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

Diagnosis: Cholelithiasis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the hospital emergency department (ED) with right upper abdominal pain. She had a past medical history of hypertension and human immunodeficiency virus (HIV) infection. She was not tender in the right upper abdomen. At the time of presentation, the patient was without a fever and her vital signs were normal. The white blood cell count (WBC) count was normal at 5.0 thousand (K). The complete metabolic panel identified elevated transaminases and bilirubin. An ultrasound in the ED showed gallstones and a 15-millimeter (mm) common bile duct (CBD). A formal abdominal ultrasound showed gallstones and no biliary ductal dilatation. A computed tomography (CT) scan confirmed the diagnosis of cholelithiasis and no ductal dilatation.
She was initially treated with intravenous (IV) fluid and IV antibiotics. The patient underwent a cholecystectomy. A cholangiogram was not able to be performed due to the inability to advance the cholangiocatheter. The operative dictation describes an otherwise uncomplicated cholecystectomy procedure. She was started on a clear liquid diet. She was considered to be stable for discharge home.
At issue is the medical necessity of an inpatient stay. An inpatient admission was not medically necessary in this case.
This patient presented to the hospital with symptomatic cholelithiasis/cholecystitis and elevated liver enzymes. She underwent an uncomplicated cholecystectomy procedure. A cholangiogram was not able to be completed during surgery. However, her post-surgical course was uncomplicated and lab data showed a decreasing trend of liver enzymes. Her diet was advanced. The vital signs remained normal. The pain was controlled with oral medication, and the patient was discharged home.
An inpatient stay was not consistent with the referenced Milliman Care Guidelines (MCG) during this time. The MCG Gallbladder or Bile Duct Inflammation state that the goal length of stay is ambulatory, but that inpatient care is needed when there is:
1) Failure to achieve discharge status criteria,
2) Conversion to open surgery,
3) Severe systemic infection,
4) Care for active comorbidities,
5) Complications of the procedure.
In this case, the submitted documentation does not support that any of these clinical conditions existed to warrant an inpatient level of care.
A lower level of care would have appropriately provided for pre-surgical assessment, operative treatment and post-surgical care and monitoring including overnight care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fatigue; weakness.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female with a history of hypertension, mitral insufficiency, supraventricular tachycardia, Crohn's disease, and small bowel obstruction status post colonic resection and ileostomy (with reversal).  She presented to the hospital with fatigue and generalized weakness.

The patient's labs demonstrated a hemoglobin 6.1, white blood cell count 10,840, and creatinine 1.75.  Chest x-ray showed no acute process.  The electrocardiogram showed sinus rhythm without acute ischemic changes.  The high-sensitivity troponin was 89.  The patient was afebrile with a blood pressure 162/73 and pulse 96.  The patient had only a modest degree of acute kidney injury without uremia, hyperkalemia, acidosis, or volume overload.  

The patient's renal function improved promptly with hydration and transfusion of packed red blood cells.  One unit of packed red blood cells was transfused in the emergency department.  Gastroenterology consulted and noted that the patient had a possible anastomotic ulceration on the most recent colonoscopy.  Serial hemoglobins were followed and intravenous fluids were provided.  A second unit of packed blood cells was transfused.  The creatinine dropped to 1.56 and hemoglobin rose to 7.6.

No, the Inpatient admission was not medically necessary.

The patient had symptomatic anemia but did not have evidence of bleeding or hemolysis.  The hemoglobin rose appropriately in response to transfusion of packed red blood cells.  The patient remained hemodynamically stable.  There was no evidence of altered mentation, thrombocytopenia, syncope, acute myocardial ischemia, acute peripheral arterial ischemia, arrhythmia, or hypoxia.  The patient did not require endoscopic evaluation, and gastroenterology determined that the likely source of the anemia was a slow gastrointestinal bleed from a previous anastomotic ulceration.  The minimally elevated troponin was not attributed to acute coronary syndrome.  The patient had only a modest degree of acute kidney injury without hyperkalemia, uremia, acidosis, or volume overload.  

In summary, acute inpatient hospital stay was not medically necessary.  The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Progressive Alzheimer's dementia, coronary artery disease, constipation, hypertension, major depression, vitamin D deficiency, glaucoma, and incontinence of bowel and bladder.
Treatment:  Personal Care Aide - 24 hours per day - seven day(s) per week (Split Shift) - a total 168 hours per week.

The insurer denied the Personal Care Aide - 24 hours per day - seven day(s) per week (Split Shift) - a total 168 hours per week.  The denial is overturned. 

The patient is a male with a complex medical history including progressive Alzheimer's dementia, coronary artery disease, constipation, hypertension, major depression, vitamin D deficiency, glaucoma, and incontinence of bowel and bladder.  The patient lives alone with family support.  His son works out of town frequently.  The patient recently has experienced a significant decline in his cognitive function, motor function, sensory function and requires assistance with all aspects of adult daily living and instrumental adult daily living tasks.  Recently, the patient has demonstrated a decline in function that prevents the patient from providing any meaningful self-care; the patient has experienced increased falls and near falls, wandering behavior from his apartment and dangerous actions to the extent that the apartment has been childproofed in order to limit the patient's abilities to harm himself using electronics, microwave, stove, coffee pot and other electronic appliances.  The patient currently requires 24/7 around the clock medically necessary skilled care in order for the patient to remain in his current independent living environment.  Documentation of the patient's decline is provided by the patient's primary care physician.

Yes, the proposed treatment, Personal Care Aide - 24 hours per day - seven day(s) per week (Split Shift) - a total 168 hours per week, is medically necessary.

At the time of the health plan's review, based upon available information at that time, the health plan denied the Personal Care Aide - 24 hours per day - seven day(s) per week (Split Shift) - a total 168 hours per week.  However, additional medical records and documents demonstrate a significant decline in the patient's underlying medical condition, including Alzheimer's disease with cognitive and physical deterioration rendering the patient unable to provide himself with any adult daily living task or instrumental adult daily living task.  The patient currently has a level of disability, documented by his primary care physician and son, that requires seven days per week 24-hour split shift care in order for the patient to remain in his current living environment.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory
Inpatient Hospital

Diagnosis: Bradycardia
Treatment: Inpatient Stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a woman with a history of schizoaffective disorder, cocaine use and homelessness who presented to the emergency room requesting psychiatric evaluation. She reported feeling depressed - unclear if suicidal ideation, and speech was incoherent. Her pulse was 87 beats per minute (bpm) initially, then decreased to 45 and as low as 39 bpm. Blood Pressure (BP) 104/71 mm Hg, respiratory rate 18 and she was afebrile. Per the notes, she was transferred from the psychiatric emergency room (ER) to the medical ER due to bradycardia.

The inpatient hospital admission was not medically necessary. The patient has a history of cocaine use, schizoaffective disorder and bipolar disorder. She presented initially for psychiatric evaluation for suicidal ideation and psychosis. She was re-directed for medical admission due to bradycardia. Her heart rate did drop to as low as 39 bpm, as documented by electrocardiogram (EKG). History was difficult to obtain, due to the patient's psychiatric condition. However, the EKG did not show ischemic changes and troponin was not elevated. Bradycardia was evaluated and felt to be asymptomatic, due to medication effects. The patient could have been cared for at a lower level of care. She had ruled out for myocardial infarction, undergone lab testing, including thyroid function tests, and had been evaluated by cardiology. No further testing was recommended for the patient's asymptomatic bradycardia. A lower level of care was appropriate for 24 hrs.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: ICD-10 B20 (HIV) And ICD-10 R64 (Cachexia)
Treatment: Formulary exception for Serostim 
The insurer denied the Formulary exception for Serostim.
The denial is upheld. 

The patient is a male with HIV (human immunodeficiency virus), IBD (inflammatory bowel disease), and HSV (herpes simplex virus) whose formulary exception for Serostim is under review. The patient has a CD4 (cluster of differentiation 4) count of 394 cells/ul (microliter) on Tivicay and Descovy. Per the provider, the patient is with cachexia. It is unknown when the patient was diagnosed with HIV or cachexia. His current BMI (body mass index) is 29.4. Duration of HIV, CD4 nadir, and duration of prior Serostim is not provided. 

No, the health plan should not cover the Formulary exception for Serostim. 

The patient currently does not have AIDS (acquired immune deficiency syndrome) by the CD4 provided (CD4 percentage is unknown). According to the package insert indication, Serostim can be used in HIV cachexia (1), but with a BMI of 29.4, the patient is overweight and borderline obese, so it is hard to justify that this patient has AIDS wasting/cachexia. Any rationale for continued use of Serostim is not documented in the records, and therefore, the health plan should not cover the formulary exception for Serostim.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic obstructive pulmonary disease.
Treatment:  Spiriva Respimat.

The insurer denied coverage for Spiriva Respimat.  The denial is overturned.

This is a male patient with a history of chronic obstructive pulmonary disease (COPD), hypertension (HTN), obstructive sleep apnea (OSA), atrial fibrillation and nocturnal hypoxemia.  The patient has history of severe COPD with his last spirometry showing forced vital capacity (FVC) 2.71 65%, forced expiratory volume in one second (FEV1) 1.24 39% and FEV1/ FVC 46%.  The patient also has had a low-dose Computed Tomography (LDCT), which revealed some sub-centimeter lung nodules and calcified pleural plaques and possible round atelectasis and emphysema.

The patient's prescriptions had included Spiriva Respimat and Ventolin.  The patient was also on home oxygen (O2).  The patient had been maintained relatively symptom free on these medications without significant exacerbations.  Due to a change in the preferred formulary, the patient's insurance company recommended that the patient be treated with the preferred long-acting muscarinic antagonist (LAMA), which was Incruse Ellipta Dry Powder Inhaler (DPI).  They recommended that the patient should have tried this drug, and, if not effective, other drugs could be considered.

It was noted that the patient was unable to use DPI (Incruse Ellipta), which resulted in return of symptoms of shortness of breath (SOB) and cough.  The patient was started on Advair and also Tudorza.  Incruse was discontinued after a trial for one and a half months, as it was not working for the patient, and the patient started getting worsening of symptoms.

The medical practitioner clearly stated that this patient was prescribed Incruse.  It was stated that the patient tried Incruse for one and a half months and noted worsening of symptoms; hence the request was made to go back to Spiriva Respimat.  This patient has been noted to have severe COPD with low lung volumes, which do impact threshold inspiratory flow rates, and patients with COPD may have problems in achieving minimal flows.

Given the above and the history of inadequate response to the preferred drug Incruse, as stated by the patient's treating provider, Spiriva Respimat is medically necessary.  The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for Spiriva Respimat is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance Abuse.
Treatment:  Admission for Inpatient Substance Abuse Detoxification.

The insurer denied the Admission for Inpatient Substance Abuse Detoxification.  The denial is upheld.

The patient is an adult male, who was admitted to inpatient rehabilitation substance use disorder treatment of opioid (heroin), stimulant (crack cocaine), alcohol, hallucinogen (PCP) and cannabis (marijuana) use disorders.  Despite participating in a methadone maintenance treatment program (MMTP), the patient was using 2 bags of heroin and $150 worth of crack cocaine three to six times per week together with daily use of marijuana ($10 per day) and intermittent use of alcohol and PCP.  The inpatient level substance use disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions and recovery groups with peer support.  The patient easily transitioned to rehabilitation treatment with continued use of methadone at 30 mg daily.  He actively participated in individual, group and educational sessions.  He was prescribed melatonin and ibuprofen and had the availability of nicotine replacement therapy throughout his stay.  He was also provided with continued vitamin replacement therapy.

The requested Admission for Inpatient Substance Abuse Detoxification is not medically necessary for this patient.

The Admission for Inpatient Substance Abuse Detoxification in this case scenario was amenable to treatment at a lower level of care.  The patient was motivated and following detoxification treatment with the continued use of methadone, the patient was capable of effectively continuing in substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing.  The patient did not need the structure or intensity of services or monitoring of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment.

There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission and the continued inpatient level services and treatment.

This answer is consistent with prevailing standards of professional practice, American Society of Addiction Medicine (ASAM) Criteria, and the published guidelines and the scientific literature, as well as the application of NY State OASAS LOCADTR 3.0 Criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Weakness, fatigue, myalgias, headache, dizziness, fever/chills, nausea and SOB (shortness of breath).
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a homeless male.  He presented to the ER (emergency room) with one week of weakness, fatigue, myalgias, headache, dizziness, fever/chills, nausea and SOB (shortness of breath).  He had been COVID (coronavirus disease)-positive recently.   

The patient's VS (vital signs) were as follows: Temperature 99.6, heart rate 83, respiration rate 18, blood pressure 116/85, oxygen saturation 99%.  His exam was unremarkable.  His labs revealed the following:  WBC (white blood count) 4.1, H/H (hemoglobin/hematocrit) 10.3/31.3, Plt (platelets) 114, Na (sodium) 145, K 3.3 (potassium), BUN/Cr (blood urea nitrogen/creatinine) 10/1.3, Glu (glucose) 171, Lactate 2.8, EtOH (ethanol) 299, AST (aspartate aminotransferase) 134, ALT (alanine aminotransferase), 69.  His CIWA (clinical institute withdrawal assessment) score was 0.  His CXR (chest x-ray) revealed NAD (no active disease).  His head CT (computerized tomography) revealed NAD (no active disease).  

The patient was admitted with alcohol intoxication with impending withdrawal.  The plan of care included IVF (intravenous fluids) and CIWA (clinical institute withdrawal assessment) protocol.  

The patient's vital signs were stable.  No progress report.  EKG (electrocardiogram) revealed NSR (normal sinus rhythm). 

The patient's vital signs were stable.  CIWA (clinical institute withdrawal assessment) was discontinued.  The patient was cleared for discharge.  

No, the Inpatient admission was not medically necessary.

This patient was admitted in setting of alcohol intoxication and impending withdrawal.  The patient was hemodynamically stable and afebrile.  He did not have tachycardia or arrhythmia.  He did not have persistent vomiting, delirium, seizures, or gross tremor.  Labs were remarkable for lactic acidosis, consistent with dehydration.  The patient was admitted with plan for IVF (intravenous fluid) and CIWA (clinical institute withdrawal assessment) protocol.  The hospital stay is unremarkable.  The patient was clinically stable and did not have findings of alcohol withdrawal.  He did not have symptoms that required an acute inpatient level of care.  He had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.  Withholding the treatment would not have been reasonably expected to affect the patient's health adversely.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Migraine. 
Treatment: Formulary exception for Aimovig 140 MG/ML SC SOAJ. 

The insurer denied the Formulary exception for Aimovig 140 MG/ML SC SOAJ. 
The denial is overturned. 

The patient is a female with migraine headache disorder. She has been treated with topiramate, propranolol and Botox. She is currently treated with duloxetine and Aimovig. 

Yes, the health plan should cover the Formulary exception for Aimovig. 

The patient is not currently treated with Botox, as this was denied coverage per the chart notes. She has tried and failed two preferred oral agents from different classes, topiramate and propranolol, and she has a contraindication to the use of preferred antidepressants given current treatment with duloxetine. It would be considered standard of care given the medications she has tried and failed or has a contraindication to using, to continue Aimovig here. 

Therefore, given the above, the health plan should cover the Formulary Exception for Aimovig.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 diabetes mellitus

Treatment: Humalog (brand) 100U/mL

The insurer denied coverage for Humalog (brand) 100U/mL.

The denial is overturned. 

This is a female patient with a diagnosis of Type 1 diabetes mellitus. The patient's Type 1 diabetes was uncontrolled. The patient has hypoglycemia at lunch on the days when she is active (3 times a week). The patient's provider created a second basal program for the days when she is active, and the patient was referred to a dietician to discuss healthy eating habits. The patient's provider prescribed Humalog U-100 Insulin 100 u/mL (units per milliliter) subcutaneous solution; with instructions to use 100 units daily in the insulin pump.  

Per the patient's endocrinologist, the patient had severe allergic reactions to Admelog in the past. It is not safe for the patient to try Admelog again. In addition, the patient may develop similar severe allergic reactions to other insulin brands that she has not tried before. The patient presented to a Drug Allergy Center. Per the visit notes, the patient's history was most consistent with delayed hypersensitivity reaction to Admelog that was started 2 weeks prior to the onset of rash and started improving after stopping Admelog and switching back to Humalog. The patient's skin test to Admelog was negative. This negative skin testing was predictive only for immunoglobulin E (IgE)-mediated reactions and was not predictive of delayed non IgE-mediated allergic reactions. The notes also state that Admelog is an insulin biosimilar drug and should be avoided for this patient. 

As per literature review, Admelog is a generic drug for Humalog and the patient claims to be allergic to Admelog. The patient was evaluated by the Drug Allergy Center and was advised to avoid Admelog based on her allergic rash and other signs of hypersensitivity. This is concerning as the patient may develop a life-threatening reaction. Admelog has been shown to be biosimilar in pharmacokinetics with Humalog in terms of pump therapy or continuous subcutaneous insulin infusion (CSII). In addition, Lispro is a biosimilar, and since a generic version for Humalog was trialed with adverse reaction, Lispro is not recommended for this patient. The patient has been using Humalog successfully with no adverse reactions. Thus, Humalog (brand) is considered medically necessary for this patient's case.
     
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for Humalog (brand) 100U/mL should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Micronodular basal cell carcinoma
Treatment: Mohs micrographic technique
The insurer denied Mohs micrographic technique.
The determination is overturned.

The patient has a micronodular basal cell carcinoma (BCC) to the breast, treated with Mohs micrographic surgery for definitive surgical removal. At issue is the medical necessity of the Mohs micrographic technique.

This is medically necessary. According to the American Academy of Dermatology appropriate use criteria for Mohs, BCCs with aggressive histology (micronodular) and greater than 2 centimeter (cm) in size on the trunk are appropriate cancers for Mohs. BCCs with a surface greater than 1 cm (2) and aggressive histology (morpheaform and micronodular), and a patient age greater than 80 years are strong predictors for two or more rounds of Mohs micrographic surgery (MMS) being required and are appropriate cases for Mohs. These are three things, each of which are strong indicators of more aggressive disease. The patient does not need to have all three factors present. The requested Mohs micrographic technique is medically necessary for this patient with micronodular basal cell carcinoma to the breast.