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

Diagnosis: pulmonary embolism
Treatment: Eliquis
The insurer denied Eliquis. The health plan's determination is upheld. 

This is a female with a provoked pulmonary embolism for which she was treated with Eliquis. Coverage for Eliquis is the subject of this review.

A formulary exception is not indicated in this case. Neither Xarelto nor warfarin have been demonstrated to be inferior to Eliquis. The included documentation does not indicate that this patient is intolerant of either of the formulary alternatives nor that she has failed them. Similarly, there is a paucity of documentation indicating this patient has a contraindication to the formulary alternatives. Neither the authors of UpToDate nor the peer-reviewed literature recommend one of these agents as being superior to another and thus given their relative equivalency, the formulary options are reasonable and would not have adverse effects that the non-formulary alternative would.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Pulmonary arterial hypertension. 
Treatment: Letairis 10 MG (milligrams). 

The insurer denied: Letairis 10 MG (milligrams). 
The denial is overturned. 

The patient is an adult female with Group 1 pulmonary arterial hypertension is prescribed brand name Letairis. This request is denied because patient has not tried generic ambrisentan or there is lack of clinical documentation of intolerance to generic ambrisentan. This denial is being appealed because patient has tried and failed generic ambrisentan. 

The health plan should cover the proposed treatment. 

The patient has severe group I pulmonary arterial hypertension who is being treated with sildenafil, Letairis and IV (intravenous) remodulin. The patient was transitioned to generic ambrisentan but the patient had side effects and had worsening symptoms of pulmonary hypertension. The patient's symptoms improved with brand name Letairis. The medical documents provided report that the generic ambrisentan has adverse side effects. The formulary drug, ambrisentan thus would be ineffective for this patient and would not be as effective as the requested non-formulary drug. The plan should cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperlipidemia. 
Treatment: Repatha. 

The insurer denied: Repatha. 
The denial is upheld. 

The patient is a female with a history of hypertension, hyperlipidemia, chronic left bundle branch block (LBBB), and multifocal fibromuscular dysplasia involving the vertebral and carotid arteries complicated by bilateral carotid dissections. The patient has had difficulty taking statin therapy due to myalgias. However, the patient was prescribed Crestor 20 milligrams (mg) daily for treatment of hyperlipidemia. The patient's treating provider recommended Repatha to treat hyperlipidemia and reduce patient's cardiovascular risk in the setting of intolerance to atorvastatin. In addition, the patient has also been referred for coronary angiogram for evaluation of chest pain. The patient's health plan has denied coverage for Repatha due to lack of medical necessity. The subject under review is the medical necessity for Repatha. 

The health plan's determination is upheld. 

No, the treatment with Repatha is not medically necessary for this patient. While the patient has a history of hyperlipidemia and intolerance to atorvastatin causing myalgias, the patient has been prescribed rosuvastatin instead. Records provided for this case review do not demonstrate intolerance to rosuvastatin nor document an adequate trial of treatment to determine if patient will be able to achieve an appropriate low density lipoprotein (LDL) goal. This is consistent with the standard of care. If the patient demonstrates intolerance to rosuvastatin or inadequate LDL reduction after an appropriate trial period, Repatha may be appropriate to lower her LDL and reduce her cardiovascular risk at that point. (1)
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Anterior cervical discectomy.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is modified.

 
This case involves an adult diagnosed with spinal stenosis of the cervical region who presented to the hospital for a scheduled anterior cervical (C) discectomy and fusion at C3-C4, C4-C5, C5-C6, and C6-C7, with total disc arthroplasty at the same levels. The brief operative note indicated that there were no complications. Records noted the patient had a history of sepsis, type 2 diabetes mellitus, gastroesophageal reflux disease, high cholesterol, hypertension, hypothyroidism, and sleep apnea. Total surgery time was approximately 6 hours with the patient remaining intubated and sedated through the following morning. Her pain was controlled with Robaxin, Tylenol, and Toradol. Her heart rate and blood pressure were stable, and her surgical drain was removed the following day. She was advised to continue incentive spirometry, continue bowel regimen, and advance her diet as tolerated. She had no reports of dysphagia, and her Foley catheter was removed. Lab results showed elevation in the patient's white blood cell count at 14.1 and 14.5, up from the day prior at 13.3. Her hemoglobin levels were low at 11.3 and 11.4 respectively. Hematocrit was also low at 33.2 and 33.8 respectively. Her sodium had normalized, and her surgical site was clean, dry, and intact. She was neurologically intact in the upper extremities. The patient's white blood cell count started improving, although hemoglobin and hematocrit remained low. Her sodium level had also gone down to 133 with serum glucose elevated at 133. Her calcium was low at 7.8, although she remained neurologically intact in the upper and lower extremities. The patient was assessed, she remained neurologically intact in the upper and lower extremities. She reported some incisional pain, but took a few steps the day prior, was voiding freely, passing flatus, and denied chest pain, shortness of breath, abdominal pain, nausea/vomiting, or lightheadedness. Her vital signs were stable with reports of mild/asymptomatic hyponatremia, and hypertension with continued Lopressor. Her hemoglobin A1C was improving, and she would continue weekly Trulicity and Lantus. She will continue Synthroid to address the hypothyroidism, continue proton pump inhibitors to counteract gastroesophageal reflux disease, and was given aspirin 81 milligrams (mg) to be taken daily to prevent deep vein thrombosis. The patient was subsequently discharged.  

It was therefore determined that a denial of coverage for full hospital admission was not appropriate, but denial of coverage for continued admission only, was reasonable. She could have been safely downgraded to lower level of care.

Based on the above, the insurer's denial must be modified. The health care plan acted reasonably in part. The medical necessity for full hospital admission is modified to allow coverage for the first two days and deny the continued stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left ear keloid scar
Treatment: Outpatient services (69300, 14060) x 1 Ambulatory Surgery
The insurer denied coverage for Outpatient services (69300, 14060) x 1 Ambulatory Surgery
The denial is upheld
 

The patient appeal indicates that the patient is suffering from emotional distress, but the patient is not documented to have participated in psychological counseling. The keloid distorts the earlobe but is not causing any health or functional problems. Keloid repair will change the appearance but will not improve health or function and is cosmetic for this patient.

According to the Milliman Care Guidelines (26th Edition), Scar revision may be indicated when ALL of the following criteria are met:

1.	Scar has been present at least 1 year
2.	Scar causes symptoms, including 1 or more of the following:
a.	Loss of range of motion of joint
b.	Signicant pain
3.	Symptoms persist despite medical treatment, including 1 or more of the following:
- Physical, occupational therapy
- Corticosteroid injection
- Silicone gel sheeting
- Pressure therapy
- Radiation therapy
- Laser therapy
- Cryotherapy
- 5-Fluorouracil injection

The keloid scar is not causing loss of range of motion of a joint or significant pain.  The records do not document any functional problems due to the scar. The American Society of Plastic Surgeons recognizes that most scar revisions are not required for health or functional indications. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Outpatient services (69300, 14060) x 1 Ambulatory Surgery is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Lichen planopilaris
Treatment: Formulary Exception for Tacrolimus Powder Compound
The insurer denied Formulary Exception for Tacrolimus Powder Compound
The denial is overturned

The patient is an adult with a diagnosis of lichen planopilaris (LPP). The patient has significant scalp involvements with scarring alopecia. The request is for topical 0.1% compounded tacrolimus solution. No formulary alternatives were provided by the insurer.

Topical tacrolimus is available as an ointment; however, this product is difficult to apply in the scalp due to its consistency and base. The use of a non-steroidal solution is preferable to systemic therapies as an initial treatment strategy. No Food and Drug Administration (FDA) approved medications are available for the treatment of LPP. The use of compounded tacrolimus 0.1% solution is clinically appropriate for the patient's condition.

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 request for Formulary Exception for Tacrolimus Powder Compound is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure. 
The health plan's determination is upheld. 

This is a female patient diagnosed with low back pain. The patient was recommended to undergo the Intracept procedure, which was denied by the insurance carrier as experimental and investigational.

The Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). However, the MRI shows multiple significant findings including multilevel disc herniations, nerve root compression, retrolisthesis, and varying degrees of central stenosis and foraminal stenosis that are likely pain generators. The Intracept procedure is not indicated as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure. 
The health plan's determination is upheld. 

The patient is a female with chronic neck, mid, low back pain and right hip pain. She states that her pain has been present for multiple years. Prior treatment has included injections, therapy, as well as medications. The pain impacts activities of daily living (ADL) and function. 

The proposed Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This procedure is not recommended despite promising early reports, and further trials with longer-term outcomes and less risk of bias are required. An Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure. 
The health plan's determination is upheld. 

This is a female who has a several year history of chronic neck mid and low back pain. She has lower back and right buttock pain with radiating pain down to right lateral thigh. Her pain is increased with prolonged sitting, standing and ambulation. She had tried Tylenol, non-steroidal anti-inflammatory drugs (NSAIDs) without improvement. She was unable to complete physical therapy (PT) due to severe pain.

The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. This patient was recommended for Intracept procedure at L3 L4 and L5 levels. However, the available medical records did not reveal enough evidence that this patient's back pain is from L3 L4 and L5 vertebral bodies. An MRI revealed Type 1 Modic changes at L4/5 endplate, and a disc bulge with right subarticular disc herniation impinging upon the descending right L5 nerve root. This patient has right buttock pain with radiating pain to right lateral thigh which is consistent with radicular pain from her L5/S1 disc herniation. In addition, no Modic changes at L3 level are documented in the MRI report. Current clinical studies supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the patients with clinical evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies. This patient is not an appropriate candidate for the Intracept procedure based on current clinical studies and her clinical presentation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Iron Deficiency Anemia
Treatment: Intravenous (IV) iron infusion [Injectafer (ferric carboxymaltose)]
The insurer denied coverage for IV iron infusion [Injectafer (ferric carboxymaltose)].
The denial is overturned.

The patient has iron deficiency anemia. The patient reported unsuccessful use of oral iron in the past. She had a syncopal episode when vacationing and was seen at a hospital where the hemoglobin level was 7.3 grams per deciliter (g/dL), mean corpuscular volume (MCV) 68.9, and ferritin level was 3.7. The patient received intravenous (IV) iron therapy and had significant improvement in iron levels, hemoglobin, and resolution of pica.

In this case of symptomatic iron deficiency anemia not responsive to oral iron, the treatment with iron [Injectafer (ferric carboxymaltose)] is considered medically necessary for this patient. 

As IV iron preparations have become safer, they are increasingly being used as initial therapy. Injectafer is Food and Drug Administration (FDA) approved to treat iron deficiency anemia in adults and pediatric patients 1 year of age and older. It is indicated for treatment of iron deficiency anemia in adult patients who have intolerance to oral iron or have had unsatisfactory response to oral iron, which is the exact situation 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 treatment with iron [Injectafer (ferric carboxymaltose)] is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periodontal pocketing

Treatment: dental deep gum and root cleaning

The insurer denied coverage for dental deep gum and root cleaning

The denial is upheld

Based on the submitted documentation which includes copies of periodontal charting, and select undated periapical radiographs and insurer correspondence, it appears that this patient presented for evaluation for dental services and periodontal therapy. The dentist reported periodontal chartings indicating 2-4 millimeter (mm) generalized periodontal pocketing with focal 5 mm depth readings. The recommended treatment was scaling and root planing of the left and right mandible.

Upon review of the submitted documentation, both the radiographs and periodontal probing depths, there is minimal if any loss of alveolar bone height affecting these teeth. The focal 5 mm increased pocket depths likely represent pseudo pocketing due to superficial calculus accumulation and poor oral hygiene. There is minimal significant periodontal probing over 5 mm depth. The insurer has correctly applied the clinical criteria in denying scaling and root planing services.

Uphold denial of coverage for dental deep gum and root cleaning as not medically necessary as the clinical and radiographic documentation does not support or substantiate scaling and root planing services.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for dental deep gum and root cleaning services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Ovarian Cyst
Treatment: Inpatient Hosptial Stay
The insurer denied: Inpatient Hospital Stay
The denial is: Upheld

The patient is a female with a large 20 centimeter (cm) left-sided ovarian cyst who presented with sudden onset of severe abdominal pain that woke her from sleep. She had reported the pain to be constant and worse with movement or touching. She stated that the abdomen was less protuberant than before, but her pain was much worse.  The patient had no other past medical or surgical history. She had no known allergies. She was taking ibuprofen for pain at home. Vital signs were stable. Her exam was noted to be well appearing in distress from pain. The heart was tachycardia but regular rhythm. The lungs were clear to auscultation. The abdomen was soft and tender to palpation throughout with rebound and guarding present. The patient was given morphine 4 milligrams (mg) intravenous (IV) and made nothing by mouth with IV fluids started. The patient was pending going to the operating room for ruptured cyst with noted free fluid on ultrasound exam. A computed tomography (CT) was also ordered. The patient was hemodynamically stable at that time except for mild tachycardia and pain was to be treated as needed. The patient was admitted by the gynecological (GYN) team for surgical management.

The patient was taken to the operating room and was found to have a large mobile mass to the level of the umbilicus for exam under anesthesia. Diagnostic laparoscopy was performed with no adequate visualization of the mass for assessment. Decision was then made for an exploratory laparotomy and a large amount of straw-colored ascites was evacuated from the pelvis and sent for cytology. Following surgery, the patient appropriately advanced diet and was discharged home on oral pain medication as she was stable and meeting postpartum goals. The patient was scheduled for follow-up in the clinic in 2 weeks following discharge.

The health plan's determination is upheld.

The inpatient hospital stay was not medically necessary at the acute inpatient level of care status for this patient who was admitted for a ruptured right laparoscopic cystectomy for an ovarian cyst. Based on review of the medical documentation and the Milliman Care Guidelines (MCG), there was no medical necessity for acute inpatient admission as the patient had no evidence for care that required acute inpatient admission as outlined by the Guideline. The patient could have been managed at a lower level of care status and met discharge criteria following the procedure. Based upon a review of the medical records and the procedures and course of care there would be no medical necessity for acute inpatient level of care for a postoperative stay after salpingectomy due to a ruptured ovarian cyst.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Personal Care Aide Level II Services From 42 Hours Per Week To 84 Hours Per Week (12 hours/day, 7 days/week)
The insurer denied: Increase Personal Care Aide Level II Services From 42 Hours Per Week To 84 Hours Per Week (12 hours/day, 7 days/week)
The denial is overturned

The patient is an elderly female. The patient is alert and oriented times two and lives alone. Her cognitive skills are minimally impaired, and she does have memory problems. She is maximal assistance with meal preparation, total dependence with ordinary housework extensive to maximal assistance with managing medication using stairs, shopping and transportation, limited assistance with bathing, supervision with personal hygiene and dressing upper body, extensive assistance with dressing lower body, limited assistance with toilet use. The patient ambulates with a walker, indoor and outdoor. She requires assistance with activities of daily living due to pain and limited range of motion and osteoarthritis. The patient is occasionally incontinent of bladder and frequently incontinent of stool.

The patient had Uniform Assessment system evaluations last year and earlier this year. Between these evaluations, there has been significant change in the patient's status. Before, the patient was continent of stool and bladder, and the patient was more independent.

The request is to Increase Personal Care Aide Level II Services From 42 Hours Per Week To 84 Hours Per Week (12 hours/day, 7 days/week).

The requested Increase Personal Care Aide Level II Services From 42 Hours Per Week To 84 Hours Per Week (12 hours/day, 7 days/week) is medically necessary.

The patient has deteriorated compared to the previous assessment. Currently, the patient is stool and urine incontinent. The patient's condition has deteriorated. The stool and urine incontinence are new, and the patient was found on multiple occasions wandering in the lobby and hallway outside of her apartment because of dementia.

The health plan's approved Personal Care Aide Level II Services 42 Hours Per Week is insufficient to provide enough care for the patient, especially with the patient's condition deteriorating, the patient's advanced dementia, and leaving the house and wandering in the hallway. Also, the patient is incontinent for stool and urine.