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

Diagnosis: Takayasu's arteritis 
Treatment: Remicade (Infliximab) 10 MG (milligrams) administered at a Hospital-Based Center 
The insurer denied Remicade (Infliximab) 10 MG administered at a Hospital-Based Center. 
The health plan's determination is overturned.

The patient is a woman with Takayasu's arteritis (TA), hypertension (HTN), seronegative arthritis of multiple sites and obesity. In terms of TA, the patient has vascular occlusions and narrowing secondary to vasculitis with aortic coarctation of the left subclavian artery, right renal artery, celiac artery stenosis and superior mesenteric involvement. She has been on Remicade and is stable. 

Remicade administered at a hospital-based center is medically necessary for this patient.
The patient has Takayasu's arteritis (TA) with (w/) vascular occlusions and narrowing secondary to vasculitis w/ aortic coarctation of the left subclavian artery, right renal artery, celiac artery stenosis and superior mesenteric involvement. She has been on Remicade since April of 2020 and is stable. A non-hospital setting would not be appropriate. The patient is high risk for cardiovascular (CV) complications due to the extent of her disease and administering Remicade at a non-hospital based center would not be consistent with the standard of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Other constipation
Treatment: Motegrity
The insurer denied coverage for Motegrity.
The health plan's determination is overturned.

The patient is a male with a diagnosis of gastroparesis. He has had early satiety, postprandial fullness, belching, nausea and epigastric pain. He had concurrent dyspepsia, heartburn and globus. He reports chronic constipation with three bowel movements per week. A gastric emptying study showed a half-emptying time of 371 minutes. An esophagogastroduodenoscopy was done that showed an accepted variation of the normal anatomy of the stomach (J-shaped stomach) and esophagitis. An x-ray of the abdomen for the indication of chronic idiopathic constipation showed extensive stool in the colon and rectum consistent with constipation. He has been on Motegrity and has shown improvement. He has been on Metoclopramide, Dexilant and Erythromycin, he could not use Domperidone due to a long electrocardiogram representation of ventricular depolarization and repolarization of the heart (QT) interval. He has attempted dietary modification.

The request for Motegrity is supported as more effective than the formulary alternatives. The patient has had chronic constipation symptoms. Motegrity has shown efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain. Additionally, Motegrity has demonstrated greater efficacy than placebo for the treatment of gastroparesis in a crossover study. The patient has previously attempted first-line therapy (according to the most recent American College of Gastroenterology guidelines) for the treatment of gastroparesis with Metoclopramide. The formulary alternatives may be effective for the treatment of constipation but are not supported for the treatment of gastroparesis. For these reasons, the continuation of Motegrity is supported as medically necessary in this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Reflux Symptoms.
Treatment: Nexium 20mg Capsules.
The insurer denied Nexium 20mg Capsules.
The health plan's determination is overturned.

The patient is a female who is being treated with Nexium 20 milligram (mg) capsules for the treatment of reflux. The coverage of this medication was denied by the insurance company.

In the health plan's denial notice, they state that the patient has not had a trial of all formulary alternatives. Formulary medications for the treatment of reflux include Dexilant, Pantoprazole, Omeprazole, Dexlansoprazole, Esomeprazole, Lansoprazole, and Rabeprazole. According to the medication coverage denial letter, the patient only tried Dexilant, Pantoprazole, and Omeprazole. Since she had not tried the other formulary drugs, she was denied coverage for the non-formulary drug Nexium 20 mg capsules.

A letter of support for this appeal was provided by the treating physician. The letter states the following: "We believe that the brand name Nexium is medically necessary to treat the patient's medical conditions of gastroesophageal reflux disease (GERD)." She failed trials of Pantoprazole and Ranitidine, both of which "made her quite ill." There was no further explanation provided as to the medical necessity of the brand name Nexium versus the generic Esomeprazole in the letter, but subsequent office visit notes provided some detail as explained below.

For previous drug trials, the appeal request states that Dexilant caused a rash and was not effective. Pantoprazole had no benefit for her GERD. The use of Prilosec resulted in an increase in symptoms with use.

Although not included in the initial appeal paperwork, there is also documentation that she tried Esomeprazole with "ineffectiveness and worsening symptoms." This is also reflected in this medication being on the treatment list note from gastroenterology. Lansoprazole was tried with no effect. Rabeprazole was also tried with an increase in reflux symptoms.

A progress note from the treating physician was provided for review. The notes state that her GERD "got much worse on generics." The patient declined referral to a gastrointestinal (GI) specialist for further workup.

For coverage of the brand name drug, which is not on the formulary, the insurance company requires that the patient has tried all formulary drugs for the treatment of acid reflux. In this case, they require trials of Dexilant, Pantoprazole, Omeprazole, Dexlansoprazole, Esomeprazole, Lansoprazole, and Rabeprazole. The notes provided demonstrate that the patient has tried and had intolerance or ineffectiveness to all of these medications over the past five years. She did not have treatment success with generic Esomeprazole. She is having good control of her symptoms with the brand name Nexium.

Notes submitted to demonstrate the trial of numerous medications without benefit. She has achieved clinical benefits with the non-formulary medication. This verifies the medical necessity of ongoing treatment with the requested drug.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Diabetes Mellitus Type 2.
Treatment: Jentadueto XR (extended release) 2.5/1000 tablet.
The insurer denied Jentadueto XR 2.5/1000 tablet.
The determination is overturned.

This is a patient with type 2 diabetes treated with Jardiance and Jentadueto. The patient's hemoglobin A1C was 7.8 percent (%). The patient has tried Janumet and metformin. Jentadueto extended release (XR) is under review.

This request is for Jentadueto XR for the treatment of type 2 diabetes. The formulary alternatives are Janumet and Xigduo. This patient has already tried Janumet in the past. The patient is already on Jardiance and it is not appropriate to use Xigduo and Jardiance together due to both containing sodium glucose co-transporter-2 inhibitors. In addition, Jentadueto has a dipeptidyl peptidase 4 (DPP-4) inhibitor, whereas Xigduo does not. Therefore, Janumet and Xigdu are not appropriate alternatives as they will be either not as effective as Jentadueto XR 2.5/1000 milligrams (mg) tablet or would have adverse effects.

This patient is stable on Jentadueto XR. Without Jentadueto XR, this patient will be at increased risk of hyperglycemia, which can cause neuropathy, nephropathy, and retinopathy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting and Diarrhea.
Treatment: Inpatient Hospital Stay.

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

The patient was brought to the emergency department with vomiting and diarrhea. He had a past history of asthma managed with inhaled steroids and albuterol as needed, and a history of seizures well controlled on Keppra. He had been discharged after a three-day hospitalization for pneumonia, during which time he was treated with intravenous (IV) ceftriaxone and discharged on amoxicillin. He was respiratory syncytial virus (RSV) and coronavirus positive during that admission (not coronavirus 2019 [COVID-19]). In follow up with his pulmonologist, Augmentin and Prednisone were added, due to a persistent cough. His mother brought him to the emergency department (ED), because he was having non-bilious, non-bloody vomiting and non-bloody diarrhea for one day. He still had a cough, but no respiratory distress or wheeze. On arrival to the emergency department (ED), his vital signs were normal, including an oxygen saturation of 97% on room air. On exam, he was active and in no acute distress, non-toxic appearing, with moist mucus membranes, crying tears, capillary refill less than two seconds, and normal heart and lungs. His electrolytes were normal. He was given IV fluid in the ED and admitted to the pediatric floor, where the admission exam was repeated and again normal. While hospitalized, he continued to have loose non bloody stools, but no vomiting. He took fluids and solids orally, and he was discharged home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient was brought back to the emergency department four days after discharge from a three-day hospitalization for a respiratory illness. He was on antibiotics and oral and inhaled steroids, as he continued to recover from that respiratory illness. He also had a history of seizures. He was brought to the ED not for seizures or any respiratory problems, but for one day of vomiting and loose stool. He did not have physical or laboratory signs of dehydration. He was making tears, had moist mucus membranes, normal capillary refill, and normal electrolytes. To whatever extent he was "dry," but short of dehydrated, that dryness was corrected with the IV fluid he received in the ED. He was taking fluids and solids by mouth (PO), which would allow him to stay adequately hydrated as an outpatient despite the vomiting. Routine diarrhea, whether it was caused by the Augmentin or an infection, is not an indication for hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic hematoma, pelvic collection, and sepsis

Treatment: continued inpatient admission

The insurer denied coverage for continued inpatient admission

The denial is upheld 

This is the case of a patient with past medical history of Crohn's colitis and rectal cancer with meds such as Remicade and Humira in the past status post (s/p) colectomy in the past and due to frequent colitis flares, and newly diagnosed rectal cancer s/p abdominoperineal resection (APR). She was referred because of fever of 101.3. She denied any symptoms except for the discharge and mild discomfort from her rectal wound. The Jackson Pratt drain was removed. On exam she had a small amount of purulent discharge from the incision site and tenderness around the wound area. White blood cell (WBC) count was 17.9. A computed tomography (CT) was done and revealed a pelvic collection, and the patient was started on Zosyn and admitted to surgery. 

She underwent incision and drainage with wound vac placement. She underwent wound vac changes two more times. The patient was afebrile, and her vital signs were unremarkable. Her antibiotics were completed on. She remained stable and was discharged. There were no plans for a hospital level of intervention. The patient should have been discharged to a lower level of care for ongoing management. The clinical information provided for this appeal did not support the need for inpatient hospitalization per health plan guidelines. In a prior denial letter the insurer noted that the patient could have been safely discharged. Continued stay is not covered starting that day as there was no report that there was a continued need for medications inn the vein.

Based upon the records provided, the inpatient days under review were not justified at the acute care level of care. The patient was stable and was waiting for a vacuum dressing change by the bedside which did not require for her to be inpatient. In addition, her antibiotics had been completed and therefore there was no need for continued inpatient care but rather observation. The patient did not require further continued acute inpatient care as she met discharge criteria. She was afebrile, wound was acceptable, and no infection was evident. 

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

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

Diagnosis: Anemia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with chronic hepatitis C, HTN (hyperyension), peripheral artery disease on Brillenta and Eliquis, awaiting vascular surgery. He presented with a Hgb (hemoglobin) of 5.

The patient's stools were brown, without evidence of red blood in the stool or melena. He was hemodynamically stable, without syncope or hemolysis. He was transfused 2 units of blood. His Hgb (hemoglobin) rose to 8. EGD (esophagogastroduodenoscopy) was negative, and he was discharged to return for vascular evaluation.

No, the Inpatient Hospital Admission  was not medically necessary.
While the patient had anemia, the patient was hemodynamically stable without mental status changes, syncope, active GI (gastrointestinal) bleeding, abdominal pain or obstruction. Therefore, acute inpatient hospital stay was not medically necessary.

Yes, as acute inpatient hospital stay was not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetic Foot Infection
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a past medical history (PMH) of diabetes mellitus type 1 (DM1) who was admitted with complaints of (c/o) stepping on a nail that penetrated his right foot. The vital signs were notable for tachycardia and respiratory rate (RR) 20. The physical exam was significant for no acute distress/non-toxic appearing, red streak on sole of the right foot and warm with tenderness to palpation (TTP). Lab work was notable for hyperglycemia. A right foot radiograph showed no fracture or foreign object, magnetic resonance imaging (MRI) of the right foot showed no osteomyelitis or abscess. The patient was diagnosed with a diabetic foot infection and treated with Zosyn initially, then transitioned to Ancef with worsening symptoms, so he was transitioned back to Zosyn. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient hospital stay.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the emergency department (ED) with c/o stepping on a nail that penetrated his foot. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, leukocytosis, did not meet systemic inflammatory response syndrome (SIRS) criteria, there was no animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with intravenous (IV) antibiotics, expert consultations, and clinical monitoring, and this could have been safely provided at a lower level of care for the management of a cellulitis infection because it allows frequent reevaluation to assess response to therapy while avoiding inpatient admission. Overall, this patient could have been safely treated at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I molar and canine relationship
Treatment: Braces
The insurer denied the braces
The denial is upheld

The patient is a female requesting orthodontic benefits. She has a Class I molar and canine relationship. 

The prior denial was due to the patient not reaching the 26 threshold on the handicapping index scale.

No, the proposed treatment is not medically necessary based upon documentation provided.
The provider stated that the patient had an "anterior crossbite", which would have been an automatic qualifier. However, the photos provided do not show any evidence of an anterior crossbite of the patient's teeth.  The photos showed there are no orthodontic problems with this patient.

Yes, the health plan act reasonably, with sound medical judgment and in the best interest of the patient
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left elbow cellulitis
Treatment is an inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is overturned.

This is a patient with past medical history significant for left elbow bursitis who presented to the emergency room with complaints of left elbow pain. He reported taking Bactrim and Keflex without relief. 

Vitals on presentation included: T (temperature) 97.3 F (Fahrenheit) , BP (blood pressure)  -109/50, P (pulse)-44, RR (respiratory rate) -18, O2 sat (oxygen saturation)-100% on RA (room air). Laboratory results included the following: WBC (white blood cell count) -9.89, HGB (hemoglobin) -13.6, HCT (hematocrit)-40.8, creatinine-1.10, glucose-92, lactate-0.78, CRP (C-reactive protein) -47.
 
The patient was admitted with a possible left elbow cellulitis. He was empirically started on intravenous antibiotics (vancomycin and Zosyn). An X-ray of left elbow was within normal limits. The patient remained afebrile, and hemodynamically stable. He was discharged to continue oral antibiotics (Ceftin) as an outpatient. 

According to documentation, the patient presented with worsening left elbow pain, erythema, and swelling despite treatment with oral antibiotics (Bactrim and Keflex) as an outpatient. The patient underwent drainage of the elbow by Orthopedics prior to admission. Cultures apparently grew Staphylococcus. Based on the above findings, including failure of outpatient management, a hospital admission for intravenous antibiotics was medical necessary. 

Prior determination of denial of an inpatient hospital admission from is overturned.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid arthritis.
Treatment: Humira.
The insurer denied Humira.
The determination is upheld.

The patient has rheumatoid arthritis (RA). She had prior treatment with Plaquenil and nonsteroidal anti-inflammatory drugs (NSAIDs). Per a letter from the patient's provider, the patient is not a candidate for methotrexate (MTX) as she drinks alcohol daily and she is unwilling to stop drinking. Humira was denied by the health plan as the patient has not tried formulary alternatives, specifically methotrexate (MTX) 15 milligrams (mg) weekly times (x) 90 days. At issue is the medical necessity of Humira.
The requested health service/treatment of Humira is not medically necessary for this patient. There is no medical reason the patient cannot undergo a trial of methotrexate (MTX). Per a letter from the patient's provider, the patient drinks alcohol daily and is unwilling to stop drinking, which is not the same as a clinical diagnosis of alcohol use disorder but rather patient preference. MTX is a staple drug used in the treatment of rheumatoid arthritis (RA) and is commonly used as first-line therapy unless there is an absolute contraindication (e.g. elevated liver function tests (LFTs), cirrhosis, pulmonary fibrosis, pregnancy).  Per UpToDate, 'we suggest MTX as the disease-modifying anti-rheumatic drug (DMARD) of choice for the initial treatment of patients with active RA. MTX typically serves as the "anchor" drug for the most commonly used DMARD combinations.' Moreover, 'randomized head-to-head trials have found that MTX has a faster onset of action, comparable or greater efficacy, and better long-term tolerance compared with other nonbiologic DMARD monotherapy. MTX has also been shown to improve survival (both cardiovascular and all-cause mortality) in patients with RA compared with other nonbiologic DMARDs'. Additionally, the Cochrane Database Syst Rev (4) published a report in 2014 that found that 'based on mainly moderate to high-quality evidence, methotrexate (weekly doses ranging between 5 milligrams (mg) and 25 mg) showed a substantial clinical and statistically significant benefit compared to placebo in the short-term treatment (12 to 52 weeks) of people with RA, although its use was associated with a 16% discontinuation rate due to adverse events.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nasal congestion.
Treatment is balloon sinus ostial dilation.
The insurer denied coverage for balloon sinus ostial dilation.
The denial is upheld.

This is a patient with a history of snoring, nasal congestion, and mouth breathing. It is worse at night with coughing and gasping and never fully clear. A chronic headache was reported daily. It was severe last two weeks. She has had sinus pressure and headaches for 2 years. The patient is morbidly obese with a BMI (body mass index) = 30.0-34.9.

An endoscopic examination noted: "Blocked OMU (osteomeatal unit), bilateral inferior turbinate hypertrophy, and nasal swell body formation." A CT (computed tomography) report noted: CT IMAGING: A greater than 3mm (millimeter) thickening of the bilateral sinus cavities resulting in an obstruction of the osteomeatal units. Also, generalized edema of the lining of the nasal cavity with inferior turbinate hypertrophy, and nasal swell body formation resulting in narrowing of sinonasal outflow tracts and nasal passages were noted.

The medical data included several coronal sections of the paranasal sinus which are inconsistent with the above report. The peer-reviewed literature appears to have no published guidelines. Two articles were reviewed. The 2011 Cochran review states: "Authors' conclusions: At present, there is no convincing evidence supporting the use of endoscopic balloon sinus ostial dilation compared to conventional surgical modalities in the management of CRS (cytokine release syndrome) refractory to medical treatment. With the escalating use of balloon sinuplasty, there is an urgent need for more randomized controlled trials to determine its efficacy over conventional surgical treatment modalities. (1)" A more recent 2022 review states: "There is limited high-quality evidence that assesses the efficacy of BSD (balloon sinus dilation) versus FESS (functional endoscopic sinus surgery) in the management of CRS patients. To better inform CRS management, future studies should compare BSD with endoscopic sinus surgery, hybrid procedures, and/or medical management alone using validated objective and patient-reported outcome measures. 2"

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient as from the information available there were no indications for balloon sinuplasty. The ostiomeatal unit (OMU) noted in the coronal images supplied was open. 

Balloon sinus ostial dilation is not considered to be medically necessary for this patient as there was no evidence in the information available that she indicated balloon sinus ostial dilation.
The denial should be upheld as there were no indications for balloon sinus ostial dilation.

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

The insurer's denial of coverage for balloon sinus ostial dilation is upheld. Medical necessity is not substantiated.