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

Diagnosis: Hyperammonemia.
Treatment: Carbaglu.
The insurer denied Carbaglu as not medically necessary. 
The health plan's determination is upheld.
 
The patient is a female with recurrent hyperammonemia of unknown etiology. Her ammonia at birth was as high as 780 and has been above normal most of her life (80-90). Multiple genetic tests were negative including Whole Exome Sequencing (WES) at GeneDx. Gastroenterology and hepatology workups were negative. She was placed on Carbaglu. 
At issue is the medical necessity for the requested medication, Carbaglu.
 
The health plan's determination of medical necessity is upheld, in whole.
 
According to the package insert, Carbaglu is indicated as:
- Adjunctive therapy for the treatment of acute hyperammonemia due to the deficiency of the hepatic enzyme N-acetylglutamate synthase (NAGS).
- Maintenance therapy for the treatment of chronic hyperammonemia due to the deficiency of the NAGS.
Carbaglu can also be used as an adjunctive therapy to methylmalonic (MMA) and propionic acidemias (PPA).
According to the records, the patient has never been found to have NAGS deficiency, MMA or PPA, despite the very extensive workup done, which would test all 3 of these conditions both biochemically and genetically. If hyperammonemia was treated, then there are other substances that are typically used (such as sodium benzoate and phenylacetate) while Carbaglu is only indicated in one urea cycle disorder which is NAGS.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine headache disorder
Treatment: Formulary exception for Nurtec 75 milligrams (mg) ODT (orally disintegrating tablets)
The insurer denied the formulary exception for Nurtec 75 mg ODT, pre-service.
The denial is upheld.

The patient is an adult female with migraine headache disorder. She has tried and had an adverse response to Emgality. The provider is requesting Nurtec for migraine prevention. The requested medication was denied coverage as the patient has not tried and failed the preferred medications: Ajovy and Aimovig.

The health plan should not cover the proposed formulary exception for Nurtec.

There is no reason the patient cannot be treated with the preferred formulary agents. Both remaining preferred agents are considered standard of care migraine preventive agents (Khan, et al, 2019). There is no evidence to support that switching to a preferred agent would jeopardize her clinical stability. The clinical trial leading to the Food and Drug Administration (FDA) approval of Nurtec tested efficacy against placebo (Croop, et al, 2021). There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Nurtec relative to the preferred, Aimovig and Ajovy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I Occulusion.
Treatment: Braces.
The insurer denied: Braces.
The denial is: Upheld.

The patient is a male with a Class I occlusion with appropriate overbite and overjet. He has maxillary and mandibular spacing. He is treatment planned for orthodontics to correct his malocclusion but his insurance company rejected the claim on the basis that treatment is not medically necessary. The subject under review is the medical necessity for braces and monthly visits.

The health plan's determination is upheld.

There is no medical reason to correct his malocclusion with braces. While the patient has maxillary spaces, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1 This patient presents with none of those conditions.

His overbite is appropriate and there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows he does not have a traumatic deep bite. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient. There is no indication from the photographs provided there is a severe overjet autoqualifier present.

This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion.2 If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara Infusion 390 milligrams (mg) intravenous (IV)
The insurer denied: Stelara Infusion 390 milligrams (mg) intravenous (IV)
The denial is: Overturned

The patient is a female with indeterminate colitis likely Crohn's disease diagnosed with initial presenting symptoms of abdominal cramping, bloody diarrhea and nighttime bowel movements. Initial endoscopy showed colitis with histology showing granuloma in duodenum. Induction using infliximab after three doses was discontinued due to pancreatitis which was initially thought to be due to the infliximab but now known to be due to cystic fibrosis transmembrane regulator (CFTR) mutation. Ultimately, due to severe colitis/megacolon, patient underwent emergency colectomy with diverting ileostomy. Repeat endoscopy showed ongoing proctitis despite twice daily Canasa. Esophagogastroduodenoscopy (EGD) and ileum were both normal grossly and histologically. Ileostomy take down remains pending due to ongoing clinical symptoms, inflammation noted in rectum(proctitis) endoscopically and in laboratory studies. The subject under review is the medical necessity for Stelara infusion 390 milligrams (mg) intravenous (IV).

The health plan's determination is overturned.

The requested treatment of Stelara 390 mg IV is medically necessary as the patient was already on an anti-inflammatory medication Canasa and had suboptimal response to it as noted by ongoing clinical symptoms, endoscopic and histologic findings. Labs are also consistent with ongoing inflammation as can be noted from elevated serum inflammatory markers and anemia.
Based on the medical records sent, this patient's inflammatory bowel disease (indeterminate colitis likely Crohn's disease) remains poorly controlled which has subsequently led to the inability of her ileostomy take down procedure to be done. Laboratory tests, endoscopic findings, histology and clinical symptoms show that the disease has not responded to the immunosuppression used. Though the health plan states that Stelara can only be used in children with Crohn's disease 18 years and over, several papers have been published that show safety and successful use of Stelara in children less than 18 years with moderate to severe Crohn's disease which has resulted in clinical remission and mucosal healing endoscopically. Thus, the use of Stelara in this case is medically necessary and supported by the literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast hematoma. 
Treatment: Inpatient stay. 

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

This female presented to the Emergency Department (ED) complaining of increasing left chest swelling and pain x 1 day status post left breast mastectomy. Two Jackson-Pratt (JP) drains were in place with serosanguinous drainage. Her pain level was 10/10. Physical examination revealed left chest wall with significant swelling, tenderness to palpation, and left mastectomy with steri strips to incision. Labs were drawn and a chest x ray was completed. Hemoglobin and hematocrit were low at 10.6/33.1. She was prepared to undergo emergent surgery. 

The inpatient hospital admission was not medically necessary. The patient could have been managed a lower level of care. According to Milliman Care Guidelines (MCG) General Admission Criteria 26th Edition: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations." This patient was medically stable following surgery and was discharged following her procedure after routine post-anesthesia care unit (PACU) care. She could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

This patient reported a history of chest pain and dyspnea on exertion and presented to the hospital for elective cardiac catheterization. Past medical history was significant for hypertension, transient ischemic attack (TIA), seizure disorder and colon cancer. Cardiac catheterization was performed and revealed severe triple vessel coronary artery disease. The patient was prescribed guideline directed medical therapy and referred for cardiothoracic surgical consultation. There were no perioperative complications. He was discharged on the day of presentation.

Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. (Reference1-4) Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). 

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: Deep Vein Thrombosis.
Treatment: Full Hospital Admission.
The insurer denied: Full Hospital Admission.
The denial is: Upheld.

The patient is a male with a history of metastatic renal cell cancer currently taking cabozantinib that presented to the hospital with a 3-day history of left lower extremity edema. The patient had a doppler that demonstrated a deep vein thrombosis. The patient was admitted for inpatient care including anticoagulation. The patient was subsequently evaluated by interventional radiology; clot retrieval was not recommended. The patient subsequently received physical therapy and was evaluated with a positron emission tomography (PET) / computed tomography (CT) due to concern of progression. The patient was discharged to home physical therapy/occupational therapy. The subject under review is the medical necessity for a full hospital admission.

The health plan's determination is upheld.

The full hospital admission was not medically necessary for this patient.
The authors of UpToDate note that hospitalization is not required for all patients with an acute deep vein thrombosis (DVT).
"Outpatient therapy can be considered when patients have all of the following features:
- Hemodynamically stable
- A low risk of bleeding
- No renal insufficiency
- A practical system in place at home for the administration and surveillance of anticoagulant therapy (e.g., good living conditions, caregiver support, phone access, understanding and ability to return to the hospital should deterioration occur)."
This patient meets these criteria. He was hemodynamically stable. He was evaluated for central nervous system (CNS) disease and had no clear evidence of an increased risk of bleeding. His renal status was stable. There is no evidence he lacked support at home for outpatient care (and he was ultimately discharged there). This approach is supported in the peer-reviewed literature and in national guidelines. For these reasons, medical necessity for inpatient care cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine Leiomyomas.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is: Upheld.

In this case, the patient is a female who was admitted for plan of abdominal myomectomy due to leiomyomas of the uterus. The patient had general anesthesia without complications and had an estimated blood loss of 2200 milliliters (mL) during surgery. She was noted to have an 18 week sized uterus with 45 fibroids existed. There were three incisions made into the uterus with one entry into the endometrium. The right fallopian tube was oversewn due to bleeding. She had 4 units of blood given during the operation with one unit of Tranexamic acid (TXA) for hemorrhage. The patient also underwent an abdominoplasty procedure during the surgery. Vasopressin was used for control of uterine blood flow during the myomectomy. The patient had an additional dose of Ancef due to excessive bleeding during surgery. The patient was also noted to have hypertension.
In this case, the patient was admitted to the hospital post-op due to excessive surgical bleeding with myomectomy and abdominoplasty. Following surgery, vital signs were stable with afebrile status at 99.2 Fahrenheit (F) with blood pressure of 121/87 and hear rate of 74. She had a normal pulse ox of 100%. She had a respiratory rate of 18. Her hemoglobin was 7.8 after surgery and recovered to 13.3 with blood transfusion. Her hematocrit was 24.1 after surgery and recovered to 40.2%. Pain was managed on oral Motrin and oxycodone. She was on Amlodipine 5 milligrams (mg) per day for hypertension. She had good urine output and a Jackson-Pratt (JP) drain with 100 cubic centimeters (cc) fluid out. She was discharged to home with follow-up in the outpatient setting. Hemoglobin was 9.8 with hematocrit of 29.1%.
The subject under review is the medical necessity for inpatient hospital admission.

The health plan's determination is upheld.

Based upon a review of the medical records in this case, the inpatient hospital admission was not medically necessary. The care could have been provided safely and effectively at a lower level of care status. In this case, the patient was noted to have a myomectomy by abdominal incision with removal of 40 plus (+) myomas. She also underwent an abdominoplasty. This was completed subsequent to the myomectomy. Thus, the patient was noted to have 2200 mL of total blood loss and the patient also underwent abdominoplasty without complication after the blood loss from the myomectomy. The recovery was uncomplicated. Vitals following surgery were stable and the patient was afebrile. Thus, in conclusion this patient was found to have no medical necessity for acute inpatient hospitalization under the Milliman Care Guidelines (MCG) Care Guidelines for dates of stay in question.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough and wheezing.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient a medical history significant for sickle cell trait and two prior admissions for wheezing that presented to the emergency department (ED) with a two-day history of cough and wheezing. He had no fever or gastrointestinal (GI) symptoms. The vital signs included a temperature 37.7 degrees Celsius, heart rate 178, respiratory rate 38. The examination was significant for acute distress with tachypnea, prolonged expiration, nasal flaring, retractions, wheezing, moist mucous membranes, and non-toxic appearance. He was initially treated with three DuoNebs, Decadron, and magnesium. Laboratory evaluation revealed white blood cell count (WBC) count 17.1 thousand (K), left shift 88 percent (%), glucose 141, potassium 3.2, carbon dioxide (CO2) 21, negative screens for coronavirus disease (COVID)/ respiratory syncytial virus (RSV) /influenza. He was admitted for further care. At the time of the admission exam, six hours had passed since his last albuterol treatment. On that exam, he was tachypneic, with mild respiratory distress and nasal flaring. He was diagnosed with acute reactive airway disease (RAD) /asthma exacerbation, possible bronchiolitis, possible pneumonia. Admission orders included regular diet, encourage oral hydration, albuterol nebulized every four hours, and blood culture for fever spike. He remained afebrile for the duration of his hospital stay. He tolerated his diet and had no need for supplemental oxygen. He was doing well but because pharmacies were closed for outpatient medications and a nebulizer, he was discharged the following day, to complete five days of oral steroids and continue albuterol treatments every four to six hours. At issue is the medical necessity of an inpatient stay.
This patient with a history of wheezing including two hospitalizations (one in the Pediatric Intensive Care Unit (PICU)) presented with wheezing and respiratory distress. He improved with aggressive treatment in the ED but not sufficiently to discharge home. He was admitted for breathing treatments and systemic steroids. While it was not unreasonable to monitor this child in the hospital for improvement, administering frequent breathing treatments, he was overall hemodynamically stable with no supplemental oxygen requirement, no evidence of impending respiratory failure, and no other complications (except inability to fill prescriptions). He did not require acute inpatient management and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

This is a child with a history of type 1 diabetes who presented to the emergency department with abdominal pain and vomiting. He was lethargic on examination. He was tachycardic and tachypneic. His blood sugar was 437 with a pH (potential of hydrogen) of 7.34 and a beta hydroxybutyrate of 2.17 with an anion gap of 25 and a bicarbonate of 18 and a lactate of 5.6. Osmolality was 309. He was started on ceftriaxone and insulin. The patient's acidosis improved over the next 2 days. The patient was able to tolerate oral intake over the next 2 days. The patient's insulin regimen was reinstated appropriately.

Hospitalization for diabetic ketoacidosis is universally medically necessary. Patients with diabetes and diabetic ketoacidosis (DKA) initially generally require intensive care unit (ICU) level care until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring ICU level care. Most hospitals admit patients with DKA to the ICU due to rules regarding level of service with q (every) 1 hour blood draws and nursing rules. The patient was admitted for treatment of diabetic ketoacidosis. The patient had hyperosmolality as well as mild DKA and dehydration from these conditions as well as gastroenteritis. The patient was appropriately admitted and treated with intravenous hydration, insulin, antibiotics, and monitoring. The requested admission is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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

Diagnosis: Incontinence
Treatment: Myrbetriq 50mg (milligrams) Tab ER (extended release) 24hour 30.0 (for 30 days)
The insurer denied: Myrbetriq 50mg (milligrams) Tab ER (extended release) 24hour 30.0 (for 30 days)
The denial is overturned

The patient is an adult female with urinary urgency, frequency, and mixed urinary incontinence. She failed anti-cholinergic treatment. She is requesting treatment with Myrbetriq 
50 milligrams (mg) daily. 

The proposed treatment with Myrbetriq is medically necessary.

Overactive bladder (OAB) syndrome is defined by the International Continence Society (ICS) and International Urogynecological Association (IUGA) as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology. The American Urologic Association (AUA) guidelines recommend a stepwise approach to treatment, including behavioral modification and medical management as first line.
First line medical management of overactive bladder includes anticholinergics, such as tolterodine or oxybutynin or the beta-three agonist mirabegron. Mirabegron has been shown in 
multiple prospective randomized trials with large numbers of patients to have equal efficacy to anticholinergic medications treating this condition, but with reduced adverse events such as dry mouth and deterioration in mental status especially in the elderly. This has contributed to increase adherence to therapy over time with this medication compared with anticholinergics and thus higher patient satisfaction with treatment. 
This is a patient who is requesting mirabegron for frequency and urgency. Per the medical record, the patient has previously used anticholinergic medications without relief of symptoms. 
This request for Myrbetriq is supported by guidelines and medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence
Treatment: Myrbetriq 50mg (milligrams) Tab ER (extended release) 24hour 30.0 (for 30 days)
The insurer denied: Myrbetriq 50mg Tab ER 24hour 30.0.
The denial is overturned.

The patient is an adult female with urinary urgency, frequency, and mixed urinary incontinence. She failed anti-cholinergic treatment. She is requesting treatment with Myrbetriq 50 milligrams (mg) daily. 

The proposed treatment with Myrbetriq is medically necessary.

Overactive bladder (OAB) syndrome is defined by the International Continence Society (ICS) and International Urogynecological Association (IUGA) as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology. The American Urologic Association (AUA) guidelines recommend a stepwise approach to treatment, including behavioral modification and medical management as first line.

First line medical management of overactive bladder includes anticholinergics, such as tolterodine or oxybutynin or the beta-three agonist mirabegron. Mirabegron has been shown in multiple prospective randomized trials with large numbers of patients to have equal efficacy to anticholinergic medications treating this condition, but with reduced adverse events such as dry mouth and deterioration in mental status especially in the elderly. This has contributed to increase adherence to therapy over time with this medication compared with anticholinergics and thus higher patient satisfaction with treatment. 

This is a patient who is requesting mirabegron for frequency and urgency. Per the medical record, the patient has previously used anticholinergic medications without relief of symptoms. This request for Myrbetriq is supported by guidelines and medically necessary in this case.