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

Diagnosis: Benign prostatic hyperplasia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with benign prostatic hyperplasia. He also has history of smoking and alcohol use. He failed medical therapy, and he underwent uneventful transurethral prostatectomy. He was admitted to acute inpatient service for continuous bladder irrigation.

The patient's labs revealed normal serum creatinine 0.9, hgb (hemoglobin) 13.1 (normal 13.3+) and hematocrit normal at 41.8%. He remained hemodynamically stable. The CBI (continuous bladder irrigation) was discontinued. He passed trial of void and was discharged to home.

No, the Inpatient admission was not medically necessary.
This patient has a history of benign prostatic hyperplasia, smoking and alcohol use. His operative report indicates that he did very well without complication, and the irrigant returned from his bladder mild pink. He was transported to the recovery room in good condition. The patient's post-operative labs revealed a normal hemoglobin. The patient was not identified to have any significant co-morbidities requiring monitoring outside of the routine postoperative monitoring. The patient's urine remained mild pink, and the patient was hemodynamically stable. This patient could have been managed at a lower level of care.

The plan denied the inpatient admission, indicating that it was not medically necessary. The provided documents support that the patient did not have any co-morbidities requiring inpatient monitoring. The operative report indicates that the patient had no complications, that the irrigant returned mild pink, and that the patient was transported to RR (recovery room) in good condition. Thus, given the lack of co-morbidities requiring inpatient monitoring, the procedure without complications, hemodynamic stability, and normal postop hemoglobin, the patient could have been managed at a lower level of care. The literature supports transurethral prostatectomy at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is the case of an adult female, for which an inpatient level hospitalization is under review. There was history of hypertension, diabetes, coronary artery disease (CAD), percutaneous coronary intervention (PCI), and she was admitted electively for percutaneous intervention of the left anterior descending artery (LAD). Vital signs were essentially normal. The creatinine was normal. She underwent the procedure without complication. She remained stable and was discharged. 

"In terms of adverse cardiovascular outcomes, same day discharge was neither superior nor inferior to overnight hospital stay following PCI in those patients with stable CAD." (Bundhun, P. K. et al. 2017) 

"Conclusion: In the population studied, same-day discharge after PCI is safe and feasible. Adequately powered randomized prospective studies are necessary to confirm these results." (Nascimento, F. O. et al. 2014) 

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure, hemodynamic instability, cerebrovascular accident, severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications, or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. 

This setting, an inpatient level hospitalization, compared to an outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case. 

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

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

Diagnosis: HCAP HCAP [healthcare associated pneumonia] vs exacerbation of bronchiectasis 

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient has a history of asthma/ chronic obstructive pulmonary disease (COPD)/emphysema on home oxygen (O2). There is questionable history of bronchiectasis on medical monitoring treatment program (MMTP). The patient was in a nursing home (NH) after recent discharge from NYU (New York University) for treatment of pneumonia (PNA) and COPD exacerbation.

The patient presented to the emergency department (ED) with complaint of chest pain and shortness of breath (SOB). The patient also complained of increased productive cough with greenish expectoration.

Vital signs (V/S) at presentation Temperature (T) 98.4 F, Blood Pressure (BP) 107/54,  Heart Rate (HR) 85, Respiratory Rate (RR) 18, Oxygen (O2) saturations 97% (percent) on 2 liters (L). The patient had bilateral (B/L) rhonchi and wheezing on exam.

White blood cell count (WBC) was 12.1K (thousand), venous blood gas (VBG) 7.35/56/70 93%. Chest x-rays revealed (CXR) revealed right (R) sided infiltrate, consistent with pneumonia viral vs atypical and possible bronchiectasis.

The patient was seen by both Infectious Diseases (ID) and Pulmonary who recommended intravenous (IV) antibiotics for possible flare of bronchiectasis vs HCAP [healthcare associated pneumonia] (due to recent discharge from NYU after treatment for PNA)
The patient initially received Vancomycin /Cefepime. The patient had a history of Pseudomonas colonization.  The patient was switched to Ceftriaxone and was also treated with intravenous (IV) Steroids and bronchodilators.

The patient developed acute Respiratory acidosis during course of hospitalization with acute worsening of arterial blood gases (ABG) with PH (potential of hydrogen) 7.03 and PaCO2 (partial pressure of carbon dioxide) >105. The patient was placed on bilevel positive airway pressure (BIPAP).

Sputum culture and sensitivity (C/S) came back with Pseudomonas. The patient was switched back to Cefepime and inhaled Tobramycin.

Admission was appropriate for this patient with a complicated pulmonary history and underlying multiple medical issues. This patient had relapsed after a recent hospital stay for Pneumonia/COPD exacerbation. The patient had failed outpatient medication and was admitted for treatment of possible HCAP vs exacerbation of bronchiectasis. The patient's sputum C/S grew Pseudomonas for which he was treated with IV antibiotics and inhaled Tobramycin.

Given patient's complicated history and protracted clinical course and infection with resistant organisms admission was appropriate. This patient was not stable enough to be handled in observation setting.

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 inpatient admission from is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient had a history of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) as well as a recent hospitalization for COVID (coronavirus). She presented with watery diarrhea, was afebrile and her vital signs were stable. The abdominal exam was benign. The blood urea nitrogen (BUN) level was 84 and the creatinine level was 1.8. She was diagnosed with a gastroenteritis. Intravenous (IV) hydration was given, and the diarrhea resolved.

Milliman Care Guidelines (MCG) Clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, hemodynamic instability, acute vomiting, or acute dehydration. Acute kidney injury is part of acute dehydration. However, to qualify for acute care, there needs to be a two-fold rise in serum creatinine as well as failure to respond to hydration, altered mental status, cardiac arrhythmia, significant hypoxemia, or a severe electrolyte or metabolic abnormality. 

This patient had a gastroenteritis with kidney injury from dehydration. The creatinine of 1.8 without a significant cardiac, neurological, or metabolic complication did not meet MCG criteria for admission for gastroenteritis. IV hydration was needed but could have been given with observation status; inpatient admission was not medically necessary treatment for the patient's condition.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. 

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

Diagnosis: Tore Meniscus

Treatment knee surgery (procedure codes 29879 and 29880)

The insurer denied coverage for knee surgery (procedure codes 29879 and 29880)

The denial is upheld

This is the case of a male with a medical history of ulcerative colitis, nephrolithiasis, hyperlipidemia, diabetes mellitus and left knee pain not relieved by conservative treatment. The clinical impression of the magnetic resonance imaging (MRI) performed was "tear at the posterior horn and posterior root of the medial meniscus. Abnormal signal in the single image at the junction of the body and anterior horn of lateral meniscus, cannot exclude tear." The patient underwent left knee arthroscopy.

The indications for this type of operation require confirmation of a pain generator and failure to improve with conservative treatment. There should be consistency of subjective complaint, objective finding on physical examination and imaging. The records show the patient had an MRI and surgery a month apart. 

The duration and progression of the patient's pain and patient limitations were not noted. There was no report of mechanical symptoms. There were no physical findings described. There was no description of non-operative management. A person with a torn cartilage would be treated with a course of physical therapy, brace, possible injection and activity restriction. None of these services were documented. Based upon the above, there would be no indication for surgery at that time. 

The health plan acted reasonably, with sound judgement and in the best interest of the patient.

The insurer's denial of coverage for the knee surgery (procedure codes 29879 and 29880) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)

Treatment Prolastin

The insurer denied coverage for Prolastin

The denial is upheld

This is an adult female with a history of chronic obstructive pulmonary disease (COPD). She is a former smoker.The patient was evaluated by Pulmonology. She complained of exertional dyspnea. Results of pulmonary function tests (PFTs) were: forced vital capacity (FVC) 1.98 (61% [percent]); forced vital capacity1 (FEV1) 1.40 (56%) and ratio 72%. Diffusing capacity for carbon monoxide (DLCO) was reduced (49% of predicted). The patient had moderately severe ventilatory defect with evidence of air trapping and reduced DLCO, consistent with COPD. A chest X-ray revealed 2 small pulmonary nodules. A computed tomography (CT) chest revealed mild bibasilar atelectasis, mild to moderate centrilobular emphysema and small pulmonary nodules. The patient's alpha 1-antitrypsin (AAT) levels were 78 milligram (mg)/deciliter (dL) and her phenotype was Pi MZ (antitrypsin deficiency). She was prescribed Anoro and Prolastin.

The patient's AAT levels are above the threshold of 57 mg/dL. In addition, she does not have one of the phenotypes.  Prolastin is not indicated in this patient given her Pi MZ (antitrypsin deficiency) phenotype and AAT level of 78.

There was sufficient evidence to support that Prolastin was not considered medically necessary treatment for the patient's condition.

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

The insurer's denial of coverage for Prolastin is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Left hip labral tear. 
Treatment: Formulary exception for Diclofenac Patch. 

The insurer denied the Formulary exception for Diclofenac Patch. 
The denial is overturned. 

The patient is a female with a history of a left hip labral tear.  She has undergone conservative treatment in the form of physical therapy, intra-articular steroid injections, as well as oral and topical medications.  The patient has failed two separate NSAIDs (nonsteroidal anti-inflammatory drugs), Tylenol and diclofenac gel. She has had a good response to the requested diclofenac patches.  The requested medication was denied by the health plan, as three formulary medications have not been failed. 

Yes, the health plan should cover the Formulary exception for Diclofenac Patch. 
The patient is a female with a history of a left hip labral tear.  She has undergone conservative treatment in the form of physical therapy, intra-articular steroid injections, as well as oral and topical medications.  The patient has failed two separate NSAIDs (nonsteroidal antiinflammatory drugs), Tylenol and diclofenac gel. She has had a good response to the diclofenac patches. 

Given that the patient has failed two NSAIDs (nonsteroidal antiinflammatory drugs), it is unlikely that another oral NSAID (nonsteroidal antiinflammatory drug) is likely to be of benefit.  Given that the patient has had benefit from the requested medication, it is unlikely that any of the formulary drugs are likely to be of benefit or as beneficial as the requested non formulary drug.  There have been no adverse effects documented.  In fact, the patient had a good response to the patch and therefore should expect to have similar results in the future.  Given that the options are limited, and the patient has exhausted conservative treatment, the requested formulary exception for diclofenac patch should be covered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperlipidemia. 
Treatment:  Livalo TAB 2mg. 

The insurer denied the Livalo TAB 2mg. 
The denial is upheld. 

The patient is a male with history of hyperlipidemia. As per physician's letter, the patient previously had a trial of atorvastatin and simvastatin, which he did not tolerate. He was given a sample of Livalo (pitavastatin), which he did tolerate, although there is no documentation of his response in terms of lipid lowering. Coverage for non-formulary Livalo (pitavastatin) was requested, however it was denied by the plan, as the patient did not meet the criteria for medical necessity, specifically there is no documented use and failure of pravastatin or rosuvastatin. 

No, the requested Livalo is not medically necessary. 

The patient has a history of dyslipidemia, requiring therapy with lipid lowering agents. He was reported to have a prior adverse reaction to atorvastatin and simvastatin - both lipophilic agents. There is no documented history of a trial of a hydrophilic statin agent, such as pravastatin or rosuvastatin. It would be reasonable to have a trial of these agents in this clinical scenario. Therefore the medical necessity of using non-formulary Livalo (pitavastatin) could not be established.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Reflux and Esophageal Symptoms.

Treatment sucralfate suspension.

The insurer denied coverage for sucralfate suspension.

The denial is upheld.

The patient is an adult female patient that suffers from reflux and esophageal symptoms when she has bouts of atrial fibrillation. To prevent this, her physician has recommended that the patient takes Dexilant 60 milligrams (mg) once daily and Carafate 1 gram (g) per 10 milliliters (ml) by mouth at bedtime. According to the letter, the patient has had a poor response or tolerance to other medications in their class; and this has been a successful combination in controlling the patient's esophageal symptoms and reflux in the past. 

There is no documentation of any prior trials of formulary alternatives, including sucralfate tablets. There is no documentary evidence that the formulary alternative tablet formulation was clinically ineffective. Despite the fact that the member has been maintained on sucralfate suspension, this does not preclude a trial of formulary alternative of sucralfate tablet, with documentation of clinical benefit or lack thereof. Until such clinical information is substantively provided, the request for this medication is denied as not meeting medical policy. 

The insurer's denial of coverage for Formulary Exception for sucralfate suspension is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Treatment: Ubrelvy (ubrogepant), Pre-service
The insurer denied the Ubrelvy (ubrogepant).
The denial is upheld. 

The patient is an adult female who has migraine headache disorder.  She has tried and failed sumatriptan and rizatriptan.  The provider indicated an allergy to triptans, but details of the allergy are not documented.  The provider is requesting Ubrelvy.  However, the request is being denied coverage because the insurer requires failure of three preferred medications.

No. The health plan should not cover the requested Ubrelvy.

There is no reason the patient cannot be treated with the preferred formulary triptans.  The provider indicated an allergy to triptans, but she has then tried two triptans (rizatriptan, sumatriptan) and the adverse effect is not documented to preclude the use of additional preferred agents.  Triptans are FDA (Food Drug Administration) approved for acute treatment of migraine headaches and are considered first line, standard of care, abortive agents (Thorlund et al., 2017).  There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Ubrelvy relative to the preferred agents.  As such, the request for Ubrelvy should not be covered at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plaque psoriasis and psoriatic arthritis.
Treatment: Cosentyx Sensoready (300mg) 150MG/ML SC SOAJ, Pre-service.
The insurer denied the Cosentyx Sensoready (300mg) 150MG/ML SC SOAJ, Pre-service
The denial is overturned. 

The patient is a male with moderate to severe plaque psoriasis and psoriatic arthritis for whom Cosentyx is requested. He has tried and failed multiple high potency topical steroids, vitamin D derivatives and phototherapy with Xtrac laser. He drinks alcohol regularly. He has started methotrexate.

Yes, the proposed treatment with Cosentyx is medically necessary.
The patient has severe psoriasis for which systemic therapy is indicated. He is not a candidate for further phototherapy because of failure of Xtrac treatment. In the era of biologic therapies for psoriasis, use of methotrexate, cyclosporine or acitretin is not the most appropriate first line treatment because their long term safety and efficacy are inferior to biologic therapies.

Biologics show superior results to conventional systemic therapies (70% improvement versus 40% improvement) for the treatment of patients with moderate to severe psoriasis, as measured by decrease in simple-measure for assessing psoriasis activity (S-MAPA) (physician global assessment [PGA] multiplied by body surface area) at week 24. These results were observed despite the fact that patients on biologics had a greater baseline severity and had a greater number of previous treatments.

Based on the above data, Cosentyx is medically necessary for this patient.

In the era of biologic therapies for psoriasis, use of methotrexate, cyclosporine or acitretin is not the most appropriate first line treatment because their long term safety and efficacy are inferior to biologic therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of nephrolithiasis, chronic marijuana use, chronic abdominal pain with multiple past admissions for intractable vomiting

Milliman care guidelines (MCG) clinical indications for admission for vomiting (M-370) include gastrointestinal obstruction a significant metabolic derangement, hemodynamic instability. Severe hypokalemia with acute findings or which does not correct after observation care, or acute renal failure. The patient did not have these conditions. 

MCG clinical indications for admission for undiagnosed abdominal pain (M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these condition.

This patient had vomiting that was felt to be related to cannabinoid use. She required intravenous hydration and Pepcid and her symptoms improved. The potassium could have been replaced in the emergency room as an outpatient. The leukocytosis and lactate level responded to treatment. She did not meet MCG criteria for admission for either vomiting as undiagnosed abdominal pain. She could have received the intravenous hydration and electrolytes replacement with observation status. The healthcare plan acted with reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

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 admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis

Treatment the requested airway clearance device

The insurer denied coverage for the requested airway clearance device

The denial is overturned

The patient has a diagnosis of bronchiectasis. Computed tomography (CT) of the chest revealed right middle lobe (RML) and right lower lobe (RLL) bronchiectasis with secretions noted. The patient also has some lingular involvement. In addition, some distal atelectasis noted. The patient also has a diagnosis of chronic bronchitis. Has had aspergillus and penicillium detected on sputum culture and sensitivity.

The patient complains of daily yellow sputum production which has been going on for over 6 months. The patient is unable to mobilize her secretions. She lives alone and does not have a caregiver. Medications tried so far include nebulization, HT (hypertonic) Saline and Mucomyst. The patient's physician prescribed her a Smartvest due to excessive daily sputum production which the patient is unable to mobilize. The patient has been using the vest and reports increased mobilization of secretions with that.

This patient has chronic bronchiectasis, lives alone and has not been able to mobilize her respiratory secretions with other medications and techniques. A vest is appropriate for her.

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 airway clearance device is reversed. Medical Necessity is substantiated.