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

Diagnosis: Cardiac/Circulatory. Treatment: Inpatient Hospital. The insurer denied inpatient stay. The denial is upheld.

This female was admitted to the hospital in transfer from another facility where she had presented with palpitations and chest discomfort and was found to have runs of nonsustained ventricular tachycardia (NSVT). Prior to transfer cardiac catheterization was performed and showed no significant coronary artery disease. An echocardiogram was normal. She was then transferred for catheter ablation of her NSVT. During the procedure, the patient had premature ventricular beats originating in the septal right ventricular outflow tract. The focus was ablated using radiofrequency energy. The procedure was uncomplicated. Post-procedure the patient developed tachycardia while walking in the hallway. Her heart rate was 140-150 beats/minute. She had no symptoms at the time. The mechanism of the tachycardia was initially unclear. However, her rhythm slowed to 86-99 beats/minute upon returning to bed. An electrocardiogram showed sinus rhythm. The patient was observed in the hospital overnight and discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

An inpatient stay was not medically necessary. This patient complained of palpitations and was found to have nonsustained ventricular tachycardia originating in the right ventricular outflow tract (RVOT). Her heart was structurally normal. RVOT tachycardia in patients with structurally normal hearts is typically a benign arrhythmia. The arrhythmia focus was ablated, and the procedure was uncomplicated.
In the study reported by Theodoreson et al., 897 patients underwent radiofrequency catheter ablation of either supraventricular tachycardia or RVOT tachycardia. Of these 897 patients, 805 were discharged home the same day. Among all patients with a same-day discharge, none had a subsequent complication that would have been detected had they remained in the hospital overnight. Thus, inpatient admission post-ablation in this situation is not medically necessary. This patient was not discharged on the same day as the procedure since she developed sinus tachycardia while walking in the hall several hours post-procedure. While it was reasonable to monitor her overnight, this did not warrant an inpatient level of care. This could have been accomplished at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Digestive system
Inpatient hospital

Diagnosis: Upper Gastrointestinal Bleed
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy who presented to the emergency department following an episode of syncope.
He was well until the evening prior to presentation when he vomited in the middle of the night. He continued to vomit the following day and noted some dark red blood in his emesis. He also had 2 episodes of bloody stools. That afternoon he had an episode of syncope which was witnessed by his grandmother. This was preceded by dizziness, and he hit his head when he passed out. He was unconscious for 1-2 minutes. He had no prior episodes of syncope and had received his flu shot the day prior.
In the emergency department, he had a heart rate of 129 beats per minute (bpm). His examination was significant for conjunctival pallor and tachycardia. He received intravenous (IV) Protonix as well as 2 boluses of normal saline. Laboratory values were obtained as well as an electrocardiogram (EKG). His fecal occult blood test was positive and the EKG was normal. He was admitted for further care for a probable upper gastrointestinal (GI) bleed, for intravenous fluids, continuous monitoring, and additional studies including an esophagogastroduodenoscopy (EGD).

The inpatient hospitalization was medically necessary for this patient. He required intravenous fluids, parenteral treatments, urgent endoscopy, and continual monitoring in an inpatient setting.
This is a young boy who presented after an episode of syncope related to an upper gastrointestinal (GI) bleed. He had experienced hematemesis as well as bloody stools. At the time of presentation, he was tachycardic and had conjunctival pallor. He required 2 boluses of normal saline as well as intravenous (IV) Protonix. He was admitted for further care, continuous monitoring, and evaluation for probable upper GI bleed with subsequent syncope. He required an urgent endoscopic evaluation to identify the source of bleeding and to initiate appropriate treatment .
The decision-making at the time of admission for this patient was consistent with his young age, the presence of a significant GI bleed associated with syncope, and the need for prompt initiation of intravenous fluids, as well as additional therapies and evaluation along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Otezla. 

The insurer denied Otezla. The health plan's determination is upheld. 

The patient is a male with moderate to severe psoriasis (21% body surface area involvement) affecting the arms, legs, trunk, and sensitive areas of the groin and genitals (inverse psoriasis). The patient has tried and failed topical triamcinolone and oral prednisone. The use of Otezla is under review for medical necessity. 

Otezla is not medically necessary for this patient. 

The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, and/or Phototherapy. Therefore, the requested Otezla is not medically necessary. 

Modern dermatology literature supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Otezla, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Otezla is not medically necessary.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Relapsing Remitting Multiple Sclerosis.
Treatment: Rituxan.

The insurer denied the Rituxan.  The determination is upheld.

The patient was diagnosed with relapsing remitting multiple sclerosis (RRMS). She has been treated with Rituxan (rituximab). Continued treatment with Rituxan is the issue of this review. The health plan denied the therapy because the patient had not tried and failed the generic biosimilars of Truxima and Ruxience.

At issue is whether the Rituxan is medically necessary for this patient.

The Rituxan is not medically necessary. The patient has relapsing remitting multiple sclerosis. She is prescribed Rituxan (rituximab). The drug is off-label for the treatment of RRMS.

In a preliminary randomized trial of 104 adult patients with RRMS, treatment with intravenous (IV) rituximab (1000 milligrams (mg)) given on days 1 and 15 reduced reduction in both total and new gadolinium-enhancing lesions on brain magnetic resonance imaging (MRI) at 24 weeks when compared with placebo. In addition, rituximab treatment reduced the proportion of patients who had a clinical relapse by week 24. Further randomized trials would be needed to establish the long-term effectiveness and safety of rituximab for RRMS, but these trials are unlikely.

In an observational study of 256 patients with stable RRMS who switched to rituximab or fingolimod after stopping natalizumab due to John Cunningham virus (JCV) antibody positivity, the rituximab group had lower rates of clinical relapse, adverse events, and treatment discontinuation compared with the fingolimod group. In another observational study of 494 patients diagnosed with RRMS identified from a Swedish MS registry, rituximab treatment was associated with a lower discontinuation rate compared with other disease modifying therapies, including interferons, glatiramer acetate, dimethyl fumarate, fingolimod, and natalizumab. In addition, rituximab treatment was associated with a lower rate of clinical relapses and MRI measures of disease activity compared with interferons, glatiramer acetate, and dimethyl fumarate. However, the same investigators published a registry-based cohort study of over 6400 patients with RRMS from Sweden that examined the risk of infection associated with exposure to rituximab, natalizumab, fingolimod, interferon beta, and glatiramer acetate. Among these, treatment with rituximab was associated with the highest rate of serious infections.

The plan offers two generic formulations of rituximab: Truxima and Ruxience. The patient has not tried or failed either of these options. She does not have a contraindication to these options. The products are biosimilar and have the same mechanism of action as compared to the brand drug Rituxan. There is no medical or scientific reason why the brand drug is required for treatment of relapsing remitting multiple sclerosis, especially given that the use is off-label.

Therefore, the Rituxan is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins
Treatment: Endoluminal Ablation of Varicose Veins 
The insurer denied the Endoluminal Ablation of Varicose Veins. The health plan's determination is overturned.

The patient is a woman with symptomatic bilateral lower extremity varicose veins and venous insufficiency. The patient had a long history of swelling and varicose veins. She was evaluated five years before for venous insufficiency and was scheduled for surgical therapy that was deferred. The patient has been using compression stockings and taking non-steroidal agents. She was noted to have prominent varicose veins on both legs with edema.
A venous duplex exam demonstrated incompetence of the bilateral small saphenous veins. The patient was offered ablation of the bilateral small saphenous veins.
A repeat venous duplex exam demonstrated incompetence of the bilateral small saphenous veins with reflux at bilateral saphenopopliteal junctions.
The issue at hand is if an Endoluminal Ablation of Varicose Veins is medically necessary.

Endoluminal ablation of the bilateral small saphenous veins is medically necessary. The patient has symptomatic bilateral lower extremity varicose veins and venous insufficiency of the bilateral small saphenous veins.
The proposed endovenous ablation of the bilateral small saphenous veins is the treatment of venous insufficiency and symptomatic varicose veins. Endovenous ablation is the standard of care for the treatment of venous insufficiency and symptomatic lower extremity varicose veins. The patient will benefit from the treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure (CHF).
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

This patient is a man who presented to the hospital for elective implantation of a biventricular implantable cardioverter defibrillator for primary prevention of sudden cardiac death and management of heart failure. His medical history was remarkable for coronary artery disease, multiple coronary stents, ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, left bundle branch block and hypertension. The procedure was uncomplicated. Post-procedure the patient was admitted to the hospital. He had no complaints. He remained in sinus rhythm with brief runs of nonsustained ventricular tachycardia (3-7 beats). During the evening post-procedure his blood pressure ranged from 95-124/56-67 millimeters of mercury (mmHg). He remained stable and was discharged . Coverage for an inpatient admission is at issue.

I uphold, in whole, the health plan's determination that an inpatient level of care was not medically necessary.

No. Based on the documentation provided an inpatient admission was not medically necessary. This patient presented for elective biventricular implantable cardioverter defibrillator (ICD) placement. The procedure was uncomplicated, and he remained hemodynamically stable post-procedure. While admission for overnight observation after this procedure is still the preferred approach for many implanting physicians, this can generally be accomplished safely under an "observation" level of care; an inpatient admission is not medically necessary for the vast majority of patients. In fact, same day discharge after ICD implantation (including biventricular device implantation) is an increasingly common practice and has been shown to be feasible and safe in most cases, with no increase in death, readmission or procedural complications when compared to patients who were admitted overnight.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Hospital admission for medical necessity. 
The denial was overturned. 

This member is a female infant. She presented to the emergency room for vomiting, decreased oral intake and decreased urine output for 2 days. Her parents were positive for coronavirus 2019 (COVID-19) at the time. She was diagnosed with dehydration. She tested positive for COVID-19. She was admitted and started on intravenous fluids.
At issue is the medical necessity of the Inpatient stay.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Inpatient stay was medically necessary for this patient.
This patient presented for vomiting, decreased urine output and clinical signs of dehydration. She was not able to self-hydrate and required support via intravenous fluids. She was also COVID-19 positive, which likely caused her clinical picture. Due to her age and inability to maintain hydration, she was at risk of severe complications and even death. Admitting this patient was necessary in order to restore hydration status, advance her diet slowly and monitor for COVID-19 complications. Outpatient management was not possible due to continued vomiting and the need for intravenous hydration and close monitoring.
Therefore, the Inpatient stay was appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Braces.
Treatment: Adjustments Of Braces, Pre-service.
The insurer denied the Adjustments Of Braces, Pre-service.
The denial is overturned. 

The patient is a female. The request is for dental benefits for monthly adjustments to on-going orthodontic treatment (Braces) that is in process.

Yes, the requested monthly adjustments for orthodontic therapy (Braces) are medically necessary.
The patient's orthodontic treatment was started. As a result of loss of employment, the patient's original dental insurance coverage was terminated. The initial treatment plan was for 24-months, the patient has completed over half of the treatment time already.

Orthodontic treatment is complex and invasive. It is imperative to monitor and keep all adjustments on a timely manner to avoid creating new dental problems and not lose the treatment benefits that have been gained from the start of treatment.

The health plan is denying the coverage, because the Patient's teeth do not exhibit handicapping malocclusion at this time. The fact is, the treatment is well over 50% completed. Therefore, the teeth will look very different from how they would have looked prior to the commencement of treatment.

Furthermore, given the complexities of orthodontic treatment, by not monitoring and maintaining regular visits for adjustments puts the patient's dental health at great risk; damage to the teeth/bone can occur as a result of not completing the treatment.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Open Angle Glaucoma

Treatment: Lumigan (bimatoprost)

The insurer denied coverage for Lumigan (bimatoprost)

The denial is overturned

According to the documentation submitted, this is the case of a female with a history of primary open angle glaucoma.  In his appeal letter, Ophthalmology specialist writes that the patient was previously treated with Latanoprost and Travatan Z; these caused an adverse reaction. 

The formulary drugs are likely to cause the patient an adverse reaction. Per Ophthalmology specialist, the patient has tried and had adverse reactions to formulary alternatives (latanoprost, Travatan Z).
 
The formulary drugs have been ineffective based on the patient's clinical history. The patient had intolerance to the formulary alternatives.

All three agents are prostaglandin analogues and the prostaglandins are considered initial therapy. As per the letter from Ophthalmology specialist, the patient had adverse reactions with the 2 formulary agents. Lumigan- bimatoprost which is also a prostaglandin is thus ok.

"Results from the systematic reviews showed bimatoprost to be clinically superior over other prostaglandin analogues (including latanoprost, travoprost, and tafluprost) with respect to intraocular pressure; whereas with the exception of a crossover trial, none of the randomized trials with a parallel group design demonstrated the clinical superiority of bimatoprost. Most studies concluded that the clinical profile of the four prostaglandin analogues is similar." (Islam & Spry)

The requested Lumigan would not be more effective than the formulary drugs. There is no evidence in the literature that Lumigan is superior to other prostaglandins in controlling intraocular pressure. All prostaglandin analogues have been shown to equally and significantly reduce the intraocular pressure (IOP) in glaucoma patients (El Hajj 2018, Kim 2019); however in a patient who has not tried other prostaglandin analogs, Lumigan would be essential to control IOP and prevent vision loss from glaucoma. The denial for Lumigan is reversed because the patient has tried and failed, or has intolerance to other prostaglandin formulary alternatives.

The insurer's denial of coverage for Request for Formulary Exception for Lumigan (bimatoprost) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history (PMH) of hypertension (HTN), obesity, asthma, diverticulitis status/post (s/p) colostomy with (w/) reversal and tobacco use who was admitted with complaints of (c/o) left lower quadrant (LLQ) abdominal pain associated with vomiting and diarrhea. Vital signs were notable for significant HTN of 212/135. The physical exam was notable for no apparent distress (NAD) and the patient resting comfortably. Lab work was notable for a creatinine of 1.34, lipase 905, white blood cell count (WBC) 12, aspartate aminotransferase (AST) 74. A computed tomography (CT) scan of the abdomen showed no acute pathology. The patient was diagnosed with abdominal pain and mild acute kidney injury (AKI) secondary to dehydration and treated with intravenous (IV) fluids, pain control, proton-pump inhibitors (PPI), and anti-hypertensives. The patient was discharged against medical advice (AMA). At issue is the medical necessity of an inpatient level of care. 

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o LLQ abdominal pain associated with vomiting and diarrhea. The patient did not have associated high-risk features, such as severe renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. The patient did not have a bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, he was documented to be resting comfortably and in no acute distress, his CT scan showed no acute pathology, and he did not have pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with abdominal pain with a mild AKI, was treated and responded to intravenous fluids (IVF) and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient presented to the emergency department complaining of two weeks of chest pain and exertional dyspnea. His medical history was remarkable for renal artery stenosis treated with a stent, hypertension, hyperlipidemia, hypertrophic cardiomyopathy, pancreatitis, bipolar disorder, obesity, bariatric surgery, cigarette smoking and alcohol abuse. His blood pressure was 158/108 millimeters of mercury (mmHg) with a heart rate of 73 beats/minute. His respiratory rate was 20 breaths/minute with a room air oxygen saturation of 99%. He was afebrile. An electrocardiogram showed sinus rhythm with left ventricular hypertrophy. There was lateral ST segment depression suspicious for ischemia. His serum troponin level was elevated at .21 nanograms/milliliter (ng/ml) (no repeat value was provided). His blood glucose level was 383 milligrams per deciliter (mg/dl) with a hemoglobin A1c of 9.9%. The patient was treated with aspirin, nitroglycerin and a statin and admitted to the hospital with suspected non-ST segment elevation myocardial infarction. Cardiac catheterization showed no obstructive disease. The patient was seen by an endocrinologist for newly diagnosed type 2 diabetes and was then discharged. At issue is the medical necessity of an inpatient admission.
This patient, with multiple cardiac risk factors, presented with exertional dyspnea and chest pain, an elevated serum troponin level and an abnormal electrocardiogram, all of which were consistent with a diagnosis of non-ST segment elevation myocardial infarction (NSTEMI). Based on his HEART [History, electrocardiogram (EKG), Age, Risk factors, and troponin] score he was at high risk for major adverse cardiac events. Given the risk for adverse outcomes, current guidelines recommend inpatient admission for patients with evidence of NSTEMI. While coronary angiography showed nonobstructive disease, this could not have been predicted. In the meantime, he required careful and continuous observation with the ability to intervene emergently, if needed. This warranted an inpatient admission.