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

Diagnosis: Sickle cell crisis.
Treatment: Inpatient admission. 	
The insurer denied coverage for an inpatient admission.
 The denial is overturned.

The patient has a history of hypertension, sickle cell disease, and chronic kidney disease. The patient presented to the emergency room via emergency medical services (EMS) with diffuse body pain for 2 days. A chest x-ray showed cardiomegaly and mild pulmonary venous congestion. He was admitted to telemetry for sickle cell crisis. The patient had elevated troponin levels and was given 2 liters of humidified oxygen via nasal cannula and aspirin. He described his pain as 10/10, but another note says that he described it as "mild but starting a couple days ago". He was complaining of chest pain and pressure, and headaches. He was tachycardic.

The health care did not act reasonably and with sound medical judgment and in the best interest of the patient. The request for an inpatient admission is considered medically necessary for this patient. 

The presence of chest pain is an ominous finding on a sickle cell patient and indicates an admission because of the concern for Chest Syndrome. The only way to fully rule it out is to treat and observe for resolution. The patient required the requested level of care during treatment to rule out chest syndrome. Therefore, the inpatient admission is considered medically necessary for this patient.

Friend, A., & Girzadas, D. (2021), "Acute chest syndrome (ACS) is the result of various inciting events causing vaso-occlusion within the pulmonary vasculature of patients with sickle cell disease (SCD). ACS can occur in any SCD phenotype. However, it is most common in HbSS [Hemoglobinopathies: Sickle Cell Disease (HbSS)]. ACS can progress quickly and is the most common cause of death in patients with SCD. Therefore, it is important to make the diagnosis and begin treatment as soon as possible."

Per Simon E. et al. (2016), "SCD patients experience significant morbidity and mortality secondary to cerebrovascular accident, acute chest syndrome, acute vaso-occlusive pain crises, SCD-related multi-organ failure, cholecystitis, acute intrahepatic cholestasis, acute sickle hepatic crisis, acute hepatic sequestration, priapism, and renal disease. Emergency physicians must recognize acute manifestations of SCD in order to deliver timely management and determine patient disposition."

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Onychomycosis
Treatment: Formulary exception for Jublia
The insurer denied the Formulary exception for Jublia
The denial is upheld.

The patient is a female. She suffers from onychomycosis. She has an intolerance to ciclopirox and ketaconazole. There are notes that the patient has also tried clotrimazole and terbinafine. It is also noted that Itraconazole is contraindicated. The health Plan writes that the formulary alternatives are itraconazole and terbinafine. Jublia was ordered for her.

No, The plan should not cover the proposed treatment. The formulary medication would be just as effective as the non formulary medication. The side effect profile is also very similar. The formulary drug would be no more harmful than the nonformulary drug. While studies have shown that Jublia is a good alternative to oral medications in the treatment of onychomycosis it's overall efficacy varies from 10 to 20% (percent) this is very similar to the formulary drug efficacy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath, COPD.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a history of hypertension (HTN), hyperlipidemia, asthma and chronic obstructive pulmonary disease (COPD) who presented with 3 days of increasing shortness of breath (SOB) and a productive cough.
In the emergency department (ED), the initial vital signs were a temperature of 98.4 degrees Fahrenheit, blood pressure (BP) 155/62, heart rate (HR) 100, respiratory rate (RR) 25, peripheral capillary oxygen saturation (SpO2) 87% on room air (RA); subsequent vital signs were a temperature of 99 degrees Fahrenheit, blood pressure (BP) 125/73, heart rate (HR) 95, respiratory rate (RR) 20, SpO2 100% on Bilevel positive airway pressure (PAP) with 40% fraction of inspired oxygen. She was not in distress, has tachypnea and was using accessory muscles, wheezing and crackles present, alert and oriented. The white blood cell count (WBC) was 4.1, sodium (Na) 138, bicarbonate (bicarb) 27, blood urea nitrogen (BUN) /creatinine (Cr) 19/0.86, troponin (Tn) 0.038; coronavirus disease (COVID) and flu testing negative. A chest x-ray (CXR) showed mild elevation of the left hemidiaphragm and questionable left base infiltrate.
In the emergency department (ED), she was started on BiPAP and improved; she was also started on ceftriaxone and azithromycin for possible community acquired pneumonia (CAP), started on intravenous (IV) steroids and nebulized bronchodilators for a COPD exacerbation. She improved over the day of admission and by that night, the BiPAP was able to be removed.
The next day, she was feeling better and left against medical advice (AMA).
At issue is the medical necessity of an inpatient stay.

Yes, an inpatient stay was medically necessary.
While the patient improved quickly enough to leave against medical advice (AMA), she did present with severe respiratory distress and acute hypoxemic and hypercarbic respiratory failure, severe enough to require non-invasive ventilation (NIV). Patients with this severity of respiratory disease require close inpatient monitoring to ensure there is no subsequent deterioration. This degree of close observation cannot be achieved at a lower level of care. Other factors supporting her need for inpatient admission include an elevated troponin (also a predictor of poor outcome), elevated carbon dioxide (CO2), and an elevated DECAF [Dyspnea, Eosinopenia, Consolidation, Acidemia and Atrial Fibrillation] and Ottawa COPD risk scores. With a severe presentation and multiple risk factors predicting a higher risk of poor outcome, an inpatient admission was needed for inpatient only treatments, NIV and monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eating Disorders/Other/Binge Eating
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested medication, VYvanse as not medically necessary. The health plan's determination is upheld.

The patient is a female with a history of binge eating disorder and attention deficit disorder. She is being prescribed Vyvanse as she continues to binge and gain weight despite intervention. The following review is evaluating the medical necessity for use of Vyvanse.

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

No, the use of Vyvanse 60 mg (milligrams) is not medically necessary. Vyvanse is not a Food and Drug Administration (FDA) approved treatment for binge eating disorder in children/adolescents and is only approved in adults for this condition. In addition, therapy is the mainstay of treatment for adolescent binge eating disorder. [1]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease with Ileocolitis. 
Treatment: Gattex. 

The insurer denied coverage for Gattex. 
The denial is upheld. 

The patient has Crohn's disease with Ileocolitis. A subtotal colectomy was done, and she has an ileostomy. She had been on a variety of biologic agents and most recently is on Stelara. She required a small bowel resection for adhesions. Magnetic resonance imaging (MRI) enterography showed diffuse small bowel disease. She has had high volume output from the ileostomy and has been treated with Questran and Lomotil. Teduglutide has now been requested for short bowel syndrome. She has been able to tolerate a diet. 

Gattex is a glucagon-like peptide which is indicated for the treatment of Short Bowel Syndrome in patients who are dependent on parenteral support. Up To Date has an article titled "Management of the short bowel syndrome in adults." Patients with Crohn's disease who have surgical resections can develop short bowel syndrome. The article addresses glucagon-like peptides (GLP)-2 analogues. The article states that we reserve the use of teduglutide to patients with short bowel syndrome who are unable to be weaned from parenteral nutrition despite aggressive use of more conventional measures. In clinical studies, teduglutide modestly reduces the volume and number of days of parenteral support. Additional studies are needed to determine whether the intestinal adaptation due to teduglutide is sustained after discontinuation of therapy and if long-term use is associated with a reduction of complications associated with parenteral nutrition. 

This patient has Crohn's disease and has required intestinal resections. However, she has been able to maintain her nutritional needs without the requirement of parenteral nutrition. The patient is underweight but there is no recommendation from the gastrointestinal society guidelines or any large scale study that recommends Gattex for Crohn's patients when they do not require parenteral nutrition support. 

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

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

Diagnosis: Intrauterine device (IUD) removal

Treatment: Outpatient services in an outpatient hospital department, current procedural terminology (CPT) code 58562- hysteroscopy, surgical; with removal of impacted foreign body

The insurer denied coverage for Outpatient services in an outpatient hospital department, current procedural terminology (CPT) code 58562- hysteroscopy, surgical, with removal of impacted foreign body

The denial is upheld 

This patient had diagnosis of a lost string of an IUD requiring removal. She was admitted to the hospital for a hysteroscopy for removal of the IUD. The procedure was performed without complications.

The medical records and medical literature were thoroughly reviewed. The patient has no significant medical co-morbidities. A hysteroscopy was planned. The Health Plan has apparently confirmed that an ambulatory surgicenter was available for performance of this procedure.  Hysteroscopy is a minor surgical procedure. It can be safely performed within the standard of care in an ambulatory surgicenter setting in a patient with no significant co-morbidities. Therefore, the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Outpatient services in an outpatient hospital department, current procedural terminology (CPT) code 58562- hysteroscopy, surgical; with removal of impacted foreign body is not considered medically necessary for this patient.

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

The insurer's denial of coverage for outpatient services in an outpatient hospital department, current procedural terminology (CPT) code 58562- hysteroscopy, surgical; with removal of impacted foreign body is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Herniated Disc, Cervical
Treatment: Total Disc Arthroscopy (22856)
The insurer denied the Total Disc Arthroscopy (22856)
The denial is upheld

The patient is a male with previous C5-6 (fifth cervical spine vertebra-sixth cervical spine vertebra) ACDF (Anterior Cervical Decompression and Fusion). The patient had improvement after that surgery with right hand symptoms. Over prior several weeks, the patient noted new symptoms in his right arm. The patient attempted NSAIDs (nonsteroidal anti-inflammatory drugs), and has not attempted PT (physical therapy) or pain management.

The patient underwent C4-5 (fourth cervical spine vertebra-fifth cervical spine vertebra) arthroplasty and removal of previous instrumentation.

No, the health plan should not cover the Total Disc Arthroscopy (22856).
The patient had a previous ACDF (Anterior Cervical Decompression and Fusion). There is no clear evidence that performing arthroplasty in the setting of previous ACDF (Anterior Cervical Decompression and Fusion) is medically appropriate. The patient has a fused segment of the spine and there is no clear benefit to performing arthroplasty in this setting. The standard of care does not support the use of arthroplasty in this setting, and therefore this is not medically appropriate.

No, the Total Disc Arthroscopy (22856) is not more beneficial.
The idea of hybrid procedures was popularized several years ago, but this is not considered standard of care or medically appropriate. This patient does not have any finding that warrants arthroplasty over ACDF (Anterior Cervical Decompression and Fusion) at C4-5 (fourth cervical spine vertebra-fifth cervical spine vertebra).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypogonadal Osteoporosis
Treatment: Teriparatide (Forteo)
The insurer denied the Teriparatide (Forteo)
The denial is overturned.

This is a male with seizure disorder and osteoporosis with vertebral compression fractures. His T-score is - [minus] 1.6. The request for Forteo is under review. The prior request was denied as the patient has not tried and failed bisphosphonate therapy. The physician is appealing this determination as the patient has vertebral compression fractures and Forteo is being used to assist with healing of these fractures. The patient requires anabolic therapy with Forteo. The patient had six to eight vertebral compression fractures noted on magnetic resonance image (MRI).

Yes, the proposed Forteo is medically necessary.
Unlike bisphosphonates, Forteo is an anti-osteoporosis drug that increases bone mineral density. Forteo is approved for the treatment of osteoporosis in men with osteoporosis at high risk for fracture, such as this patient with a history of multiple vertebral fractures. He is also at increased risk due to the use of anti-seizure medications.  After an average of 18 months of therapy, Forteo reduces the risk of vertebral fractures by 65% (percent) and nonvertebral fragility fractures by 53% in patients with osteoporosis. Additionally, Forteo has been shown to improve healing of osteoporotic fractures, including in a systematic review of randomized clinical trials. This is clinically important in this patient with multiple vertebral fractures. Bisphosphonate has not been shown to have the same effect. Without Forteo, this patient will be at increased risk of additional fragility fractures and poor healing of his vertebral fractures. Therefore, the requested Forteo is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested Forteo was denied. Forteo is medically necessary in this clinical situation to reduce fracture risk and to enable healing of his multiple vertebral fractures.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atrial fibrillation
Treatment: Eliquis

The insurer denied coverage for Eliquis
The denial is overturned

This is a patient with a history of atrial fibrillation, left atrial catheter ablation, non-obstructive coronary artery disease, and diabetes mellitus. His CHADSVASC (congestive heart failure, hypertension, age, diabetes, stroke, vascular disease, and sex) score of three meets guideline directed criteria for oral anticoagulant therapy. He was treated with Apixaban for several years without any issues.  Following a change in his health insurance formulary, he was transitioned to treatment with rivaroxaban. He subsequently reported frequent epistaxis, gum bleeding and ecchymosis over his upper extremities. A letter from his cardiologist documents these issues.  

The 2019 American Heart Association, American College of Cardiology and Heart Rhythm Society Guidelines list a Class I (level of evidence A) recommendation for treatment with novel oral anticoagulant regimen instead of warfarin. This recommendation was based on several randomized clinical trials that enrolled thousands of patients. The direct thrombin inhibitor medications and the Factor Xa (anticoagulant) inhibitor medications (including Xarelto/Rivaroxaban) were at least non inferior and in some cases superior to warfarin therapy. When Xarelto was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated non-inferiority to warfarin in preventing stroke or systemic embolism (Reference 2). This patient had clear evidence of bleeding while being treated with Xarelto necessitating the use of an alternative such as apixaban (Eliquis). In fact, when Eliquis was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated superiority to warfarin in preventing stroke or systemic embolism. In addition, patients treated with Eliquis had less bleeding and a lower mortality than those treated with warfarin (Reference 3).

In conclusion, the patient should be treated with Eliqis/Apixaban. Formulary alternatives have caused bleeding (harm) documented by his Cardiology NP (nurse practitioner). Warfarin, another formulary alternative may also cause harm. As the patient had been stable on apixaban for years, it is clear that the requested drug would be more effective.

The insurer's denial of coverage for Formulary Exception for Eliquis is overturned.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a  female with a past medical history significant for seizure disorder who was two months postpartum and presented to the hospital with a seizure that lasted 2-3 minutes. It was reported that the seizure activity involved shaking, tongue biting, and urinary incontinence. The patient stated that she did not take her antiseizure medications that day.

At the time of the initial evaluation, the patient was awake and alert. She was hemodynamically stable and had no signs of central nervous system (CNS) infection. There was no evidence that she had focal neurologic signs. Per history, she had only one single episode of seizure on the day of admission. Reportedly, she totally recovered from the seizure by the time she was seen by the admitting physician, and the imaging studies did not show any acute abnormalities that required intervention.
There was no evidence that the seizures were associated with significant electrolyte abnormalities, or caused by withdrawal. There was no evidence that the patient had any unstable concomitant conditions that would necessitate admission at the acute inpatient level of care.
Taking into consideration all these facts, the patient did not require admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: breast cancer, diabetes, heart failure and dementia.
Treatment: Increase Personal Care Assistance From 84 Hours Per Week To 24 Hours Per Day Per Week (monday through sunday), split Shift.
The insurer denied the Increase Personal Care Assistance From 84 Hours Per Week To 24 Hours Per Day Per Week (monday through sunday), split Shift.
The denial is overturned.

The patient is a female. Her conditions include breast cancer, diabetes, heart failure and dementia. She is under hospice care. She lives alone. Denial of increase personal care assistance (PCA) from 84 hours per week to 24 hours per day per week, split shift, is being appealed.

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with housework, managing finances and medication, and shopping; maximal assistance with meal preparation, bathing, lower body dressing, and toilet use; extensive assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and bed mobility; and limited assistance with eating. The patient has bowel and bladder incontinence. Her daughter reports that there has been a decline in her cognitive status and she is more confused and agitated at night. The daughter reports that the patient wakes up for toileting two to three times per night.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase personal care assistance (PCA) from 84 hours per week to 24 hours per day per week, split shift, is being appealed.

This patient has multiple chronic conditions. She is under hospice care. She is noted to have decline in cognitive and physical functioning. Uniform Assessment System (UAS) evaluation completed shows she requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living). She has bowel and bladder incontinence. Her daughter reports that the patient wakes up for toileting two to three times per night. This patient's needs for assistance with transfers and toileting through the night demonstrate has continuous needs. The frequency of care during night would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested increase in personal care assistance to 24 hours per day, spilt shift, is medically necessary.