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

Diagnosis: Obesity

Treatment: Wegovy (semaglutide injection)

The insurer denied coverage for Wegovy (semaglutide injection)

The denial is overturned
 

This is an adult male diagnosed with obesity and pre-diabetes. This request is for Wegovy. As per letter he has been struggling with his weight since childhood. He has unsuccessfully tried for years different regimens of treatments such as low calorie-diet, intermittent fasting, Jenny Craig program, Atkins and exercises. His body did not respond to any of these treatments; except being on Ozempic. His insurance doesn't cover Ozempic. As per visit note he is on Ozempic and he is doing well. 

His weight was 300 pounds (lbs); Body Mass Index (BMI) was 40.69 His glycated hemoglobin (A1C) was 5.8 %

Semaglutide is a Glucagon-like peptide 1 receptor (GLP1R) agonist(1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity(5-7). This medication is now available for the treatment of obesity in the form of Wegovy. The standard of care requires that the patient is participating in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension, hyperlipidemia. Note that Wegovy is FDA approved up to 2.4 milligrams (mg)/week while Ozempic is FDA approved to 1.0 mg/week in single prefilled pens. 

The patient has a BMI of 40.69 and participates in lifestyle modifications such as diet and exercise. The request meets the standard of care and is there for medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Wegovy (semaglutide injection) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurring pericarditis

Treatment: Arcalyst 220 milligram (mg) vials

The insurer denied coverage for Arcalyst 220 milligram (mg) vials

The denial is  overturned.

 
Asked to review the case of a woman with a history of recurrent pericarditis. She initially presented with pleuritic chest pain following a COVID 19 infection and was diagnosed with pericarditis.  Findings at that time revealed diffuse PR depression on the electrocardiogram (ECG).  Serum troponin was not elevated and echocardiogram demonstrated no evidence of effusion.  She was treated with ibuprofen and colchicine with initial improvement. She was seen in follow up and reported recurrent severe pleuritic chest pain and was treated with steroid therapy.  C reactive protein was 2.9 and erythrocyte sedimentation rate (ESR) was 20 at that time.  Following steroid taper, the patient remained on colchicine and non-steroidal anti-inflammatory (NSAID) medications and noted resolution of symptoms. She presented to the hospital complaining of severe 10/10 chest pain and steroid therapy was restarted with prednisone. Chest X-ray was remarkable for pericardial calcification.  The patient was hospitalized after presenting with pleuritic chest pain lightheadedness and weakness following a fourth course of steroids and colchicine therapy. On presentation vital signs were stable (Blood Pressure 106/68, Pulse 76 ).  Physical examination was unremarkable.  12 lead electrocardiogram revealed sinus rhythm with PR depression.  Echocardiogram revealed normal left ventricular function with a left ventricular ejection fraction (LVEF) of 65% (percent) and no valvular abnormalities or pericardial effusion.  Cardiac magnetic resonance imaging (MRI) was ordered and plans were made to begin treatment for recurrent pericarditis. 

This patient presented with viral pericarditis.  Following a trial of colchicine and NSAID therapy symptoms largely resolved and then recurred. Based on guidelines, this patient met criteria for a diagnosis of recurrent pericarditis (Reference 1). Current guidelines for use of Anakinra- inter leukin (IL) 1 inhibitor recommend using after relapsing pericarditis that is diagnosed following several weeks of therapy with colchicine and NSAID therapy or colchicine and steroid therapy.(Reference 1,2). Rilonacept (Arcalyst) is an interleukin 1 alpha and 1 beta cytokine trap and has been shown to be efficacious in patients with recurrent pericarditis. (Reference 3) This patient has documented evidence of recurrent highly symptomatic pericarditis despite treatment with guideline directed medical therapy. She would greatly benefit from Arcalyst therapy.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Arcalyst 220 milligram (mg) vials is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a past medical history of human immunodeficiency virus (HIV), asthma, seasonal allergies, bipolar disorder, anxiety and chronic lower back pain who presented to the emergency room with diarrhea, nausea and vomiting. He had been seen in the emergency room (ER) a few days prior and was discharged. He was hemodynamically stable and afebrile. His abdominal examination was benign. A computed tomography (CT) scan of the abdomen showed focal gastric thickening suggestive of peptic ulcer disease (PUD). He was admitted as an inpatient and was started on intravenous (IV) fluids, anti-emetics, and a proton pump inhibitor (PPI). Gastroenterology was consulted and did an esophagogastroduodenoscopy (EGD) which revealed 4 ulcers likely related to nonsteroidal anti-inflammatory drug (NSAID) use. His symptoms gradually resolved. He was started on clear liquids which were advanced as tolerated, and he was discharged home with outpatient follow up. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of Inpatient hospital stay was not medically necessary for this patient. The patient could have been managed at a lower level of care.
The medical records provided do not indicate that the patient had evidence of systemic inflammatory response syndrome (SIRS) or sepsis. He did not have cholangitis or pancreatitis. There is no indication that he was febrile and hemodynamically unstable and he did not have peritoneal signs and did not meet criteria for an inpatient status. Nausea and vomiting result from a variety of pathophysiological processes, involving gastrointestinal and non-gastrointestinal causes. The initial diagnostic evaluation involves distinguishing gastrointestinal causes of chronic nausea and vomiting (e.g., gastroparesis, cyclic vomiting syndrome) from non-gastrointestinal causes (e.g., medications, vestibular, and neurologic disorders). After excluding anatomic, mechanical and biochemical causes of chronic nausea and vomiting, gastrointestinal causes can be grouped into two broad categories based on the finding of delayed, or normal, gastric emptying. Non-gastrointestinal disorders can also cause chronic nausea and vomiting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented to the hospital complaining of a cough for two days.  The patient also complained of some chest pain, nausea, vomiting, and shortness of breath (SOB).  On arrival the patient was afebrile.  Vital signs at presentation included: Temperature 97.7 Fahrenheit (F), pulse 145, respiratory rate 24, oxygen saturation 90% on room air.  Bilateral wheezing was heard on lung exam. The patient was tachycardic.  The patient was alert and oriented x 3.  A chest x-ray (CXR) showed some perihilar infiltrates.  A venous blood gas (VBG) revealed a pH of 7.43, bicarbonate of 34, and carbon dioxide of 42. The patient's electrolytes were within normal limits.

Due to tachycardia and hypoxia, the patient underwent a computed tomography angiogram (CTA) of the chest to rule out pulmonary embolism (PE).  The CTA revealed bilateral ground glass opacities.  No pulmonary embolism was noted.  Troponins were negative.  The patient's electrocardiogram (ECG) showed sinus tachycardia with no acute changes.  The patient received intravenous (IV) fluids, steroids, and magnesium.  The patient was admitted to the hospital for treatment of possible viral pneumonia and reactive airway disease.  A urine culture and sensitivity revealed Escheria Coli (E. Coli). The patient was subsequently started on IV Rocephin and Azithromycin.  The patient improved within one day of admission and was medically cleared for discharge home on oral (PO) Augmentin and tapering steroids.

Based on a review of the medical records, it appears that this patient did not need acute inpatient hospitalization. The patient could have been placed in observation status. Observation could be for up to 48 hrs. During this time the patient could have been placed on treatment and diagnostic tests ordered as needed. This patient rapidly improved after a day in the hospital. The patient had a mild pneumonia. Their CURB-65 (Confusion, bUn, Respiratory Rate, Blood Pressure, Age > 65) score was Zero. The patient was tachycardic and had low oxygen saturations of 90% on room air (RA) but these resolved rapidly after initiating treatment and 
patient was back to baseline by the next day. The patient's mild urinary tract infection (UTI) could have been treated with PO antibiotics in the outpatient setting.  The patient was stable for observation level of care and could have been discharged home on oral medications after a period in observation with close follow-up in the outpatient setting.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Urticaria

Treatment: Xolair 150 milligrams/milliliter (mg/ml) syringe

The insurer denied coverage for Xolair 150 milligrams/milliliter (mg/ml) syringe

The denial is upheld 

The patient has been under the provider's care for treatment of chronic urticaria. A single progress note states that the patient was last seen that same month and had been started on Xolair and had received 2 doses up to the time of this visit. It is stated that the patient developed a flare of hives and was concurrently taking antihistamines and doxepin (PRN as needed) with a little help which is described as reduced hives but continued itching/burning. Imuran was discontinued in which was said to have controlled the hives by "80-89% (percent)." Prior dapsone and methotrexate treatment was said to have not controlled the patient's symptoms. It is stated that the hives recur on the 3rd week when Xolair is due.  
 
The past history is significant for Ehler-Danlos Syndrome (EDS), postural orthostatic tachycardia syndrome (POTS), and urticarial vasculitis. Also, the patient has a history of past asthma, positive aeroallergies and a positive patch test in the past. The patient had normal tryptase level and no tyrosine-protein kinase (KIT) mutations, but the urinary histamine was said to be elevated (actual lab report not supplied). The patient was treated with a burst of tapered prednisone. Xolair 300 milligrams (mg) was administered with plans to administer every 3 weeks. There is no mention of Histamine-2 Receptor Blockers (H2B) or latency-reversing agents (LRA) treatments in the progress note or appeal letter. The appeal letter states that the patient has been controlled on every 3 week Xolair but there are no progress notes supplied other than the progress note and there is no medication/pharmacy log of actual Xolair being dispensed.  

The denial correspondence includes a review by the patient's dermatologist, who stated that she was unable to determine if Xolair was requested as a continuation or new start and that it was unclear when Xolair was last administered, and that more information was needed. There is no H2B treatment listed in either the progress note, or appeal note even though this treatment was mentioned in the provider's review.   

In summary, there is inadequate documentation to determine that Xolair continuation should be approved, and further documentation is required for this consideration.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the prescription drug Xolair 150 milligrams/milliliter (mg/ml) syringe is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

This patient has a past medical history significant for hypertension, diabetes mellitus, status-post amputation of right hallux who presented to the emergency department with complaints of right foot pain. 

Vitals on presentation included: Temperature 98.8 degrees Fahrenheit (F), blood pressure (BP) 152/91, pulse (P) 95, respiratory rate (RR) 19, oxygen (O2) saturation 97% on room air (RA). Laboratory results included the following: white blood cell count (WBC) 8.8, hemoglobin (HGB) 11.1, hematocrit (HCT) 33.5, creatinine 1.41, glucose 440, c-reactive protein (CRP )<0.2, erythrocyte sedimentation rate (ESR) 24. 

The patient was started empirically on intravenous antibiotics (vancomycin and Zosyn) for right foot cellulitis. Wound cultures grew staphylococcus aureus. Magnetic resonance imaging (MRI) of the foot was negative for osteomyelitis. Infectious Diseases consulted. She remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (Augmentin) as an outpatient. 
 
According to documentation, patient presented with right foot cellulitis. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal WBC and CRP. MRI was negative for osteomyelitis. Patient had no evidence of a disseminated infection and no surgical intervention was required. Based on above findings, patient met criteria for observation level of management. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

This is an adult female patient who presented to the emergency room with worsening abdominal pain, nausea, multiple episodes of vomiting and diarrhea for 2 days. In the emergency department, the patient's alkaline phosphatase was 132, aspartate aminotransferase (AST) was 163, alanine aminotransferase (ALT) was 80, and lipase was 445. Computed tomography (CT) of the abdomen showed intrahepatic biliary ductal dilation, common bile duct (CBD) of 9.2 millimeters (mm), and common bile duct stones. The patient was treated with intravenous (IV) Zofran 4 milligrams (mg), intravenous Pepcid 20 milligrams, and intravenous fluids 1 liter (L). The patient was positive for COVID-19 (coronavirus disease). The patient underwent magnetic resonance cholangiopancreatography (MRCP) which showed common bile duct stone. Her diet was slowly advanced as tolerated. The patient was treated with Augmentin. On day #2, gastroenterology was consulted. The patient reported no abdominal pain, nausea / vomiting. The plan was for an endoscopic retrograde cholangiopancreatography (ERCP). However, it was later stated that the plan would be for an endoscopic retrograde cholangiopancreatography as an outpatient. The patient was discharged. 

The proposed treatment was not medically necessary. 

An inpatient level of stay was not medically necessary since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have respiratory distress from COVID-19, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. On day #2 the patient was comfortable without complaints.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal Bleeding/ Bleeding of Intestines. 
Treatment: Inpatient hospital admission. 

The health plan denied: Inpatient hospital admission. 
The determination is upheld. 

The patient is a male with a medical history of celiac disease and hyperlipidemia. He presented to the emergency department with two days of melena. He had recently undergone an upper endoscopy. His vital signs were unremarkable and the physical examination was notable for a soft, nontender, nondistended abdomen with normal bowel sounds present. The labs showed a low hemoglobin of 13.2 and hematocrit of 38.8 percent (%,) as well as an elevated blood urea nitrogen of 23. His chest x-ray showed no radiographic evidence of acute cardiopulmonary disease. He was treated with intravenous fluids and pantoprazole. He was made nil per os. Esophagogastroduodenoscopy (EGD) showed diffuse gastric erythema consistent with non-erosive gastritis, and the duodenal sweep showed the biopsy site with overlying clot and fresh blood present. Four hemostatic clips were placed. Following the EGD he denied nausea, vomiting, hematemesis, melena, hematochezia, diarrhea, and abdominal pain. The patient reported feeling much better and was tolerating a diet. His labs showed a low hemoglobin of 13.0 and hematocrit of 38.0%. He was discharged on pantoprazole twice daily with a plan for Primary Care and Gastroenterology follow-up.
At issue is the medical necessity of the inpatient level of care. 

The health plan's determination of medical necessity is upheld in whole.

The inpatient level of care is not supported as medically necessary. In this case, the patient presented with melena after upper endoscopy, with findings of bleeding from a duodenal biopsy site. This was appropriately and successfully treated with hemostatic clip placement on the day of presentation and no high-risk stigmata, such as bleeding ulcer, were found. Additionally, there was no sustained tachycardia, hypotension, or documented ongoing visible gastrointestinal bleeding and his hemoglobin remained stable. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-6]. All of the measures that were undertaken during the brief hospital stay, including monitoring, labs, proton pump inhibitor therapy, and endoscopy with hemostatic clip placement, could have been performed without acute inpatient level of care [2-4].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Inpatient Admission
The insurer denied Inpatient Admission.
The denial is upheld.

The patient is an adult male. He presented to the ED (emergency department) in the evening with complaint of 2 days of back pain radiating to left lower quadrant initially intermittent but on day of presentation persistent, severe, 7/10 associated with nausea no emesis or dysuria. The patient was hemodynamically stable in the ED (emergency department), afebrile, nontoxic appearing, his creatinine was elevated at 1.49, white blood cell count of 10.82, urinalysis with 6 red blood cells, 8 white blood cells, nitrite negative, small leukocyte esterase, occasional bacteria, specific gravity 1.031. CT (computed tomography) scan demonstrated moderate left hydronephrosis and 2 distal ureteral stones up to 8mm (millimeters). He received several 1000ml (milliliter) boluses of fluids and placed on maintenance IV (intravenous) fluids. He received ketorolac, morphine 8mg (milligrams) twice, Zofran and oxycodone. He received intravenous ceftriaxone. Urology consulted recommended to admit to urology for cystoscopy, stent placement, possible ureteroscopy. The patient was admitted. He was taken to the OR (operating room) and had cystoscopy, stent placement and was discharged to home later that day. He remained afebrile, hemodynamically stable throughout his admission. The inpatient admission was denied coverage by the health plan as not medically necessary, as the patient did not meet MCG (Milliman Care Guidelines) criteria for acute inpatient admission. The denial is being appealed.

The Inpatient Admission was not medically necessary.

The patient was afebrile, hemodynamically stable, with no co-morbidities requiring acute inpatient admission. His renal function was mildly elevated and anticipated to improve with stent placement. He had a normal contralateral kidney. His white blood cell count was essentially normal. His pain improved with pain medication. The service provided is an outpatient procedure and does not require prior admission or post-operative admission. The patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Cancer
Durable Medical Equipment (DME) (including Wearable Defibrillators)

Diagnosis: Glioblastoma Multiform
Treatment: Electric Tumor Treatment Filed
The insurer denied the request for Electric Tumor Treatment Field.
The health plan's determination is overturned.

The patient is a male with glioblastoma multiform. The patient has been treated by resection humor, chemotherapy including Temozolamide and Avastatin, and radiation. Continued treatment with tumor treating fields is the subject of this review. 

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of Electric tumor treatment field is medically necessary. The patient has glioblastoma multiform. This is a primary brain cancer that generally results in death within five years. There are no known cures. All engines are in that slowing the progression of the disease and delaying death.
Electric Tumor Treating Fields (TTFields) have been shown to be safe and effective to slow the progression of the disease. Approval in the United States, Europe, and elsewhere was based on results of a clinical trial that randomly assigned 237 patients with recurrent glioblastoma to TTFields or clinician's choice chemotherapy. The majority of patients were enrolled at the time of second or greater recurrence and approximately 20 percent had received prior Bevacizumab. Median progression-free and overall survival were similar in those treated with TTFields versus chemotherapy. The objective response rate was nonsignificantly higher in patients treated with TTFields compared with chemotherapy. Consensus-based guidelines published by the National Comprehensive Cancer Network (NCCN) include alternating electric field therapy as a treatment option for patients with recurrent glioblastoma based on the trial data.
Trial also favors the use of TTFields as an up-front therapy rather than for recurrent glioblastoma. After a median follow-up of 40 months in surviving patients, those assigned to the TTFields device had improved progression-free survival compared with those assigned to Temozolomide alone for initial diagnosis of glioblastoma.
The use of electric tumor treating fields is medically necessary for this patient with a serious medical condition. The service has been shown to be beneficial in both patients who are newly diagnosed with this primary brain tumor and for those with brain tumor recurrence.

The health plan's determination of medical necessity is overturned in whole.