Diskus. 

Dulera Inhaled corticosteroid and long-acting beta-agonist (ICS/LABA) is not on the preferred formulary. The other drugs available are Symbicort (LABA/ICS), Advair (LABA/ICS) Hydrofluoroalkane (HFA) and Diskus, and Breo Ellipta (ICS/LABA). Based on available information Dulera cannot be approved at this time. 

The formulary drugs are not likely to cause the patient an adverse reaction. No details of adverse reaction to preferred formulary drugs were provided. Moreover, the patient is presently on Asmanex which is a DPI but is not willing to try Advair Diskus (which is also a DPI). Based on the assumption that the patient will not tolerate it for which there is no documentation substantiating that at this time. 

Dulera (mometasone furoate-formoterol fumarate) is not expected to be more effective than the formulary drugs. 

Based on the above, the insurer's denial for Formulary Exception for Dulera (mometasone furoate-formoterol fumarate) must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic constipation

Treatment: Motegrity

The insurer denied coverage for Motegrity

The denial is upheld

 
The patient has chronic constipation that was not relieved with increased fiber or with Miralax. An abdominal x-ray showed large amounts of retained stool. An abdominal computed tomography (CT) scan also revealed fecal retention. She has been given glycerin suppositories.  For almost two years she has been on treatment with Motegrity. She has shown improvement with bowel movements on most days. 

UpToDate has an article titled "Management of Chronic Constipation in Adults." The article discusses pharmacologic therapy. There are several recommended medications. Lubiprostone is an approved medication based on studies that have shown that significantly more patients receiving this medication had an increase in spontaneous bowel movements. There was also improvement in bloating, discomfort and stool straining. Linaclotide has also been approved by the Food and Drug Administration (FDA) for the treatment of chronic idiopathic constipation. It has also shown an improvement in spontaneous bowel movements. Prucalopride is another medication that is advised for chronic constipation. 

There are several approved drugs for the management of chronic idiopathic constipation. These include the formulary alternative of linaclotide (Linzess). In this case, the patient has not received a trial of this formulary drug. The formulary drug has not been shown to cause an adverse reaction. It has not been prescribed and has not been shown to be ineffective. It is possible that the patient may do better with Motegrity as compared to Linzess. However, since the formulary drug has not been tried, the denial of Motegrity is upheld.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Motegrity (prucalopride) to treat constipation is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent 300mg (milligrams)/2ml (milliliters) SC (subcutaneously) SOPN (solution filled pen). 

The insurer denied: Dupixent 300mg (milligrams)/2ml (milliliters) SC (subcutaneously) SOPN (solution filled pen). 

The denial is overturned. 

The patient is an adult male with severe atopic dermatitis affecting 12% body surface area (BSA) for whom Dupixent is requested. The patient has tried and failed various topical and systemic steroids and antihistamines. 

The proposed treatment is medically necessary. 

The patient has severe atopic dermatitis affecting multiple areas of the body. He is a candidate for systemic therapy as the body surface area is too large for reasonable control with topical medications. Topical therapies are not appropriate therapy for severe, widespread atopic dermatitis, affecting sensitive areas, which should be treated with systemic therapy. Dupilumab is a monoclonal antibody that inhibits interleukin four (IL-4) and interleukin thirteen (IL-13) signaling by blocking the shared interleukin four receptor alpha (IL-4Ra) and originally demonstrated efficacy in phase II clinical trials. In 03/2017, it was approved by the United States Food and Drug Administration (FDA) for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It is a subcutaneous injection administered initially at a dose of 600 milligrams and then every two weeks thereafter. 

Approval of dupilumab was based on clinical trials investigating dupilumab as monotherapy (SOLO 1 and SOLO 2) and in concomitant administration with topical corticosteroids (CHRONOS). Results from the SOLO 1 (n=671) and SOLO 2 (n=708) trials showed 36-38% of patients who received dupilumab had scores of zero or one (clear or almost clear) on the Investigator's Global Assessment scale compared with placebo (8-10%) (P< .001). Additionally, improvement from baseline to week 16 of at least 75% on the Eczema Area and Severity Index (EASI) was reported in significantly more patients who received each regimen of dupilumab than in patients who received placebo (P < .001). 

Given its unprecedented efficacy, dupilumab is now a first-line therapy for moderate-to-severe atopic dermatitis. This patient has failed topical steroids and calcineurin inhibitors.
Cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil are not Food and Drug Administration (FDA) approved for use in atopic dermatitis (Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is. Systemic steroids and cyclosporine are not a reasonable long-term treatment for moderate to severe atopic dermatitis due to their severe side effect profile. 
For the reasons above, Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: PCW (personal care worker) services 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week
The insurer denied coverage for PCW (personal care worker) services 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week
The denial is overturned

This is a geriatric patient with chronic medical problems including dementia. The patient lives alone in a private home. The patient is currently approved for Patient Care Worker (PCW) services 7 days per week, 12 hours per day; totaling 84 hours per week and the request is for 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Severely impaired- Never or rarely makes decisions."  The patient is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. Maximal assistance is also needed for bathing, personal hygiene, dressing, eating and toilet use. Extensive assistance is needed for bed mobility, locomotion, ambulation (multiple falls) and toilet transfer. The patient is frequently incontinent of bladder and infrequently incontinent of bowel. The patient's functional ability continues to decline when compared to the previous UAS report. The patient's cognitive and functional deficits are at a level or unpredictable as to require the requested PCW services 7 days/week, 24 hours/day, continuous care by more than 1 person; 168 hours/week. Based on the records reviewed (including treatment logs), the patient's health and safety are more appropriately provided and maintained by the requested PCW services 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based. From a physical medicine and rehabilitation perspective, PCW services 7 days/week, 24 hours/day, continuous care by more than 1 person; 168 hours/week is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for PCW (personal care worker) services 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, cardiac arrhythmias, asthma, arthritis, general weakness, gait abnormalities, and overactive bladder
Treatment: increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.
The insurer denied coverage for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.
The denial is overturned.

This is an elderly patient with chronic medical problems including hypertension, cardiac arrhythmia and osteoarthritis. The insurer approved consumer directed personal assistant services (CDPAS) 42 hours/week. The request is for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired. Maximal to extensive assistance is needed for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing. Extensive assistance is needed for personal hygiene, dressing, locomotion, ambulation (uses walker or cane) and toilet transfer/use. She is frequently incontinent of bowel and bladder. The patient is independent with bed mobility and eating. The patient fell in her bathroom and was able to activate Life Alert and obtained assistance. She also fell again and was sent to the emergency room (ER). The computed tomography (CT) scan was negative, and she was not admitted to the hospital. The patient was more recently admitted to the hospital and treated for pneumonia. She was subsequently discharged.     

The patient's medical condition, functional ability and mobility are at the level as to require the requested consumer directed personal assistant services (CDPAS) services 24 hours/day, 7 days/week (live-in). She is frequently incontinent, has fallen in the bathroom along  with recent falls and hospitalization, support an increase CDPAS services 12 hours/day, 7 days/week (total 84 hours/week). Given her recent hospitalization for pneumonia and likely self-sufficiency deterioration, an updated Uniform Assessment System (UAS) report may be indicated. Based on the records reviewed, the patient's health and safety would be more appropriately provided and maintained by increasing CDPAS services to 24 hours/day, 7 days/week (live-in).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Other/Dental Issues
Treatment: Surgical placement of implant body: endosteal implant (D6010)
The health plan denied the requested surgical placement of implant body: endosteal implant (D6010).
The health plan's determination is overturned.

This patient is a male who had an implant placed in the #10 area. The radiograph shows that there is an implant in the #11 area in a natural tooth in the #9 area.
At issue is the medical necessity for the requested health service/treatment of the surgical placement of implant body: endosteal implant.

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

The options in this case to restore function are an implant or a bridge. An implant is the best option. A bridge is relatively contraindicated, as one of the abutment teeth would be a natural tooth and the other would be an implant. A bridge in this case could lead to the intrusion of the natural tooth. An implant would avoid this complication. Implants are the standard of care. They are the closest thing to natural teeth, preserve the bone and are not susceptible to caries. The implant procedure is more conservative and has a better prognosis. Implants have a high rate of success and do not require procedures on adjacent teeth. This is in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hidradenitis suppurativa. 
Treatment: Cosentyx Pen (2 Pens) 150 milligrams/milliliters (mg/ml) pen injector. 

The insurer denied coverage for Cosentyx Pen (2 Pens) 150 mg/ml pen injector. 

The denial is overturned. 

The patient is an adult patient with a diagnosis of severe hidradenitis suppurativa affecting the axilla, groin, and umbilicus.  According to the submitted documentation, she has failed therapy with topical agents, oral antibiotics, light therapy, and Humira.  The requested medication is Cosentyx.  Based on the submitted documentation, Cosentyx is beneficial in the treatment of the patient's hidradenitis suppurativa. 

The patient has failed oral antibiotics as well as Food and Drug Administration (FDA) approved Humira for the treatment of her condition and is a good candidate for Cosentyx. 

Although Cosentyx is not currently FDA approved for the treatment of hidradenitis suppurativa, there is evidence to support a likely improvement in health benefit of Cosentyx in this clinical scenario in which FDA approved therapies have been exhausted. 

Cosentyx is the best available treatment for this patient. 

Potential adverse risks are not increased over standard therapies. 

In summary, the denial of Cosentyx Pen (2 Pens) 150 mg/ml pen injector should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

 
Diagnosis: Cellulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This is an adult patient with a past medical history significant for coronary artery disease, hypertension, hyperlipidemia, left lower extremity deep vein thrombosis, and obesity who presented to the emergency department with complaints of fever, chills, and malaise.

Vitals on presentation included: Temperature 103 degrees Fahrenheit (F), Blood Pressure 121/80, Heart Rate (HR) 118, Respiratory Rate 25, oxygen (O2) saturations 97% (percent) on Room Air. Laboratory values were notable for the following: white blood cell count (WBC) 12.4, Hemoglobin 12.2, Hematocrit 36.4, glucose 119, and creatinine 1.13.

The patient was empirically started on intravenous antibiotics (vancomycin and ceftriaxone) for a left lower extremity cellulitis. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (cephalexin) as an outpatient. 

According to documentation, the patient presented with a fever (103 F), tachycardia (HR 118), and laboratory results notable for leukocytosis (WBC 12.4) and left lower extremity cellulitis. 
Based on the above findings in a high-risk patient with multiple comorbid conditions, a hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident (CVA)
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
This case involves an adult under review for denied hospitalization. It was noted that the patient woke up that morning with slurred speech, left-sided headache, left hand numbness, dizziness, and dysphagia with the inability to ambulate. It was noted that stroke code was called immediately upon arrival. It was noted that neurology was consulted and requested admission to the telemetry unit for further work-up and management. The patient had a National Institutes of Health Stroke Score (NIHSS) of 3 and received intravenous (IV) fluid bolus and medication management. The patient underwent echocardiogram, transesophageal echocardiogram (TEE), and magnetic resonance imaging (MRI) of head that were all unremarkable. At the time of discharge the symptoms had resolved and the NIHSS was 0.

Milliman Care Guidelines (MCG) recommends inpatient admission for acute ischemic stroke with neurological findings to include NIHSS score greater than 2, dysphagia that warrants evaluation, significant weakness, and/or gait impairment. In this case, the NIHSS was 3 and there was slurred speech, left-sided headache, left hand numbness, dizziness, and dysphagia with the inability to ambulate. Inpatient admission was warranted for treatment and workup. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission date of service is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Syncytial Virus (RSV).
Treatment: inpatient stay.
the insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a young boy who presented to the emergency department with fever, cough, and difficulty breathing.
He was well until 3 days prior to presentation when he developed a fever and cough. He was seen by his primary doctor and was prescribed albuterol and ibuprofen. After that, he continued to have fever up to 101 at home, and continued to have a productive cough. He also had one episode of vomiting, a decrease in oral intake, and decreased activity. On the day of presentation, he developed difficulty breathing with abdominal breathing, so he was brought to the emergency department for care.

Inpatient Hospital Admission was medically necessary for this patient.
This is a very young boy who presented with wheezing and increased work of breathing from RSV infection. He also had decreased oral intake and decreased activity. He received appropriate treatment as an outpatient and in the emergency department setting, but continued to have retractions. He therefore required hospital admission for ongoing treatment with nebulized saline and chest physical therapy (PT) along with close monitoring with additional treatment as needed.
The decision making at the time of admission was consistent with his young age, the presence of persistent increased work of breathing from RSV infection despite appropriate treatment, and the need for ongoing treatment in an inpatient setting along with close monitoring for potential deterioration of clinical status.