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

Diagnosis: Asthma. 
Treatment: Inpatient Admission. 

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

The patient is a female with history of breast cancer status post bilateral mastectomy, and asthma who presented to emergency room with worsening shortness of breath (SOB) and wheezing. In the emergency room, patient was tachycardic, tachypnic and was using accessory muscles. The patient was admitted to acute in hospital level of care after failing emergency room (ER) treatment. The patient had difficult to treat asthma exacerbation and needed prolonged hospitalization for intravenous (IV) steroids and frequent nebulizations. The patient was discharged home. 

Yes, the proposed inpatient hospital admission was medically necessary. 

The patient had severe asthma exacerbation and was difficult to treat. The patient had slow response to intravenous steroids. The patient continued to have moderate to severe symptoms of asthma exacerbation. The prolonged use of intravenous steroids as well as frequent nebulization treatments were needed. The patient also had low normal oxygenation levels during this admission length of stay.  The current standard of clinical practice would be to have acute hospitalization for asthma exacerbation treatment. The lower level of care would not be safe since the patient continued to have signs and symptoms of asthma exacerbation despite aggressive treatment with intravenous steroids and nebulization. The proposed treatment was medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

The proposed treatment was medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Janumet. 
The denial is overturned.

The patient is a male with a history of diabetes, hypertension, coronary artery disease, and hyperlipidemia. His provider is requesting coverage for non-formulary Janumet. Beside Janumet, he is taking empagliflozin and glimepiride, suggesting that the patient's diabetes is difficult to control. An office visit note documents that the patient's blood control was poor on Jentadueto, along with the empagliflozin and glimepiride, compared to when he previously was on Janumet. Jentadueto was discontinued and Janumet was prescribed again. Subsequent office visit notes document adequate diabetes control on Janumet.

The plan's determination is overturned.

In this patient, the formulary drug Jentadueto/Jentadueto extended release (XR) had been ineffective compared to the non-formulary drug Janumet.
The medical records document that the patient's diabetes control was worse on the formulary drug Jentadueto compared to when he was taking non-formulary Janumet. Both medications are a combination of a Dipeptidyl-peptidase (DPP)-4 inhibitor (linagliptin in Jentadueto, sitagliptin in Janumet) combined with metformin, a biguanide. Although both linagliptin and sitagliptin are classified as DPP-4 inhibitors, they are indeed different drugs, and it is not uncommon for medications in the same class to have different effectiveness or side effects in any given patient. The information provided indicates that there is only one DPP-4/biguanide combination on the formulary, Jentadueto/Jentadueto XR. Therefore, based on the standard of care, and the peer reviewed literature, as well as the plan's non-formulary coverage criteria, the requested drug is more appropriate than the formulary drug in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis.
Treatment: Functional Electrical Stimulator.
The insurer denied a Functional Electrical Stimulator.
 The health plan's determination is upheld.

The patient is a man with multiple sclerosis. A functional electrical stimulation (FES) cycling therapy system is the subject of this review. 

The requested Durable Medical Equipment: Functional Electrical Stimulator is not medically necessary for this patient. Randomized controlled trials are lacking to show that use of the FES cycle is more effective than treatment with conventional physical and/or occupational therapy techniques. There is one small randomized controlled trial of 8 people that demonstrated FES cycling demonstrated small-to-moderate improvements on a timed walking test. The authors concluded that FES cycling is feasible for multiple sclerosis patients. A meta-analysis showed FES cycle training may reduce cardiovascular disease risk alongside trends for a reduction in spasticity post training, however the low quality of the literature precludes any definitive conclusions. Another study provided preliminary evidence for the benefits of FES cycling exercise on cognition and symptoms of fatigue and pain. However, this study called for appropriately powered randomized controlled trials of FES cycling exercise to determine its efficacy for people with multiple sclerosis (MS). In conclusion, evidence is lacking to support the routine use of FES cycling in people with multiple sclerosis. There is a lack of randomized controlled trials. There is no comparison to standard therapies to show superiority to traditional physical and occupational therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Detoxification Admission

The insurer denied the Inpatient Detoxification Admission.
The denial is upheld.

The appeal documentation describes the patient as a female who presented having been using cocaine, heroin, and alcohol each day. She had already been enrolled in a methadone program where she received 190 milligrams (mg) of methadone each day. She tested positive for cocaine, opiates, and methadone. Blood alcohol level (BAL) was zero. There was also a diagnosis of bipolar disorder for which she was prescribed Prozac, Abilify, and Neurontin. 

The medical records are consistent with the above information. On intake, there was no medical acuity present. Three was no history of blackouts or seizures, nor of overdose. Blood pressure was 108/68 with pulse of 62. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score was eight. No opioid withdrawal symptoms were documented. The patient was placed on Librium, but this was noted to make her "drowsy." Mental status exam did not reveal dangerousness to self/others or psychotic symptoms. The patient remained stable throughout her stay, sleeping well, and showing no signs of acuity.

No, the proposed treatment, inpatient detoxification admission, was not medically necessary.
The patient was demonstrating only mild symptoms of withdrawal, with a Clinical Withdrawal Assessment for Alcohol (CIWA) score of less than ten and no Clinical Opiate Withdrawal Scale (COWS) score present. This is consistent with the need for ambulatory withdrawal management without extended on-site monitoring. There was no physical or psychiatric acuity present and the patient was not suicidal, homicidal, or psychotic. Inpatient detox was therefore not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The health plan denied the admission to inpatient detox. The patent had mild withdrawal symptoms and was at minimal risk of severe imminent withdrawal symptoms. The patient had adequate support services to ensure commitment to completion of withdrawal management as she was already engaged in an opioid treatment program which would have available both counseling and increased intensity of ambulatory services. The patient could have been safely and effectively treated within an ambulatory setting.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Irritable Bowel Syndrome-Constipation. 
Treatment: Pharmacy/Prescription Drugs-Montegrity. 

The health plan denied the prescription drug Montegrity as the patient did not meet the pharmacy criteria. The reviewer has overturned in whole the health plan's determination. 

The patient has irritable bowel syndrome, constipation-predominant. She has failed Lubiprostne and Linzess, as well as MiraLAX, Senna, and Dulcolax. She has had improvement with Motegrity 2 milligrams (mg) daily, which she has been taking. The coverage is requested to continue Motegrity 2 mg daily for the treatment of irritable bowel syndrome, constipation predominant. 

The formulary drugs have been ineffective. The request for Motegrity is supported. The patient has had irritable bowel syndrome, constipation-predominant, and failed osmotic and stimulant laxatives, and advanced agents (Amitiza, Linzess) [1]. The patient has chronic constipation symptoms, and the American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as Motegrity should be used if non-pharmaceutical laxatives fail [2]. Motegrity has shown efficacy for the treatment of irritable bowel syndrome constipation-predominant and for symptoms including bloating and abdominal pain [3-7]. The patient has failed the formulary agents lubiprostone and Linzess. Furthermore, she has demonstrated improvement with Motegrity. For these reasons, the request is supported.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Lymphoblastic Leukemia
Treatment: Blincyto (blinatumomab)
The insurer denied the Blincyto (blinatumomab)
The denial is upheld

The patient is a female. The patient in this case was diagnosed with Philadelphia chromosome negative acute lymphoblastic leukemia (ALL). She was started on induction therapy consisting of inotuzumab, rituximab and mini-HyperCVAD (hyperfractionated cyclophosphamide, vincristine, Adriamycin, and dexamethasone).  She received two complete cycles and bone marrow biopsy revealed complete response.  Treatment with maintenance blinotumumab has been recommended.  In an appeal letter, it was noted that this treatment is based on a phase 2 clinical trial.

No, the requested Blincyto (blinatumomab) is not medically necessary.
There is no evidence showing that the addition of blinatumomab to the combination of mini hyperCVAD (hyperfractionated cyclophosphamide, vincristine, Adriamycin, and dexamethasone) chemotherapy plus inotuzumab can improve health outcomes. There is no indication that this patient has positive minimal residual disease after achieving complete remission. Rather, blinatumomab is being used as maintenance therapy regardless of MRD (minimal residual disease) status. That is not a standard use of this agent and given that it has not been shown to improve health outcomes in this setting, it is not medically necessary.

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

Diagnosis: Fibroid uterus with obesity. 
Treatment: 15830 Panniculectomy. 

The insurer denied the 15830 Panniculectomy. 
The denial is overturned. 

The patient is a female with an anticipated hysterectomy for fibroid uterus with abnormal bleeding. Her MRI (magnetic resonance imaging) showed a right ovarian mass. She was seen by her gynecologist, and he recommended a hysterectomy. She has a body mass index of 67, which puts her in the extreme obesity category. Her Gyn-oncologist is recommending a simultaneous panniculectomy with hysterectomy to allow for the hysterectomy to be safely performed. A general surgeon will be doing a gall bladder removal. A plastic surgeon plans a limited panniculectomy to get the exposure for the hysterectomy and cholecystectomy. 

Yes, the Panniculectomy is medically necessary. 

An extensive literature confirms the safety of this procedure in conjunction with pelvic surgery as well as its importance in improving operative exposure and enhancing the safety of pelvic surgery. Surgical access to the pelvis is compromised in the presence of a massive pannus, and panniculectomy will improve operative exposure and operative safety. This has been clearly demonstrated in the medical literature. 

This patient has an elevated BMI (body mass index), and her large pannus will compromise access to the pelvis. The standard of care as defined by the medical literature is to perform a panniculectomy at the time of pelvic surgery to improve access. The patient's gynecologist appropriately requested that the plastic surgeon perform a panniculectomy to improve access and eliminate her infections. 

According to Hardy et al, "Our findings reveal that panniculectomy combined with pelvic surgery in the morbidly obese is a safe procedure that can decrease the incidence of intraoperative complications and postoperative wound complications without significantly increasing operative time or blood loss." 

The medical literature strongly supports the position that a panniculectomy is medically necessary for this patient to ensure the safety of her gynecologic surgery. As an added benefit, the surgery will likely cure her frequent yeast infections and decrease her risk of a significant postoperative wound infection in her pannus fold. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The panniculectomy is medically necessary to facilitate the gynecology surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted permanent cuspids.
Treatment: D8070 Braces; D8670 Monthly Visit x4.
The insurer denied the D8070 Braces; D8670 Monthly Visit x4.
The denial is overturned

The patient is a female. The request is for orthodontic treatment (Braces) and four monthly visits.  Per the provider's dental clinical exam -- the patient presents with all four permanent cuspids that are impacted.

The health plan denied the claim because the patient did not score a 26, the score necessary for orthodontic treatment approval on the Handicapping Labio-Lingual Deviation (HLD) Index Report.  The Provider appealed the claim because the patient has four impacted cuspids, an automatic qualifier for orthodontic treatment per the Handicapping Labio-Lingual Deviation (HLD) Index Report.

Yes, the proposed treatment of orthodontic therapy (braces) and four monthly visits are medically necessary.
As evident on the x-rays, these impacted canines (especially on the upper arch) do not have adequate space in the arch to naturally erupt due to their position and the position of the adjacent teeth.  Under these circumstances, surgical exposure of these teeth coupled with orthodontic treatment is indicated as a corrective measure.

No, the health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.
An untreated impacted canine can damage adjacent teeth and lead to eventual tooth loss.  Additionally, proper alignment and position of the canine tooth in the mouth is essential for chewing, functional guidance, and aesthetics.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented to the emergency department complaining of fatigue, lightheadedness, palpitations, intermittent mild chest pain, near syncope and diffuse paresthesias. Her medical history was remarkable for menorrhagia, iron deficiency anemia, Helicobacter (H.) pylori infection, obesity, bariatric surgery, and obstructive sleep apnea. Her blood pressure was 118/80 millimeters of mercury (mmHg) with a heart rate of 82 beats/minute. Her room air oxygen saturation was 100%. Her physical exam was unremarkable. Her electrocardiogram showed sinus rhythm without acute changes. Her hemoglobin level was 8.4 grams per deciliter (gm/dl), which was her baseline. Her serum troponin level was normal. Head computed tomography (CT) scan showed no acute pathology. The patient was admitted to the hospital and treated with aspirin, a statin, and pantoprazole. Her troponin level remained normal. Pelvic ultrasound showed a right ovarian cyst versus follicle and was otherwise unremarkable. Her hemoglobin level was 8.3 gm/dl. Lower extremity venous Doppler studies were normal. An echocardiogram showed normal left ventricular systolic function. The patient's serum B12 level was low, and supplementation was prescribed. She was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

This patient presented with anemia, lightheadedness, chest pain and palpitations. There was some concern for acute coronary syndrome. However, there were no ischemic electrocardiographic changes and her cardiac biomarker levels were normal. The patient did not require intensive monitoring or infusion of intravenous cardioactive medications. Based on her HEART score of 1, she was at low risk for major adverse cardiac events. The care this patient received for her chest pain did not require an inpatient admission and could have been provided under a lower level of care status. The patient had a significant anemia upon presentation. However, this was a chronic problem. Her admission hemoglobin of 8.4 gm/dl was at her baseline and remained stable during her hospitalization. The patient was not tachycardic and the records provided do not mention orthostatic hypotension or other signs of hypovolemia. There was no indication for red blood cell transfusion. The patient's anemia did not warrant an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ear Nose Throat. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a female who presented to the emergency department with concerns of sore throat and abdominal pain. Pertinent history included kidney stones, constipation, and attention deficit disorder (ADD). Initial vital signs revealed a temperature of 102.4 Fahrenheit (F), heart rate (HR) 116, blood pressure (BP) 116/57, respiratory rate (RR) 28, peripheral capillary oxygen saturation (SpO2) 100% on room air. Initial examination documented a patent airway, mild oropharyngeal erythema, and diffuse abdominal tenderness to palpation. Initial laboratory testing revealed a white blood cell (WBC) 15.7, hemoglobin (Hgb) 13.5, platelets (Plt) 295, Lactate 1.45, blood urea nitrogen (BUN) 5, creatinine (Cr) 0.75, glucose (Glu) 94, carbon dioxide (CO2) 20.8, Lipase normal, liver function tests (LFTs) normal. Urinalysis unremarkable. Rapid strep test was positive. Chest radiograph noted possible infiltrates. Computed tomography (CT) of the abdomen/pelvis revealed constipation but was otherwise unremarkable. Pelvic ultrasound was unremarkable. The patient was admitted thereafter with an impression of sepsis secondary to streptococcus pharyngitis and intractable abdominal pain. 

Treatment plan includes intravenous fluids, empiric intravenous antibiotics, and analgesia. The patient remained persistently febrile with a temperature maximum (Tmax) of 104F. Infectious disease consultation was obtained who had an impression of pharyngitis with concerns for meningitis. CT of the neck revealed bilateral tonsillitis and bilateral cervical enlarged lymph nodes. Neurology consultation was obtained who recommended a lumbar puncture. Treatment plan was relatively unchanged while awaiting the spinal tap. The lumbar puncture was performed, and cerebrospinal fluid (CSF) analysis was relatively unremarkable. Back pain persisted. Neurology recommended a magnetic resonance imaging (MRI) of the brain.  Infectious disease recommended discontinuation of vancomycin and acyclovir with transition to oral Duricef. The patient was deemed medically stable for discharge. 

The health plan's determination is overturned. 

In this particular situation, the patient met criteria to prompt the suspicion for a dysregulated systemic response consistent with sepsis. Moreover, clinical indications for admission to inpatient care were met. The patient had hemodynamic instability with persistent tachycardia despite appropriate management to address such as well as the presumed underlying cause. More importantly, as clinical findings persisted despite appropriate treatment during observation care, infectious disease consultation was obtained whom had concerns for a complicated infection with suspected central nervous system (CNS) infection. Thus, inpatient treatment was necessary as parenteral antibiotics were indicated and broadened beyond observation care. [2[3]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duodenal Ulcer

Treatment: Acute inpatient hospital stay

The insurer denied coverage for the acute inpatient hospital stay.

The denial is overturned.

The patient had a complicated history including Alzheimer's, brain hemorrhage, and diabetes. He was undergoing a workup for colitis and was scheduled to have an endoscopy but was found to have a glucose over 480 and black diarrhea. He was transferred to the emergency department. A computed axial tomography (CAT) scan revealed wall thickening in the duodenum and colon. An endoscopy revealed a duodenal ulcer that was oozing blood. The ulcer was treated with bipolar cauterization. His hemoglobin decreased to 8.6. The blood urea nitrogen (BUN) was 32 with a creatinine of 3.5. Leukocytosis was present and he was treated for clostridium difficile toxin. The glucose was 420.

Clinical indications for admission for Upper Gastrointestinal (GI) Bleeding MCG (Milliman Care Guidelines) M-180 include having peptic ulcer disease with high-risk endoscopic features. Since this patient had active bleeding and needed endoscopic hemostatic therapy, he fulfilled this criterion.

This patient was having profuse black diarrhea. He was found to have active bleeding from a duodenal ulcer which required endoscopic hemostasis. This met MCG criteria for admission for Upper Gl bleeding. In addition, he had multiple active comorbid conditions such as poorly controlled diabetes and renal failure. His hemoglobin was dropping after admission. The health care plan did not act with sound medical judgment and in the best interest of the patient. An acute inpatient admission was medically necessary.

The insurer's denial of coverage for acute inpatient hospital stay is overturned. Medical Necessity is substantiated.