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

Diagnosis: Congenital Glaucoma. 
Treatment: Formulary Exception for Lumigan. 

The insurer denied the Formulary Exception for Lumigan. 
The denial is overturned. 

The patient is a male with glaucoma for whom coverage of Lumigan (bimatoprost) is the subject of review. Coverage was previously denied per formulary, which requires that the patient have tried and had inadequate treatment response or intolerance to the formulary alternatives, which include latanoprost and travoprost (generic Travatan Z). 

Upon appeal, the provider notes that the patient has tried latanoprost, timolol, brimonidine, and Combigan. The patient's intraocular pressures are not adequately controlled with latanoprost, which can result in loss of vision. Intraocular pressure is better controlled with Lumigan. 

Yes, the health plan should cover the Formulary Exception for Lumigan. 
While the remaining formulary drug, travoprost, has not been used and found to be ineffective or associated with adverse side effects in this patient, it would be expected to be less effective at lowering intraocular pressures than the requested non-formulary drug, Lumigan. 

According to the American Academy of Ophthalmology, prostaglandin analogs are the most frequently prescribed eye drops for lowering IOP (intraocular pressure) in patients with glaucoma, because they are most efficacious and well tolerated, and they need to be instilled only once daily. Therefore, prostaglandin analogs are often selected as initial medical therapy unless other considerations, such as contraindications, side effects, intolerance, or patient refusal preclude this. 

Li, et al., assessed the comparative effectiveness of first-line medical treatments in patients with POAG (primary open-angle glaucoma) or ocular hypertension through a systematic review and network meta-analysis, and to provide relative rankings of these treatments. "The mean reductions (95% credible intervals) in IOP (intraocular pressure) in millimeters of mercury at three months ordered from the most to least effective drugs were as follows: bimatoprost 5.61 (4.94; 6.29), latanoprost 4.85 (4.24; 5.46), travoprost 4.83 (4.12; 5.54), levobunolol 4.51 (3.85; 5.24), tafluprost 4.37 (2.94; 5.83), timolol 3.70 (3.16; 4.24), brimonidine 3.59 (2.89; 4.29), carteolol 3.44 (2.42; 4.46), levobetaxolol 2.56 (1.52; 3.62), apraclonidine 2.52 (0.94; 4.11), dorzolamide 2.49 (1.85; 3.13), brinzolamide 2.42 (1.62; 3.23), betaxolol 2.24 (1.59; 2.88), and unoprostone 1.91 (1.15; 2.67). 

In this case, the patient has already tried and failed latanoprost, which is more effective than the remaining formulary alternative, travoprost. Bimatoprost is considered more effective at lower intraocular pressures than both latanoprost and travoprost. Therefore, bimatoprost (Lumigan) is established as medically necessary based on standard of care, as supported by peer-reviewed medical literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems-Teeth spacing problem.
Treatment: Dental/Orthodontic Procedure-Braces.
The health plan denied the treatment of Braces with adjust of braces as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient has a Skeletal Class I occlusion. Moderate mandibular crowding and moderate maxillary crowding. Moderate overjet and moderate overbite. Anterior crossbite at tooth #10. The subject to be determined is the medical necessity for braces and the adjustment of braces.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 20 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9-millimeter (mm) or greater and underbite 3.5mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, braces and the adjustment of braces are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Overturned

immunologic Disorders
Pharmacy/Prescription Drugs

Diagnosis: psoriatic arthritis.
treatment: Xeljanz XR.
The insurer denied Xeljanz XR. 
The health plan's determination is overturned. 

The patient is a female with a history of psoriatic arthritis (PsA). The issue in this case is Xeljanz extended release (XR) 11 milligrams (mg) daily is being denied by the health plan. Formulary alternatives include methotrexate (MTX), cyclosporine, sulfasalazine or leflunomide. Prior tx (treatment) has included MTX (by previous provider). Per chart review, the patient's PsA is not well controlled on Naproxen and Otezla.

Xeljanz XR 11 milligrams (mg) is medically necessary for this patient. She has already tried MTX and her PsA is not well controlled on Naproxen and Otezla.
Although there is not a medical reason the patient cannot try cyclosporine, sulfasalazine and leflunomide; however, these drugs are rarely used in the treatment of psoriatic arthritis and are less effective than MTX and Otezla, both of which the patient has tried. MTX is usually first line followed by a biologic. The plan's formulary alternative disease modifying anti-rheumatic drugs (DMARD) are not commonly used for PsA and will likely not be effective.
A trial of Xeljanz is a reasonable next step in the treatment of her PsA.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperhidrosis.
Treatment: Botox Injection, Pre-service.
The insurer denied the Botox Injection, Pre-service.
The denial is overturned. 

The patient is a woman with primary focal axillary hyperhidrosis. She has failed treatment with topical Drysol, Qbrexa, and oral glycopyrrolate. Botox injections are requested.

Yes, the treatment with Botox is medically necessary.
The patient has primary focal axillary hyperhidrosis. There is documentation that the patient has failed topical Drysol and Qbrexa, and has intolerance to oral glycopyrrolate.

Topical antiperspirants are the preferred initial treatment for axillary hyperhidrosis, because they are widely available and well-tolerated therapies. Topical glycopyrronium is an alternative first-line treatment and an option for patients who present with a history of poor responses to prescription antiperspirants.  Patients who do not achieve sufficient improvement in axillary hyperhidrosis with topical antiperspirants may benefit from botulinum toxin injections or microwave thermolysis. Systemic therapies (anticholinergics, clonidine, beta-blockers, and benzodiazepines) can be effective for primary focal hyperhidrosis. The potential adverse effects of systemic agents inhibit the routine use of these therapies. Additional studies are necessary to confirm the long-term efficacy and safety of anticholinergic drugs when utilized for this indication.

There is documentation that the patient has tried and failed first-line topical and systemic therapies. Therefore, the treatment with Botox is medically necessary.

Individuals with primary focal hyperhidrosis typically have excessive sweating of the palms, soles, and axillae and can suffer significant psychological, social, educational, and occupational consequences. Patients with axillary, palmar, or plantar hyperhidrosis should initially be treated with topical antiperspirants such as 20% aluminum chloride hexahydrate or 6.25% aluminum chloride hexahydrate. Skin irritation is a common side effect that may be reduced with proper application technique or a low-potency topical corticosteroid. Second-line treatments for axillary hyperhidrosis include botulinum toxin injection, microwave thermolysis, and topical glycopyrronium.

Therefore, given the above, Botox injections are appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteomyelitis of the sacrum and neuropathy related to diabetes mellitus.

Treatment nursing - home care - license practice nurse visit for a total of 1 unit.

The insurer denied coverage for nursing - home care - license practice nurse visit for a total of 1 unit.

The denial is overturned.

A wound vacuum assisted (VAC) closure device was placed to aid in the healing. Osteomyelitis was suspected at the S (sacral) 4 to S5 level. The patient was discharged in stable condition, and the plan included wound care and wound VAC changes at home on three days a week.  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and his sister were present on the call.  The patient resides with his sister in a 2 bedroom apartment located on the first floor.  His sister is supportive. 

The patient is dependent for most activities of daily living and instrumental activities of daily living (IADL) due to contractures, pain related to osteomyelitis of the sacrum and neuropathy related to diabetes mellitus. The patient is also unable to participate in instrumental activities of daily living (IADL) due to being bed bound and having cognitive impairment. The patient's sister reported that the patient has a history of failure to thrive. 

The patient has a percutaneous endoscopic gastrostomy (PEG). 

The patient is totally dependent for meal preparation, ordinary housework, managing finances, managing medications, managing stairs, shopping, transportation, equipment management, bathing, dressing his upper and lower body and toilet use. He is bladder incontinent but has bowel control with an ostomy device. Per the patient's sister, the patient's sacral wound is not healing and has reoccurring infections, which is why an ostomy bag was created. The patient wears diapers for his incontinence.  The patient needs maximum assistance with phone use. He needs extensive assistance with personal hygiene. Nursing - home care - license practice nurse visit for a total of 1 unit is being requested.

The patient's need for skilled nursing care is supported by the applicable clinical standards, the medical records, the physicians' recommendations and the generally accepted practice guidelines. 

The Initial Denial was based on lack of treating physician notes and appropriate orders. The physician notes that he will be taking care of the patient and notes PEG, ostomy, wound care and turning and positioning needs (T&P) needs. He reiterates these needs at a visit. This is echoed other letters. The Final Denial notes lack of back-up care. The physician letter and an affidavit signed by the patient's sister establishes that she is the back-up. 

The patient appears to meet the conditions of the plan.

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 the requested Nursing - Home Care - License Practice Nurse visit for a total of 1 unit is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders
Pharmacy/Prescription Drugs

Diagnosis: hidradenitis suppurativa
Treatment: Humira 80mg/week
The insurer denied Humira 80mg/week. The health plan's determination is upheld. 

The patient is a female with hidradenitis suppurativa. The standard dose of Humira was used but was not sufficient to control this patient's disease.
Health plan coverage of Humira 80 milligrams (mg) /week because of disease recalcitrance is under review for medical necessity.

Humira 80 mg weekly is not medically necessary for this patient.
Current medical literature only supports the Food and Drug Administration (FDA) -approved dosage of Humira (adalimumab) at 40 mg/week. Only case series and anecdotal literature supports use of higher dosing of Humira, and safe and effective dosing at the 80 mg/week is not proven or supported by any specialty consensus at this time. Another Tumor Necrosis Factor inhibitor, Remicade (infliximab) is normally utilized as a second-line therapy that is weight-based and with the potential for higher dosing for patients who have failed Humira (as appears to be the case with this patient).
Accordingly, Humira dosing of Humira at 80 mg/week is not medically necessary for treatment because of a lack of reliable outcomes data for safe, effective control of hidradenitis suppurativa compared to the standard dosing of 40 mg/week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cleft lip and palate
Treatment: nasal/facial surgery
The insurer denied Repair of Nasal Vestibular Stenosis and Rhinoplasty for Nasal Deformity Secondary to Congenital Cleft Lip and/or Palate, Including Columellar Lengthening, Tip, Septum, Osteotomies. 

The health plan's determination is overturned. 

This female has a diagnosis of cleft lip and palate. She had surgery twice for nasal deformity and obstruction and the surgery worsened her nasal airway obstruction. She is unable to breath out of her nose and has an oral-nasal fistula. Exam shows severe septal deviation to the left, columella deviation to the left and no tip support. She has a large oral-nasal fistula. Revision septorhinoplasty and nasal reconstruction is planned.

The Repair of Nasal Vestibular Stenosis and Rhinoplasty for Nasal Deformity Secondary to Congenital Cleft Lip and/or Palate, Including Columellar Lengthening, Tip, Septum, Osteotomies are medically necessary for this patient.
Rhinoplasty is an expected stage of the overall treatment of cleft lip and palate congenital anomalies. The American Cleft Palate-Craniofacial Association lists rhinoplasty as an expected treatment after skeletal growth is complete on page 17 of their publication, "Parameters for Evaluation and Treatment of Patients with Cleft Lip/Palate or Other Craniofacial Anomalies" This patient has nasal obstruction due to tip collapse and severe septal deviation. Because the obstruction is structural rather than allergic, conservative treatment is unlikely to be of benefit. According to the American Academy of Otolaryngology Position Paper "Clinical Indicators - Septoplasty", "When the nasal septum is deformed, there is no medicine that will cause it to be straightened, so surgery is the only solution to this problem."
Management of the collapsed cleft nose with nasal obstruction often requires both a septoplasty and an osseous rhinoplasty to completely correct the airway, as is the case for this patient. The entire nasal structure is crooked and collapsed, and it is difficult to straighten only the septum when the osseous structures are distorted. Straightening the nasal pyramid helps to reset the position of the upper later cartilages, which in turn opens the airway. In addition, a straight pyramid helps to prevent recurrent deviation of the cartilage. Finally, collapse of the nasal pyramid and tip narrows the anterior and posterior airway, a finding documented on intranasal exam. According to Antunes and Goldstein, "Management of the crooked or collapsed nose and valve obstruction is a challenge for even the most experienced rhinoplasty surgeon. Optimal treatment to restore a functional airway and improve cosmesis requires addressing the nasal valves."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: 5 millimeter (mm) right ureteropelvic junction (UPJ) stone

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission.

The denial is upheld. 

This male patient has a history of renal stones and diabetes.

The insurer has denied coverage for the full hospital admission as not medically necessary. They noted the patient's presentation and the procedure done. There were no severe medical problems warranting a full hospital admission. 

Per Milliman Care Guidelines (MCG) Health (24th) renal colic and kidney stones, the patient fails to meet clinical indications for admission to inpatient care. These include hemodynamic instability, acute renal failure [stage 3 acute kidney injury (AKI)], bilateral obstruction, obstruction with single functioning kidney, etc. Also, per MCG Health (24th) Urologic surgery or procedure General Recovery Care (GRG), the patient appears to meet the GRG discharge parameter within 24 hours post procedure. As per the guideline, the cystoscopic ureteral stent insertion is usually performed in the ambulatory surgery setting.

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.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Treatment:  Formulary exception for Ubrelvy
The insurer denied the  Formulary exception for Ubrelvy
The denial is upheld. 

The patient is a female with ongoing treatment of migraines. 

The patient's migraine's began approximately thirty years prior.  It is mostly on the right side, sometimes awaking her from sleep and sometimes presenting in the morning.  She is taking Motrin on a daily basis. She averages five Imitrex per month. She has more than 10 headache days per month.  She has associated photophobia, phonophobia, nausea, vomiting, allodynia, neck stiffness, fatigue, and frequent rhinorrhea.  Her headaches are worsened by movement.  Prior medications include sumatriptan, Relpax, Motrin, nortriptyline, Topamax, and Botox.

The overall assessment is that the patient had migraine without aura G43.009.  She has high frequency of migraine headaches and may benefit from a preventative, but they were going to hold off until a trial of nerve blocks.  They were going to consider either Emgality, Ajovy versus Aimovig and recommended a trial of Ubrelvy for rescue.  She has tried and failed sumatriptan and Relpax, per the provider.

Ubrelvy is being requested. The provider indicates that there is no coverage for other drugs that may be considered for treatment of the patient.  It is indicated that it is being used for an FDA (United States Food and Drug Administration)-approved indication.  It indicated that it is prescribed at a quantity to fall within the FDA (United States Food and Drug Administration)-approved labels and the patient has reportedly previously tried and failed sumatriptan and eletriptan.  The health plan's recommended alternatives to Ubrelvy are Relpax, naratriptan, rizatriptan, sumatriptan injection, sumatriptan nasal spray, Zembrace, Nurtec ODT (orally disintegrating tablet), Zomig, zolmitriptan, and SymTouch.

The appeal is regarding formulary exception for Ubrelvy.

No, the health plan should not cover the Formulary exception for Ubrelvy.
The health plan formulary preferences indicates that there must be evidence of trial and failure of three formulary alternatives in a class where three or more alternatives are available. Per the formulary, the recommended alternatives to Ubrelvy are Relpax, naratriptan, rizatriptan, sumatriptan injection, sumatriptan nasal spray, Zembrace, Nurtec ODT (orally disintegrating tablet), Zomig, zolmitriptan, and SymTouch.

The available medical records provided for review do not document that the patient has failed at least three alternative agents.  The medical records indicate failure of two alternative agents that being eletriptan and sumatriptan.  As such, based on the medical records provided for review, the patient does not meet the formulary preferences of having failed at least three or more agents within the formulary alternative.  The available medical records do not support that the formulary drug has been ineffective for the patient except for two agents.  These are considered to be as effective as requested non-formulary agent, and there is no indication of adverse effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient presented to the Emergency Department (ED) with right upper quadrant abdominal pain and vomiting that started after a meal.

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year, and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] 

Per clinical documentation, this patient presented to the Emergency Department (ED) with a one-day history of right upper quadrant abdominal pain. There was associated nausea and vomiting. Vital signs in the ED were within normal limits. An ultrasound demonstrated cholelithiasis without findings of acute cholecystitis. Total bilirubin, alanine transferase, aspartate transferase, and alkaline phosphatase were elevated at 1.2, 220, 380, and 158, respectively. White blood cell count was 10.8. The patient had an uneventful laparoscopic cholecystectomy with intraoperative cholangiogram. There were no reported complications. There were no filling defects noted during the cholangiogram. The patient was discharged within 24 hours after the procedure. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient/ambulatory procedure. Per provided clinical documentation, inpatient admission was not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Back Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with diabetes, coronary artery disease, and hypertension who had L4-5 (fourth and fifth lumbar spine vertebra) lumbar discectomy.
  
The day after discharge for the discectomy, the patient presented to the emergency room with low back and buttocks pain.  There was no neurologic deficit.  The patient was admitted for pain control.  She was seen by Pain Management, as the surgeon did not see a need for any further surgical intervention.  Physical therapy was also initiated.

This patient presented with complaints of low back pain only a few days after surgery.  She did not require urgent admission and was hemodynamically stable.  She did not have any neurologic deficit and magnetic resonance image (MRI) did not reveal any reason for additional surgery.  Pain control and additional work-up for this patient did not require inpatient admission.  Lumbar discectomy is typically performed as an outpatient procedure.

There was no indication for re-admission or for a prolonged hospital stay.  This patient could have been managed at a lower level of care with pain medications.  Low back pain after surgery is normal and without neurologic sequelae, admission was not necessary.  Her symptoms improved with time, as they would have at a lower level of care.  The literature supports outpatient discectomy surgery.  This patient already had a longer than usual hospital stay following the index surgery.  Inpatient admission was not medically necessary.