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

Diagnosis: Sickle Cell Disease. 
Treatment: Inpatient hospital admission. 
The insurer denied coverage for inpatient hospital admission. 
The denial is upheld. 

This is a teenager with sickle cell anemia. The patient presented with leg pain and elevated white blood cell count. The patient was admitted for sepsis workup and pain management. A chest x-ray and respiratory pathogen panel was negative, and pain was well controlled. The patient's white blood cell count (WBC) significantly decreased, the patient was stable and discharged home. The request is for inpatient hospital admission. 

The patient has a history of sickle cell anemia. The patient was evaluated for osteomyelitis, which was ruled out. The patient did not have severe pain or other comorbidities, such as stroke or acute chest syndrome. The patient could have been safely managed at a lower level of care. As such, the inpatient hospital admission is not considered medically necessary for this patient. 

Per Glassberg J. A. (2017), "Pain is the leading cause of emergency department (ED) visits for individuals living with sickle cell disease (SCD). The care that is delivered in the ED is often cited by patients with SCD as the area of health care in greatest need of improvement. In 2014, the National Heart, Lung, and Blood Institute released guidelines for the care of SCD, including recommendations for the management of acute sickle cell pain in the ED. These guidelines provide a framework to understand the elements of ideal emergency sickle cell pain care; however, they do not provide guidance on barriers and facilitators to achieving these ideals in the complex system of the ED. Presented in this article are 4 tenets of implementing guideline-adherent emergency sickle cell care gleaned from the available literature and continuous quality improvement efforts at our institution. These include: (1) strategies to reduce negative provider attitudes toward patients with SCD; (2) strategies to reduce time-to-first dose of analgesic medication; (3) strategies to improve ED pain care beyond the first dose of medication; and (4) strategies to improve ED patient safety." 

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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient Hospital

Diagnosis: Acute Asthma Exacerbation
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female with a medical history of opiate use disorder (on methadone), chronic active Hepatitis C, and asthma without a documented prior history of intubation. She was admitted for an asthma exacerbation with symptoms of shortness of breath, nasal congestion, cough and wheezing that began two days prior to admission. She was treated with Albuterol and Atrovent nebulizers, Magnesium Sulfate 1gram intravenous, and Prednisone 60 milligrams (mg) oral.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient.

Based upon the severity of illness and intensity of required therapy, the inpatient hospital admission was not medically necessary. This patient with a medical history of opiate use disorder on methadone, chronic active Hepatitis C, and asthma without a documented prior history of intubation was admitted for an asthma exacerbation with symptoms of shortness of breath, nasal congestion, cough and wheezing that began two days prior to admission. In the emergency room the patient was afebrile, hemodynamically stable, was in no acute distress, speaking in full long sentences, had an oxygen saturation of 96 percent (%) on room air, was in no respiratory distress, had normal pulmonary effort but on chest auscultation had bilateral wheezing.

Although she still had bilateral wheezing, she remained in no acute distress, she was alert and awake, was hemodynamically stable, had a respiratory rate of 18 breaths per minute, and had an oxygen saturation of 98% on room air. She did not have documented hypercapnia or documented hypoxemia (partial pressure of oxygen (PaO2) less than (<) 60 millimeters of mercury (mmHg)), she did not require any ventilatory support, she did not have a sustained respiratory rate greater than (>)30 breaths per minute or sustained heart rate >140 beats per minute, she had no reported cyanosis or increased work of breathing. Her chest x-ray did not demonstrate evidence for acute infiltrates, consolidations, pneumothorax, pleural effusions, or fractures. Her asthma symptoms improved with the equivalent of an alternate level of care. 

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II bite and severe crowding
Treatment: Braces: Comprehensive Orthodontic Treatment
The insurer denied Braces: Comprehensive Orthodontic Treatment. The health plan's determination is overturned. 

The patient in question is a female with a Class II bite and severe crowding in both the maxillary and mandibular arches. Tooth 31 is impacted. The patient is treatment planned for Braces: Comprehensive Orthodontic Treatment. 

Braces: Comprehensive Orthodontic Treatment are medically necessary for this patient.
Impacted teeth can lead to bone defects of the adjacent erupted teeth. It is a generally accepted practice guideline to address the impacted tooth by attempting to surgically remove it or to gain space to allow the impacted tooth to erupt. 
The patient has an impacted mandibular right second molar. This tooth should have erupted around age 12.2. Side effects of impacted mandibular second molars include a significant increase in periodontal defects distal to the erupted first molars due to the inadequate development of bone in that region as a result of the impacted tooth. No treatment will put the mandibular right first molar (tooth 30) at risk. Therefore, the requested braces/comprehensive orthodontic treatment is indicated for this patient.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis: Skin Disorders/Acne
Treatment: Pharmacy/Prescription Drugs/Tretinoin, 0.05% cream 
The health plan denied the requested medication, Tretinoin, 0.05% cream as not medically necessary. The health plan's determination is upheld.

The patient is a female with acne. The patient has reportedly tried and failed topical Clindamycin and Benzoyl Peroxide, and the patient's paid claim history exists for these two products. Spironolactone has also been reported to have failed to control this patient. Although the provider reports that the patient had failed over-the-counter Adapalene, the clinic notes do not describe this prior use. Tretinoin, 0.025% (percent) cream reportedly only achieved fair results, and the patient was prescribed topical 0.05% Tretinoin cream to treat the papules and comedones noted on clinical examination.
Tretinoin, 0.05% cream is under review for medical necessity.

Health plan denial of coverage of 0.05% Tretinoin cream is recommended to be upheld, in whole.

No, because Adapalene gel, 0.1% and Tretinoin cream, 0.05% are of similar efficacy and tolerability for the treatment of acne, there is no medical reason for the patient to use 0.05% Tretinoin cream over 0.1% Adapalene gel.
Insufficient to no documented treatment history of failure and/or intolerance to over-the-counter Adapalene gel, 0.1% has been provided to confirm that this medication is not a viable or medically appropriate alternative for this patient. Current medical literature [1-7] does not support any overall greater efficacy of topical Tretinoin to Adapalene, and as per the health plan policy, [8] the patient is therefore ineligible for health plan coverage of topical Tretinoin.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female with medical history of chronic pancreatitis, irritable bowel syndrome, gastroesophageal reflux disease (GERD), overactive bladder, and depression. She presented to the emergency department with abdominal pain and nausea with inability to tolerate oral intake. 

The inpatient hospital admission was medically necessary. The patient had acute pancreatitis, and abdominal pain and lipase that was elevated to more than three times the upper limit of normal. The patient was appropriately treated, with intravenous fluid administration, and gradual advancement of diet. Due to the presence of acute pancreatitis without definite etiology, and the risk for complications of pancreatitis, the inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pelvic Inflammatory Disease (PID).
Treatment:  Inpatient Hospital Admission.
The health plan denied the requested inpatient hospital admission. 
The health plan's determination is upheld.

The patient is a female with right lower quadrant pain over one week in the emergency room. She had adnexal tenderness and a white discharge on exam. Vital signs were normal except for mild tachycardia. Her white count was elevated at 19.3. A computed tomography (CT) showed a complex right ovarian cyst consistent with a hemorrhagic cyst or endometrioma. She was diagnosed with pelvic inflammatory disorder (PID) and was admitted as an inpatient. She received antibiotics. She was positive for chlamydia and was discharged.

At issue is the medical necessity for the inpatient hospital admission.

I uphold, in whole, the health plan's determination of medical necessity.

The requested health service/treatment of an inpatient hospital admission was not medically necessary for this patient.

The patient had PID, however, there is nothing to support the need for an acute, inpatient admission. Her vital signs were stable, and she was hemodynamically stable. Her mild tachycardia resolved. She was not pregnant nor did she fail the outpatient management of her infection. The patient did not have severe pain nor the inability to tolerate oral intake. There was no tubo-ovarian abscess or sepsis. The patient could have been diagnosed with PID and then provided antibiotics as an outpatient. Inpatient admission was not necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Cancer.
Treatment: Guardant360 assay.
The insurer denied the Guardant360 assay.
The determination is upheld.

This is a female patient with diagnosis of breast cancer. Guardant 360 CDx molecular profiling did not reveal molecular mutations and Micro-satellite instability status (MSI) high was not detected. No additional clinical information was available for review. Additional information, medical records (lines of treatment, hormone receptor status, human epidermal growth factor receptor (HER2) receptor status, physician progress notes) were requested but not received. At issue is whether the Guardant360 CDx test is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No medical records and clinical information were available to make the determination that the Guardant360 CDx test is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.  
NexGen sequencing/molecular profiling is now a standard part of management of metastatic malignancy such as breast cancer for metastatic estrogen receptor positive breast cancer, testing for NexGen sequencing such as guardant 360 will provide molecular targets such as phosphatidylinositol-3-kinase (PI3CK) mutation. Next generation sequencing (NGS) testing results will allow patients to receive Food and Drug Administration (FDA) approved therapies such as Alpelisib for PI3CK mutation, Olaparib or Talazoparib for breast cancer antigen (BRCA) 1 and BRCA2 mutation, Larotrectinib or Entrectinib for neurotrophic tyrosine receptor kinase (NTRK) fusion, Pembrolizumab for tumor mutational burden (TMB) more than 10, Pembrolizumab or Dostarlimab microsatellite instability high (MSI-H) or deficient mismatch repair (dMMR). These recommendations are based on National Comprehensive Cancer Network (NCCN) guidelines (refer to NCCN guidelines version 3.2022 for invasive breast cancer treatment, page 87). Additional information, medical records (lines of treatment, hormone receptor status, human epidermal growth factor receptor (HER2) receptor status, physician progress notes) were requested but not received.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Cancer.
Treatment: Guardant360 assay.
The insurer denied the Guardant360 assay.
The determination is upheld.

This is a patient who is reported to have breast cancer. There are no provided notes from the treating medical oncologist that pertain to the pathology report, imaging or rationale as to why the Guardant360 CDX is requested. The only clinical documents are lab work only. The Guardant360 assay was ordered and at issue is whether it is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service, Guardant360 CDX is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The National Comprehensive Cancer Network (NCCN) guidelines recommend the following markers to assist in the selection of systemic therapy options in advanced cases of breast cancer: estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2neu), phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha (PIK3CA), estrogen receptor 1 (ESR1), neurotrophic receptor tyrosine kinase (NTRK), microsatellite instability (MSI), tumor mutational burden, breast cancer antigen (BRCA) 1/2 and rearranged during transfection (RET).
Any additional markers are not supported by The National Comprehensive Cancer Network (NCCN) guidelines. There are no randomized, controlled clinical trials that demonstrate a survival benefit when other markers are used for targeted agents as compared to standard of care drug options as recommended by the NCCN.
Therefore, the use of Guardant360 CDX assay in this case is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg Numbness, Weakness and Chest Discomfort.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This adult female presented with right leg numbness and weakness associated with pain. She also complained of a heavy sensation in the chest. Her past medical history included asthma, 
hypertension, coronary artery disease and anxiety. The leg symptoms resolved in the emergency department without intervention. The patient's vital signs were stable, and she was afebrile. Her exam was unremarkable. Her chemistries were unremarkable. The patient's complete blood count (CBC) was remarkable for a white blood cell (WBC) count of 11. The patient's head computed tomography (CT) showed faint hypo-density in the right temporal, occipital, parietal, and frontal lobes. She was admitted with a plan for serial neurological exams and magnetic resonance image (MRI). Treatment included aspirin, clopidogrel, and atorvastatin. On Day #2, the patient reported chronic left leg pain. The plan was to continue the current 
management and for magnetic resonance image. On Day #3, the patient was agitated and verbally abusive overnight. She had an episode of chest tightness associated with left jaw and upper arm numbness. Her electrocardiogram (EKG) was at baseline and Troponin was negative. The patient's magnetic resonance image was pending. On Day #4, the patient was switched from Oxy to Tramadol as needed (PRN) for leg pain.

The proposed treatment was not medically necessary. 

This patient was admitted after presenting with leg weakness, 
numbness, and pain. Her symptoms resolved while in the emergency department. The admission was denied because the patient had a negative work up and symptoms resolved without intervention. At time of admission, the patient was hemodynamically stable. Her exam and labs were unremarkable. Imaging did not reveal an acute condition. The patient had a negative cardiac work-up. She remained stable during the hospital stay. The patient did not receive intervention that required an acute inpatient level of care. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is upheld

The patient is an adult male. He presented to the emergency department with complaints of erythema, warmth and pain to the left leg. The patient also had complaints of subjective fever, chills and episode of vomiting. The patient had recently been recently diagnosed with infection in the left leg: left leg cellulitis. The patient was started on treatment with Doxycycline for three days and Augmentin for two days. The patient also reported a pruritic diffuse rash on his neck, which developed after he started taking Augmentin. The patient's evaluation in the emergency room showed following vitals: T (temperature) - 98.4, BP (blood pressure) 111/86, P (pulse) - 111, R (respiration rate) - 17, Pulse oximetry - 97%. Evaluation in the emergency room showed that the patient had full movement of his leg and normal sensation. 
Venous Doppler was negative for DVT (deep venous thrombosis). Lab results were notable for leukocytosis - WBC (white blood count) was 16 K (thousand). The patient was given Vancomycin, Ceftriaxone, Benadryl, Ketorolac and IV (intravenous) fluid in the emergency room. Augmentin was stopped. The patient was admitted to inpatient medical hospital admission for management of the cellulitis. During hospital stay, patient was treated with IV (intravenous) Clindamycin, Benadryl and topical betamethasone. During the hospital stay, the 
antibiotic regimen was changed to cefazolin and Vancomycin. The dose of cefazolin was later increased during the hospital stay. The patient responded to treatment, and the cellulitis improved. The patient was discharged on Day #5.

The Inpatient Admission was not medically necessary.

On presentation, there was concern for the current antibiotic treatment (Augmentin, Doxycycline) not adequately effective. However, the patient was afebrile and otherwise clinically stable and without mental status changes and without other systemic manifestation concerning for severe sepsis. The patient was able to tolerate oral intake and did not have other complaints.
There was concern for cellulitis not responding adequately to treatment, and there was need for change of antibiotics in view of rash. However, initial evaluation in the ER (emergency room) did not show any findings to indicate need for additional or further investigations that may need inpatient admission. The patient could have been safely and effectively treated with IV (intravenous) antibiotics and evaluated - observed in observation status to see if he was responding adequately. In view of this, medical necessity for inpatient hospital admission was not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Mounjaro 15 milligrams (mg)/0.5 milliliter (ml) pen injector injected subcutaneously (SC) as instructed by provider for one year - 2 pen injectors for a 28-day supply
The insurer denied coverage for Mounjaro 15mg/0.5 ml pen injector injected SC as instructed by provider for one year - 2 pen injectors for a 28-day supply.
The denial is overturned.
 
The patient has hypertension and obesity. There is a strong family history of diabetes, hypertension, and morbid obesity. He had taken Rybelsus but then it was denied by the insurance company. Mounjaro was started. He has lost 42 pounds and the body mass index (BMI) went from 43.9 to 37.6. The hypertension has improved. 

UpToDate has an article titled "Obesity in Adults: Drug Therapy." The article discusses treatment of obesity with a dual acting glucagon like peptide 1 (GLP-1) and a gastric inhibitory peptide (GIP). It states that treatment with this combination may be more effective than just a GLP-1 receptor agonist achieving weight loss. Terzepatide (Mounjaro) is a novel GLP-1 And GIP receptor agonist that has been shown to be effective in the treatment of obesity in patients with or without diabetes. In a double-blind placebo controlled randomized trial including over 2500 adults with obesity but without diabetes, tirzepatide was compared to placebo. Reduction of weight at all doses of tirzepatide was greater than placebo. 

The New England Journal of Medicine (2022) has an article titled "Tirzepatide Once Weekly for the Treatment of Obesity." In this phase 3 trial, obese patients without diabetes were studied. The conclusion was that tirzepatide provided substantial and sustained reductions in body weight. 

The scientific literature supports using Mounjaro for the treatment of obesity even if diabetes is not present. "In this 72-week trial in participants with obesity, 5 mg [milligrams], 10 mg, or 15 mg of tirzepatide once weekly provided substantial and sustained reductions in body weight." This patient has already had significant weight loss on this drug but still remains obese. In view of the current BMI of 38.7, it is appropriate to continue using this drug. 

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 Mounjaro 15 mg/0.5 milliliter (ml) pen injector injected subcutaneously (SC) as instructed by provider for one year - 2 pen injectors for a 28-day supply is substantiated.