Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Alopecia areata.
Treatment: Opzelura.
The insurer denied Opzelura.
The determination is upheld.

The patient is a male with alopecia areata (AA). The patient's beard is affected. The prescriber is a dermatologist. The medication under review is Opzelura.

The formulary drugs, Eucrisa, pimecrolimus cream, tacrolimus cream, alclometasone, betamethasone, betamethasone valerate, clobetasol, propionate, desonide, fluocinolone, fluocinonide, fluticasone, clobetasol, hydrocortisone, mometasone, triamcinolone, will not be ineffective, have not been ineffective, and would be as effective as the non-formulary drug, Opzelura cream 1.5 percent (%). The formulary drugs would not have adverse effects.
Ucak et al write "that topical pimecrolimus treatment is as effective as topical corticosteroids and is superior to topical corticosteroids in terms of side effects in the treatment of AA" (1). Topical calcineurin inhibitors can be effective in select cases of alopecia areata (2-3). Therefore, Opzelura is not indicated before a trial with topical pimecrolimus.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: pulmonary arterial hypertension (PAH).
Treatment: Tyvaso.
The insurer denied Tyvaso.
The health plan's determination is overturned. 

The patient is a male who is seeking approval for Tyvaso to treat pulmonary arterial hypertension (PAH). The patient was on Sildenafil 20 milligrams (mg) three times per day (TID) as well. On the right heart cath, the patient's pulmonary artery pressures were 73/26 with a mean of 44. Wedge pressure was 24. The patient has ILD (interstitial lung disease)/NSIP (Nonspecific interstitial pneumonia) and is on 2 liters of oxygen continuously. He is also on chronic prednisone. Cardiac history includes coronary artery disease, heart attack with stent placement, atrial fibrillation on Eliquis, and AVNRT (Atrioventricular nodal reentrant tachycardia) with ablation and hypertension.

Tyvaso is medically necessary for the patient according to current literature and standard of care. The patient has PAH, ILD (interstitial lung disease)/NSIP (Nonspecific interstitial pneumonia) and is on 2 liters of oxygen continuously. The patient was intolerant to sildenafil due to headaches and a congestive heart failure (CHF) exacerbation. Therefore, Tyvaso is a reasonable next option to treat pulmonary arterial hypertension.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, coronary artery disease, depression, stroke, Grover's disease, pulmonary embolism, and dementia
Treatment: Increase in Personal Care Services (PCS) to 24 hours/day (split shift), 7 days/week, a total of 168 hours/week
The insurer denied an increase in PCS to 24 hours/day (split shift), 7 days/week, a total of 168 hours/week.
The denial is overturned.

The patient is an elderly male. His medical conditions include osteoarthritis, coronary artery disease, depression, stroke, Grover's disease, pulmonary embolism, and dementia. Denial of an increase in personal care services (PCS) to 24 hours/day (split shift), 7 days/week, a total of 168 hours/week is being appealed. The health plan approved an increase to 84 hours/week. The health plan recommended splitting approved hours into two shifts. A letter from the patient's provider reports the patient needs extensive or maximal assistance with ADLs (activities of daily living) due to his medical conditions. He has been bedbound for 2 years after a femur fracture. He has a history of bed sores. He needs repositioning every two hours. The provider notes the patient is unable to walk or stand, has incontinence, recurrent pressure sores, and needs 24/7 assistance for ADLs and unscheduled tasks. He lives alone and does not have informal support.

The requested increase in PCS to 24 hours/day (split shift), 7 days/week, a total of 168 hours/week is medically necessary. 

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs, including toileting, walking, transfers, turning/positioning, or feeding. Continuous or split shift PCS 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 an increase in PCS to 24 hours/day (split shift), 7 days/week, a total of 168 hours/week is being appealed. The health plan approved an increase to 84 hours/week. The health plan recommended splitting approved hours into two shifts. This patient has multiple chronic conditions. He is reported to be bedbound. The provider has provided a statement indicating that the patient requires 24/7 assistance with ADLs and unscheduled tasks due to his inability to walk or stand, incontinence, and recurrent pressure sores. The provider reports the patient needs repositioning every two hours. The appeal statements support the patient has continuous needs with turning/repositioning. This continuous need cannot be met with splitting 12-hour shift and will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested increase in PCS to 24 hours/day (split shift), 7 days/week, a total of 168 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stones
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with a history of kidney stones. She presented with left flank pain radiating to the lower abdomen associated with nausea and vomiting. Initially, she was noted to be in severe pain with left lower quadrant and left costovertebral angle (CVA) tenderness. Initial vital sings demonstrated tachycardia to 107, temperature 98.9, and blood pressure 102/81. She received multiple pain medications including morphine 4 milligrams (mg), Toradol 30 milligrams, and Dilaudid 1 milligram. She received intravenous fluids. A computed tomography (CT) scan demonstrated a left ureterovesical junction stone 2 millimeters with mild left hydronephrosis. The patient's white blood cell count was 17, creatinine 0.86, and urinalysis was cloudy. She had positive red blood cells and white blood cells and negative nitrite and leukocyte esterase, and 13 squamous cells. The patient denied fever, chills, and dysuria. Due to the elevated white blood cell count, severe pain, and nausea/vomiting, the patient was admitted for intravenous hydration, pain control, antibiotics, and nothing to eat after midnight for possible stent placement the next day. Overnight the patient's pain improved, tachycardia resolved, there were no fevers, and repeat white blood cell count decreased to 8.8. Urology felt conservative management was best and the patient was discharged to home on antibiotics and Flomax. Urine culture showed no growth. Service was denied as not medically necessary for acute inpatient admission: did not meet Milliman Care Guidelines MCG) criteria for renal colic and kidney stone.

The requested health service was not medically necessary.

This patient presented with severe pain, tachycardia, and an elevated white blood cell count. She required multiple pain medications and hydration, which provided relief of her pain and her tachycardia. She was not noted to be hemodynamically unstable. Her urinalysis was nitrite negative and leukocyte esterase negative with 13 squamous cells. She was nonfebrile. Her computed tomography (CT) scan demonstrated a small (2 millimeter) stone with mild hydronephrosis; she had normal serum creatinine at 0.86. Her other kidney was not reported to be abnormal, and renal function was normal. She did not have a prior renal transplant. She did not fail supportive observational care. The patient could have been managed at a lower level of care and did not meet criteria for acute inpatient care. There are no reported other medical conditions that warranted acute inpatient care. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This adult male patient with a submitted diagnosis of chest pain was hospitalized. His past medical history is pertinent for known peptic ulcer disease due to non-steroidal anti-inflammatory drug (NSAID) overuse, hemorrhoids, and recent assault. He presented to the emergency department for evaluation of body spasms. The patient's vitals were stable: oxygen saturation was 100% on room air, blood pressure was 122/78, pulse was 65, and respiratory rate was 16. Chest wall tenderness was reproducible on exam. Electrocardiogram (EKG) was remarkable for sinus bradycardia, rate 46, T-wave inversion in V1-4 and biphasic T-waves in V2 and V5. Troponin returned elevated at 23.8 followed by a fall to 19. Chest computed tomography (CT) was negative for aortic dissection and pericardial effusion. The clinical impression was musculoskeletal chest pain/costochondritis, possible gastroesophageal reflux disease (GERD), and possible psychogenic component. Cardiology agreed it was noncardiac chest pain as well and recommended obtaining a prior electrocardiogram for comparison, an outpatient thallium scan to assess for possible myocardial contusion, and that he could be discharged to home. The requested coverage for inpatient hospital admission was denied and the patient is appealing the decision.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, criteria for inpatient admission were not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization, or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received for musculoskeletal chest pain, like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular.
Inpatient Hospital.

Diagnosis: Lewy Body Dementia.
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay. 
The determination is overturned.

The patient is a male with Lewy body dementia whose son brought him in for increased violence and aggression. He saw neurology as an outpatient and was recommended to go to the emergency room (ER). The patient is nonsensical which is his baseline per his son. The patient then had agitation requiring Zyprexa and Haldol. Neurology was consulted and recommended as needed medications and infectious and metabolic work-up. The patient was admitted to medicine for safe discharge planning. A computed tomography (CT) scan of the head did not show any intracranial abnormality. A urinalysis was suggestive of an infection and the patient was started on ceftriaxone. A Foley catheter was placed. A urine culture grew Escherichia (E) faecalis and the patient was switched to Zosyn. He failed his voiding trials and had to have a cystoscopy placed Foley catheter. The patient's Depakote was increased. He had difficulty managing agitation, intermittently requiring restraints and a sitter. The patient was not able to safely go home after discussions with the patient's family and with the Foley catheter and behavioral issues, there was great difficulty with placement. The patient was discharged. At issue is the medical necessity of an inpatient stay.
The patient presented with altered mental status with known dementia. He had known behavioral disturbances, which are common in dementia with an acute worsening (Ambrogio et al 2019). He was medically complex with his dementia and required 1:1 care in addition to chemical medical management making him medically complex. Most patients who present to the emergency room (ER) with altered mental status require hospitalization (Kakuma et al 2003). Confirming the need for an inpatient stay, this patient was immediately found to have a urinary tract infection by urinalysis. He qualified a complicated urinary tract infection as he is male and has significant comorbidities (i.e. dementia) and advanced age (Sabih et al 2022). Given the comorbidities, and medical complexity of management of a patient with Lewy body dementia, the patient would be expected to stay greater than (>) 2 midnights and require a complex level of management aligning with the inpatient level of care by the Centers for Medicare and Medicaid Services (CMS) guidelines (Hospital Inpatient Admission Order and Certification).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood in Urine
Treatment: Inpatient Hospital Stay

The insurer denied an inpatient hospital stay. The determination is upheld.

The patient is a male who presented after a fall from his bike. He had blood at the meatus. The patient was afebrile and hemodynamically stable on presentation. The review of systems revealed perineal pain. Lab results were grossly normal. The patient's physical exam revealed the following abnormalities: blood at the meatus and tenderness in the perineum. A computed tomography (CT) scan showed a possible urethral diverticula. The patient had an uneventful hospital course and was discharged the next day. At issue is the medical necessity of an inpatient stay.

No. An inpatient stay was not medically necessary. A majority of patients who present with urethral trauma/injury can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis, or unstable medical problems requiring inpatient management. The hospital course was essentially normal, without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status do not suggest the need for acute inpatient care. A lower level of care for this patient's clinical presentation and hospital course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gastric Adenocarcinoma.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

Abdominal pain is a common complaint amongst those presenting to the emergency department [1]. Older age has been shown to be the most important demographic predictor of admission from the emergency department [2]. After an appropriate emergency department (ED) evaluation and/or resolution of symptoms, most patients with a diagnosis of nonspecific abdominal pain can be discharged without further intervention or with plans for outpatient follow-up [3].

Per clinical documentation, the patient presented with abdominal pain, nausea, and vomiting. Past medical history was significant for a Billroth II gastrojejunostomy for gastric adenocarcinoma. The patient had a recent recurrence of gastric adenocarcinoma. Vital signs were within normal limits. Laboratory values were also normal. A computed tomography (CT) scan did not demonstrate any acute findings. The patient was scheduled for a partial gastrectomy, and was admitted to the hospital for medical optimization. Per Milliman Care Guidelines (MCG) criteria, admission for acute abdominal pain is indicated for hemodynamic instability, severe pain, peritoneal signs, inability to maintain oral hydration, bacteremia, suspected toxic megacolon, or a procedure that cannot be performed on an ambulatory basis [4]. This patient did not have any of the mentioned criteria for admission. Symptoms resolved with intravenous (IV) fluids, famotidine, and Zofran given in the emergency department. Hospitalization was not necessary for medical optimization. Therefore, the requested inpatient stay was not medically necessary. 

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: Chest Pain.
Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission. The denial is upheld. 

This is the case of a patient with a history of hypertension, chronic obstructive pulmonary disease (COPD), and active cocaine use who presented to the hospital complaining of left-sided chest pain and cough. Upon arrival at the emergency department, vital signs were stable (blood pressure [BP] 115/70, pulse 90). Physical examination revealed no significant abnormalities. 12 lead electrocardiogram (ECG) showed normal sinus rhythm without ST- or T-wave abnormalities. Serum blood testing revealed no elevation of high sensitivity troponin level. Urine toxicology testing was positive for cocaine. The patient was admitted to the hospital for further testing and observation. Cardiac catheterization performed six months earlier demonstrated nonobstructive coronary artery disease in the right and left anterior descending coronary arteries. An echocardiogram performed several months before admission demonstrated a left ventricular ejection fraction of 52 percent (%) with severe mitral regurgitation. The patient eloped after being admitted to the hospital. 

The health plan acted reasonably, with sound medical judgment, and in the patient's best interest. This patient presented with chest pain in the setting of active cocaine use. The patient's pretest probability of coronary artery disease is low (1). Utilizing the (History, ECG, Age, Risk Factors, Troponin (HEART) score the patient was considered low risk (2). Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1) (3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Investigators studying more than 300,000 hospital admissions for chest pain in the setting of cocaine use found that patients presenting with chest pain following cocaine use and no other significant risk factors had a low risk of major adverse cardiac events and mortality. They concluded that most patients did not require hospital admission (4).
In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.

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

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

Diagnosis: substance abuse.
Treatment: Inpatient Substance Use Rehabilitation .
The insurer denied Inpatient Substance Use Rehabilitation. 
The health plan's determination is upheld. 

The case involves an adult male who was admitted to inpatient rehabilitation for treatment of stimulant (cocaine), alcohol, cannabis, and nicotine (tobacco) use disorders. The patient was using up to $120 worth of crack cocaine daily together with up to 3 pints of liquor and $25 worth of marijuana. The patient was also tobacco dependent with use of one-half to one-fourth pack per day. He had a longstanding substance use disorder with limited past substance use disorder treatment episodes with the last occurring in the month prior to presentation with detoxification treatment and an against medical advice (AMA) discharge from rehabilitation treatment with relapse.

Inpatient Substance Use Rehabilitation was not medically necessary for this patient.
The inpatient substance use disorder rehabilitation services in this case scenario were amenable to treatment at a lower level of care. The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with clinically appropriate structure, monitoring, and sober supports. The patient did not need the structure of an inpatient setting 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 for the dates in question.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces, monthly visits, and retainer
The insurer denied braces, monthly visits, and retainer.
The determination is overturned.
 
The patient is a female who presented with a skeletal Class I malocclusion. She has minor crowding in the maxilla and mandible. She has an anterior crossbite of tooth 7 and an anterior open bite affecting teeth 8-10. She is treatment planned for 30-36 months of orthodontic treatment including extraction of four first premolars to address the anterior crossbite and open bite. At issue is the medical necessity of braces, monthly visits, and retainer.
Anterior open bite patients are among the most difficult patients to treat. (1) One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2) Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. (3)
Orthodontic treatment is medically necessary for this patient due to the side effect described above and the fact that this is not something that will self-correct without orthodontic intervention.