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

Diagnosis: Shortness of breath. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy with a history of asthma who presented with wheezing and shortness of breath. He was well until the day prior to presentation when he developed a cough and runny nose as well as shortness of breath. He was seen by the school nurse and was noted to have wheezing. Later that evening he also developed chest tightness. He was therefore brought to the emergency department for care. 

Inpatient Hospital Admission was medically necessary for this patient. 
This is a young boy who presented with an acute asthma exacerbation. He presented with respiratory distress and received appropriate and intensive treatment in the emergency department, but his symptoms recurred shortly after arriving home. He therefore required hospital admission for continued treatment with frequent bronchodilators (initially every 3 hours), corticosteroids, and close monitoring with additional treatments as needed. 

The decision making at the time of admission for this patient was consistent with his young age, the presence of an asthma exacerbation that continued despite appropriate and intensive treatment, his history of a prior intensive care unit admission which increases risk for poor outcomes, and the need for frequent bronchodilator therapy along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vasovagal syncope. 
Treatment: Inpatient hospital services. 
The insurer denied Inpatient Hospital Services. 
The health plan's determination is upheld. 

The patient is a male with a past medical history (PMH) of alcoholic cirrhosis, hepatic encephalopathy, iron deficiency anemia, prior syncope, diabetes mellitus type 2 (DM2), hypertension (HTN), major depressive disorder (MDD), pancreatic cancer, and chronic kidney disease (CKD) who was admitted with complaints of (c/o) syncope. Vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). Lab work was notable for ammonia at 174, and hemoglobin was 8.0. Imaging studies were a computed tomography (CT) scan of the head/cervical (C)-spine which showed no acute fracture or intracranial hemorrhage, transthoracic echocardiogram (TTE) showed normal left ventricular (LV) size/ejection fraction (EF), and aortic sclerosis. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) with prolonged QTc, no changes from prior.
The patient was diagnosed with vasovagal syncope and treated with intravenous fluids (IVF), telemetry, expert consultations, and acute coronary syndrome (ACS) rule out (r/o). The gastrointestinal (GI) team evaluated the patient and did not recommend any acute interventions. Neurology felt that the patient most likely had syncope secondary to orthostasis. The patient was discharged in stable condition. 
At issue is the medical necessity of Inpatient Hospital Services. 

The requested health service/treatment of Inpatient Hospital Services was not medically necessary for this patient. 
This patient presented to the emergency department (ED) with c/o syncope. The patient did not have structural heart disease, shortness of breath (SOB), or family history of sudden cardiac death. Additionally, the patient did not have any history of dilated cardiomyopathy, severe aortic stenosis, hypertrophic cardiomyopathy (HCM), left ventricular outflow disease, pre-excitation syndrome, or Brugada syndrome. The patient did not have a subarachnoid hemorrhage, pulmonary embolism, acute GI bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed ACS, evidence of heart failure, cerebrovascular accident (CVA), shock, coma, major trauma or cardiac arrest, or exertional syncope. The patient was diagnosed with vasovagal syncope and treated with IVF, telemetry, expert consultations, and ACS r/o. Overall, this patient could have been safely treated at a lower level of care. 
Therefore, the requested health service/treatment of Inpatient Hospital Services was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is an adult with type 2 diabetes on insulin and anxiety/depression. She reports a recent assault with a baseball bat. She is status post scoliosis surgery with instrumentation from T (Thoracic) 2 to T12. The patient presented to the emergency room with a 3-week history of back pain as well as generalized body and head pain. 

The patient did have red flag symptoms and was administered intravenous opiates. Clinical practice guidelines (1) do not support admission absent red flag symptoms.

Casazza (2) reviewed concerning symptoms (red flags) that should prompt aggressive treatment. The patient did meet these:

"Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age (i.e. ["that is"], injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis), major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and suspected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required."

The inpatient hospital admission was medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Spinal injections 62321x1
The insurer denied: Spinal injections 62321x1
The denial is overturned.

The patient is an adult female with neck and upper extremity pain. The pain has been ongoing for greater than six months. She has failed medications and physical therapy. MRI (magnetic resonance imaging) shows disc osteophyte complex and cord effacement. A cervical epidural steroid injection (CESI) has been recommended.

The requested health service is medically necessary.

The patient is an adult female with neck and upper extremity pain. The pain has been ongoing for greater than six months. She has failed medications and physical therapy. MRI (magnetic resonance imaging) shows disc osteophyte complex and cord effacement. A cervical epidural steroid injection (CESI) has been recommended. The patient's local exam, imaging, and clinical symptomatology are consistent with cervical radiculopathy. The patient has failed conservative treatment. Therefore, a cervical epidural steroid injection is reasonable and in line with typical treatment options. Alternatives include surgery, which is more invasive and offers no guarantees.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Beta Thalassemia. 
Treatment: Deferasirox. 

The insurer denied Deferasirox. 
The health plan's determination is overturned. 

This is a male with beta thalassemia and hereditary persistence of fetal hemoglobin. He was transfusion dependent for years. He has severe iron overload and was previously on deferasirox but he did not tolerate this. The patient has a secondary cardiomyopathy and magnetic resonance imaging (MRI) evidence of liver iron overload. As his labs indicate an increase in his iron stores (ferritin 1014), deferasirox has again been recommended. The formulary alternatives are deferiprone. Deferasirox is under review. 

A formulary exception is indicated in this case. 
The formulary alternative, deferiprone, has been extensively studied in this population. While it is an effective iron chelator in the non-beta thalassemia patient population, Olivieri, et al, concluded that "...Deferiprone does not adequately control body iron burden in patients with thalassemia and may worsen hepatic fibrosis...". The authors of UpToDate similarly state "... deferiprone does not appear to adequately control the total iron burden in some patients with thalassemia...". Further, they go on to state "....the efficacy and safety of deferiprone remained controversial, such that routine use had not been recommended as of 2000 .."
Given the questionable efficacy and profound safety risks, the formulary alternative would not be considered to be a viable option for the treatment of this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Precocious Puberty. 
Treatment: Lupron Depot-PED 15 mg (milligrams). 
The insurer denied coverage for Lupron Depot-PED 15 mg. 
The denial is upheld.  

This is a patient diagnosed with central precocious puberty (CPP). This request is for Lupron depot. The patient's breasts and pubic hair were at tanner 3. The patient has autism. The patient has worsening anxiety triggered by having premature monthly menses. The patient's bone age was 8 years 8 months at calculated age (CA) 10 years. 

The health plan did act reasonably and with sound judgment in the best interest of the patient as the patient does not meet the standard of care for therapy. 

The definition of precocious puberty is children who have the onset of secondary sexual characteristics younger than age 8 in girls and younger than age 9 in boys (1-6). Central precocious puberty (CPP) is diagnosed using a basal luteinizing hormone (LH) of > (greater than) 0.3 or stimulation testing with a Gonadotropin-releasing hormone agonist's (GnRHa) such as luprolide showing a pubertal response defined as an LH >5 or estradiol greater than 40 (4,7). CPP is treated with GnRH agonists (8-13) such as Lupron (14) and supprelin (15). The Food & Drug Administration (FDA) indication for GnRH agonists is for use in central precocious puberty (CPP). In addition, when used for CPP the FDA recommends discontinuation of GnRH agonists before age 11 for females and before age 12 for males (5,14). This is consistent with accepted recommendations for discontinuation of GnRH agonist therapy at a bone age of 12 in girls and 13 years in boys (2,7-10). 

There is no documentation of a basal LH > 0.3 or LH > 5 or estradiol level > 40. Precocious puberty is defined as the appearance of secondary sex characteristics before 8 years of age in girls and before 9 years of age in boys. 

The main sign to suspect the onset of puberty is breast tissue development in girls and testicular enlargement (>=4 milliliters (mL)) in boys. 

The patient has no documentation of a basal LH > 0.3 or LH > 5 or estradiol level > 40. The appearance of secondary sex characteristics started at 9 years. Although provider makes a valid point that regular periods are consistent with central puberty, it is necessary to do laboratory testing to confirm this as bleeding can be seemingly regular and caused by peripheral causes such as ovarian tumors. A pubertal LH is necessary before treatment can be approved. 

The request does not meet the standard of care and is therefore not medically necessary.  

Lupron Depot-PED 15 milligrams (mg) is not medically necessary for this patient

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 Lupron Depot-PED 15 mg is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Maxillary and mandibular crowding
treatment: Braces/monthly visits
The insurer denied braces/monthly visits. The health plan's determination is upheld. 

The patient is a young male with maxillary and mandibular crowding. Tooth 6 is unerupted. The orthodontist mentioned in the diagnosis that tooth #6 is impacted and will require surgical exposure. 

Braces and Monthly Visits are not medically necessary for this patient.
The patient is in the mixed dentition phase of development. Tooth 6 does not appear to be erupting at a poor angle on the radiograph, and it is too early to determine if it will require an exposure as maxillary canines usually erupt at 11-12 years of age. However, there is a great discrepancy in this timing. There is still much time to see if this maxillary canine will erupt successfully on its own without orthodontic intervention.

The patient does have maxillary and mandibular crowding and treatment may be indicated in the future. However, the patient does not exhibit any of the criteria to suspect his maxillary right canine is, in fact, impacted. For this reason, the requested orthodontic treatment is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient presented to the hospital complaining of abdominal pain that was similar in nature to pain that they felt several months earlier in the setting of acute ST (the interval between ventricular depolarization and repolarization) elevation myocardial infarction. Past medical history was significant for ischemic heart disease and percutaneous intervention to the right coronary and left anterior descending arteries several months prior to presentation. The patient also suffers from hypertension and diabetes mellitus. On arrival to the hospital, vital signs were stable (Blood Pressure 159/78, Pulse 77). Physical examination revealed no major abnormality. 12 lead electrocardiogram (ECG) revealed sinus rhythm with Q (the initial phase of ventricular depolarization) waves inferiorly and T (result of ventricular repolarization) wave abnormalities in the lateral leads. Serum blood testing revealed an elevated troponin level (15.4). The patient reported noncompliance with antiplatelet therapy for four consecutive days. The patient was admitted to the hospital for observation and treatment. Diagnostic coronary angiography demonstrated patent stents. Dual antiplatelet therapy was restarted, and blood pressure controlled with additional beta blocker therapy.  

This patient presented with abdominal pain that was similar in character to symptoms experienced several months earlier in the setting of ST elevation myocardial infarction. The patient's pretest probability of coronary artery disease was high. (1)  

The patient was considered intermediate risk. (2) 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati, et al. (3)  

Using the HEART [history, ECG, age, risk factors, initial troponin] score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement and cardiac catheterization were warranted prior to discharge. The patient was ultimately diagnosed with a type 2 myocardial infarction. (4)    

In conclusion, given the patient's presentation and multiple cardiac risk factors, inpatient hospital admission was medically necessary.

Based on the above, the insurer's denial is reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

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

Diagnosis: Chest pain.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

In review is the case of a woman with a past medical history of hypertension and obstructive sleep apnea who presented to the hospital with chest pain, palpitations and lightheadedness. Chest pain was intermittent for several days, non-radiating, and was exacerbated with movement.  On arrival to the hospital, vital signs were stable (blood pressure 151/96, pulse 83).  Physical examination revealed no major abnormality.  12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities. Serum troponin levels were not elevated (<0.01) and computed tomography (CT) chest revealed no evidence of pulmonary embolism or aortic dissection. Echocardiogram demonstrated a normal left ventricular ejection fraction (LVEF) 65% (percent) with no evidence of valvular abnormalities. Stress testing demonstrated no ischemia. The patient was diagnosed with musculoskeletal pain, treated with antihypertensive medication and discharged with cardiology follow up.

This patient presented with atypical chest pain and a past medical history of hypertension. Her pretest probability of coronary artery disease was low. (1)  Utilizing the History, Electrocardiogram (EKG), Age, Risk Factors, and Troponin (HEART) score she was considered low risk. (2)  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (3) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG] or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.

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 an inpatient admission is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Irritable bowel syndrome

Treatment: Chlordiazepoxide-Clidinium

The insurer denied coverage for Chlordiazepoxide-Clidinium

The denial is overturned
 

The physician has requested authorization for Librax (Chlordiazepoxide-Clidinium). The patient has a diagnosis of irritable bowel syndrome (IBS). According to the letter from Dr Milkes, the patient has failed treatment with dicyclomine, hyoscyamine sulfate, and hyoscyamine sulfate orally disintegrating tablets. 

UpToDate has an article titled "Treatment of irritable bowel syndrome in adults." The article states that antispasmodics should be administered on an as-needed basis or in anticipation of stressors with known exacerbating effects. The article also states that anxiolytics can be used for refractory symptoms but that it is best to limit its use to short term. 

The insurance company has denied Librax because the patient had not tried the formulary alternatives. In this case, the physician has documented in a letter that the patient has tried and failed the listed formulary alternatives to Librax. Since the insurance company denial is based on not trying the formulary alternatives and the physician has stated that the patient has tried the formulary alternatives, the denial is reversed.

The formulary drugs are not expected to cause adverse effects. 

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

The formulary drug is expected to be ineffective.

The non- formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Chlordiazepoxide-Clidinium to treat IBS is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 diabetes

Treatment: Mounjaro 2.5 mg / 0.5 ml SC SOPN

The insurer denied coverage for Mounjaro 2.5 mg / 0.5 ml SC SOPN

The denial is upheld

The patient has a history of Type 2 diabetes mellitus (DM) requesting Mounjaro. Patient has tried and failed metformin and glipizide in the past.

There are effective, safe alternatives that have not been trialed. Available alternatives include Victoza, Trulicity, and Ozempic. Per notes, patient has not tried and failed any formulary medications. Patient must try and fail formulary medications before requesting non-formulary, Mounjaro. Therefore, the request for Mounjaro is not medically necessary.

American Diabetic Association (ADA) (2022), "Other medications (glucagon-like peptide 1 [GLP-1] receptor agonists, sodium-glucose cotransporter 2 [SGLT2] inhibitors), with or without metformin based on glycemic needs, are appropriate initial therapy for individuals with type 2 diabetes with or at high risk for atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and/or chronic kidney disease (CKD)"

Wong, E., Cope, R., Dima, L., & Nguyen, T. (2023), "The SURPASS trials are pivotal phase 3 trials assessing the efficacy and safety of tirzepatide as monotherapy and as an add-on to different antihyperglycemic drugs for the management of type 2 diabetes (T2DM). Tirzepatide consistently showed reductions in glycated hemoglobin (HbA1c) as well as benefits with weight loss, with common adverse events reported related to gastrointestinal issues."

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 Mounjaro 2.5 milligrams (mg) / 0.5 milliliter (ml) subcutaneous (SC) solution pen injector (SOPN) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Skilled Nursing Facility
The insurer denied Skilled Nursing Facility stay.
The health plan's determination is overturned. 

This is a case review for a female admitted to a skilled nursing facility (SNF) for the diagnosis of infection and disseminated intravascular coagulation. 

SNF admission through discharge is medically necessary for this patient.

The patient had a month-long hospitalization, including intubation and pressor support in the Intensive Care Unit (ICU) for meningococcal sepsis. This is an extremely severe condition with a high mortality rate. The patient survived the hospitalization but is having a prolonged recovery period. When she was admitted to the SNF, she had numerous wounds throughout the body including numerous unstageable pressure ulcers. At the time of the proposed discharge date, the majority of these wounds had shown resolution, but she was still dealing with wounds on the plantar surfaces which were preventing advancement from non-weight-bearing status. She has shown good progress with wound recovery and will be able to proceed with additional therapy and begin to make more progress with activities of daily living once she is able to attempt weight-bearing. Given the severity of her illness and her hospitalization, it is reasonable to expect that she would require a prolonged stay at a SNF to maximize her rehabilitation potential. The nursing facility is correct in their assessment of the patient that an ongoing stay at the SNF is medically necessary and the most appropriate site of care for the patient.