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

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


The patient has a medical history of gastroesophageal reflux disease (GERD), hiatal hernia, asthma, and hypertension. She presented to the emergency department with left-sided abdominal pain and nausea for two weeks, worse over the prior 3 days. The vital signs were unremarkable. The physical examination was notable for left upper quadrant tenderness with guarding. Lab results showed an elevated white blood cell count of 14.1 thousand per microliter (K/uL) and elevated alkaline phosphatase of 138 units per liter (U/L). A computed tomography scan of the abdomen and pelvis showed acute diverticulitis of the sigmoid and descending colon, without free air, abscess, or sinus tract. She was treated with intravenous Zosyn, metronidazole, and ceftriaxone. She was made nil per os (NPO). She had abdominal pain, but resolution of nausea and vomiting. Lab results showed an elevated white blood cell count of 12.7 K/uL, low hemoglobin of 11.5 grams per deciliter (g/dL) and hematocrit of 36.3%, and normalized alkaline phosphatase. She was feeling much better, but having some left-sided abdominal pain; she was started on a clear liquid diet, advanced as tolerated. Lab results showed a normalized white blood cell count and alkaline phosphatase. She was discharged on ciprofloxacin and metronidazole, with a plan for Primary Care and Gastroenterology follow-up. At issue is the medical necessity for the inpatient level of care.

No, the inpatient level of care was not medically necessary. In patients with uncomplicated diverticulitis (without complications such as an abscess or perforation), a lower level of care than inpatient is the standard of care [1,2]. A lower level of care than inpatient is appropriate even when there is leukocytosis and significant symptoms"
[3-5]. In this case, the patient had rapid resolution of leukocytosis and gradual improvement in symptoms; there was no protracted fever or hypotension to suggest that intravenous antibiotics in the hospital were ineffective, her symptoms gradually improved [1-8]. For these reasons, the inpatient level of care is not supported, and the care provided could have been provided at a lower level of care for the duration of the stay.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cardiomyopathy.
Treatment: Coreg CR (controlled release).
The insurer denied Coreg CR. The health plan's determination is upheld.

The patient is a woman with a history of peripartum cardiomyopathy, left ventricular noncompaction, ventricular ectopy and left bundle branch block.  Per the appeal letter authored by a physician assistant, the patient has been taking Coreg CR (controlled release) for 15 years; and treatment with this medication resulted in improvement in her systolic function and switch to a generic equivalent resulted in decompensation. No further details were provided.

A formulary exception is not indicated in this case.
There are three beta-adrenergic blockers that have been shown to decrease mortality in patients with heart failure with reduced ejection fraction (HFrEF). These include metoprolol succinate, carvedilol (both immediate and controlled release) and bisoprolol. There are no high-quality data demonstrating the superiority of one of these agents over the others and current guidelines for the management of HFrEF endorse the use of any one of them.
The formulary includes metoprolol succinate, bisoprolol and carvedilol (immediate release). The appeal letter indicates that the patient experienced clinical deterioration with generic extended-release carvedilol; however, there is no documentation of a trial of metoprolol succinate, bisoprolol or carvedilol (immediate release). Based on the medical literature, any of these agents would be expected to be just as effective as Coreg CR in this situation and would not be expected to have more adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Stelara SQ 90mg. 
The denial is overturned. 

The patient is a male with Crohn's disease complicated by ileal stricture and small bowel obstruction. He has failed Humira. He started Stelara. He had improvement on Stelara 90 milligrams (mg) every 4 weeks. If he misses Stelara doses, he has recurrent symptoms 5 weeks after injections.
At issue is the medical necessity of Stelara subcutaneous (SQ) 90mg.

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

The requested health service/treatment of Stelara SQ 90mg is medically necessary for this patient.
The request to continue Stelara 90mg every 4 weeks is supported as medically necessary. Stelara is United States Food and Drug Administration (FDA) approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease. [1-3] Guidelines for the treatment of Crohn's disease recommend the use of Stelara. [4] A study showed dosing intensification (90mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response. [5-7] One study showed that dose escalation was required and approximately half of patients, and successful in 61.1% of dose escalation attempts. [5] Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted. [7] Additionally, the American College of Gastroenterology guidelines for the treatment of Crohn's disease states that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy." [4]
In this case, the patient failed Stelara every 8 weeks, with symptoms of active disease, and then had improvement on Stelara 90mg every 4 weeks. Decrease of dosing to 90mg every 8 weeks, or discontinuation of Stelara (even if an alternative therapy is attempted immediately), may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications of Crohn's disease. For all of these reasons, the request to continue Stelara 90mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.
Therefore, the requested health service/treatment of Stelara SQ 90mg is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

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

This female reportedly was admitted to this inpatient hospital in the ICU (intensive care unit) after an intentional overdose. She reportedly was then transferred to telemetry and then was discharged to be transferred to the psychiatric unit for psychiatric hospital treatment due to continued depressive symptoms, hopelessness, helplessness, anxiety, and multiple stressors with impulsivity. She reportedly had altered mental status including lethargy and drowsiness with minimal interaction and had acute toxic encephalopathy as well as tachycardia with a heart rate up to 132. She reportedly had diagnoses of bipolar disorder and Opioid Use Disorder. 

The medical records provided enough specific evidence to support that she required 24-hour hospital treatment as she was considered a danger to herself due to a serious suicide attempt as well as altered mental status including lethargy and drowsiness with minimal interaction. She also had acute toxic encephalopathy as well as tachycardia with a heart rate up to 132. The APA (American Psychological Association) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk of suicide. Suicide attempts are the single most reliable predictor of suicide. This patient was considered a high-risk patient who made an intentional serious suicide attempt by overdose of 30-40 800 mg (milligrams) Gabapentin and also took extra Wellbutrin and Clonidine with suicidal intent, depressed mood, hopelessness, and helplessness. The psychiatric consultant saw the patient and she was not deemed ready for discharge. Also, the MCG (Milliman Care Guidelines) Drug Ingestion or Overdose criteria reports that one meets criteria if one of the following are met: hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, hypertension requiring inpatient treatment, specific findings indicating severe and prolonged drug toxicity, or inpatient admission is required other than observation care. In this case this patient had a very serious suicide attempt with suicidal intent and continued depressed mood and hopelessness, and she was considered a danger to self and in need of further hospital treatment for her safety, and also was considered not safe for treatment at a less restrictive setting. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a history of asthma, schizoaffective disorder, multiple intubations and status post tracheostomy for subglottic stenosis.
The patient presented to the emergency department (ED) with complaints of dyspnea, wheezing, chest tightness, and increased cough X 2 days. The patient reported running out of medication 5 days prior.

The patient was in mild respiratory distress. Oxygen (O2) saturations 88% on room air (RA). The patient was placed on 3 liters nasal cannula (NC). Tracheostomy noted. A lung exam was performed, and bilateral (B/L) diffuse wheezing was noted. The cardiac exam was within normal (WNL). The patient was alert and oriented x 3 (person, place, time). Non-focal neuro exam. The patient was given a nebulized bronchodilator (BD), Intravenous (IV) Magnesium and IV Steroids 40 mg (milligrams) twice daily (BID).

Initial laboratory work showed a white blood count (WBC) of 11.6, electrolytes within normal limits (WNL). An electrocardiogram (EKG) showed there were no acute ischemic changes. A chest x-ray showed no acute infiltrates. 

The patient was admitted to the hospital with a diagnosis of acute exacerbation of asthma. The patient was continued on IV Steroids 40 mg bid, Duo Nebs and Singulair. ENT (ears nose and throat) was contacted for a change of the tracheostomy which was done uneventfully. The patient remained stable after admission and was discharged home on oral steroids, bronchodilators (BD), and other maintenance medications.

This patient did not need acute inpatient hospitalization. His asthma exacerbation was likely from non-compliance with medications. The patient was afebrile and hemodynamically (HD) stable. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. The observation period could be for up to 48 hours. The patient did not have pneumonia, a pleural effusion or pneumothorax on a chest x-ray. The patient was tolerating oral intake and was not described to be in any acute distress. The patient could have been switched to oral steroids and continued taking a nebulizer and other maintenance medications. He could have discharged home the next day with close follow up in the outpatient setting. The patient remained afebrile and hemodynamically stable and was tolerating oral intake. If needed the patient could have been discharged on a few liters of oxygen (O2) temporarily.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: moderate crowding and protrusive maxillary incisors
Treatment: braces/monthly visits
The insurer denied braces/monthly visits. 
The health plan's determination is overturned. 

The patient in question is a male. He has a Class II malocclusion with moderate crowding and protrusive maxillary incisors. He has approximately 10 millimeter (mm) overjet and 5 mm overbite. He is treatment planned for 24-30 months of orthodontics to correct the crowding and protrusion.

Braces and Monthly Visits are medically necessary for this patient.
There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+ (plus) mm overjet, which this patient has. For these reasons, orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Lidocaine 5% external patch. 
The denial is upheld.

This is a female diagnosed with spondylolisthesis lumbar region. Letter of denial notes that the appeal for lidocaine patch for spondylolisthesis of the lumbar region has been determined as not medically necessary as current plan approved criteria only allows coverage of lidocaine 5% patch for a diagnosis of pain associated with postherpetic neuralgia, pain associated with diabetic neuropathy, or pain associated with cancer related neuropathy. It was noted that this is a final adverse determination for this request.
Letter of appeal from the patient is appealing the denial for coverage of lidocaine 5% external patch. The patient reports she underwent gastric bypass surgery in December 2008. One restriction of the surgery that is affecting her ability to control her back pain is the inability to take non-steroidal anti-inflammatory drugs (NSAIDs). Therefore, after having multiple spinal injections done to lessen the pain, her provider suggested the use of lidocaine patch. She reports she would prefer to avoid surgical intervention or ingesting opioid-type medications and feels that this would be a viable option.
The patient was seen for follow-up visit with complaints of chronic back pain that goes into the lateral hips, rated at 10/10 at worst, 3/10 at best and currently 5/10. Past medical history was significant for cancer and arthritis. Conservative care history states that symptoms improved with injection. Examination showed full flexion, extension causes pain in the sacroiliac sulcus. There was tenderness to palpation, positive Flexion, Abduction and External Rotation (FABER) for pain in the bilateral sacroiliac. Pelvic compression test is positive for pain. There is mild tenderness to palpation at the trochanteric on the right. Positive Patrick's test for pain at the right lateral hip. The patient was recommended for cyclobenzaprine. According to a procedure report, the patient underwent a lumbar epidural steroid injection.
The subject under review is the medical necessity for a Lidocaine 5% external patch.

The health plan's determination is upheld.

The requested lidocaine 5% external patch is not medically necessary for this patient. The patient is noted to have complaints of chronic back pain that goes into the hips. The requested medication of lidocaine topical patch 5% can only be approved for the treatment of pain associated with postherpetic neuralgia, pain associated with diabetic neuralgia or pain associated with cancer related neuropathy. There is no high-grade evidence to support use of topical lidocaine patch for the treatment of chronic axial back pain. While it is noted that the patient reports on appeal that she has a history of gastric bypass and cannot use oral NSAIDs, there are multiple other medication classes that can be utilized to help manage pain. The requested lidocaine patch 5% is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: PET scan
The insurer denied the PET scan.
The determination is upheld.

This is a patient with a history of primary tumor (pT) 3 node (N) 0 Gleason 7 adenocarcinoma of his prostate gland status/post (s/p) prostatectomy with a positive margin. His prostate-specific antigen (PSA) has risen to 0.1 nanograms per milliliter (ng/mL). Request is for approval of prostate-specific membrane antigen (PSMA) (pylarify) positron emission tomography/computed tomography (PET/CT) for restaging.

The requested PET scan is not medically necessary for this patient. The patient has not experienced biochemical recurrence (defined as at least 0.2 ng/mL). The reliability of the requested PSMA PET/CT has not been established in the medical literature for a patient with such a low PSA. The Osprey and CONDOR studies which were referenced by the treating provider did not include patients with such a low PSA. The PSMA PET/CT is not supported by the medical literature nor expert consensus national guidelines in the member's setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis and osteoarthritis
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services 7 days a week, 12 hours per days; 12 hours per day, 7 days a week (split shift) For A Total of 168 Hours per Week
The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) Services 7 days a week, 12 hours per days; 12 hours per day, 7 days a week (split shift) For A Total of 168 Hours per Week
The denial is overturned.

The patient is a female. She reportedly needs extended home care services and extended hours of help and supervision. The patient has osteoporosis and osteoarthritis. She has limited mobility and ROM (range of motion). The patient has no involvement in ordinary housework and meal preparation. The patient has pain, and she is unable to ambulate. She cannot perform ADLs (activities of daily living).

Yes, the requested health service is medically necessary.
Patient was receiving 8 hours per day - 7 days a week for a total of 56 hours per week. The approved hours are not enough, as the patient is completely dependent for her ADLs (activities of daily living).

The patient has osteoporosis and osteoarthritis and has limited mobility and ROM (range of motion). The patient has no involvement in ordinary housework and meal preparation. She is completely dependent for all her meals. The patient has pain and is unable to ambulate. She cannot perform ADLs (activities of daily living).

The patient now requires maximum assistance with ambulating, bathing and personal hygiene and needs extended hours of 7 days a week, 12 hours per days; 12 hours per day, 7 days a week (split shift) For A Total of 168 Hours per Week.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Extended home services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Degenerative disc disease.
Treatment: spinal fusion.
The insurer denied coverage for spinal fusion.
The denial is overturned.

The patient complains of mostly low back pain for two years that has failed physical therapy, chiropractic treatment, medications of non-steroidal anti-inflammatory drugs (NSAID) and muscle relaxants, epidural steroid injections and facet injections. Her lumbar magnetic resonance imaging (MRI) and x-rays show degenerative disc disease at L(lumbar)4-5 and L5-S(sacral)1. She underwent a lumbar discogram at L5-S1 that was positive for condordant pain and showed annular fissures. She is significantly limited in her activities of daily living due to pain.

There are generally accepted practice guidelines by both national policies and professional medical societies that allows lumbar fusion for degenerative disc disease in patients meeting strict criteria. This patient appears to meet those criteria and due to not having any benefit after extensive conservative treatment, this surgery is in the best interest for the patient.

Lumbar fusion for degenerative disc disease is an accepted practice for certain patients meeting criteria. According to the medical records, the patient has significant low back pain that interferes with her activities despite all conservative management that has been completed. She is not a smoker and has no mental health issues that would be contraindicated. Her discogram reproduces her back pain and indicates her pain generator. Therefore, the requested anterior and posterior lumbar interbody fusion is medically necessary according to generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations.

American Association of Neurological Surgeons (AANS) give a recommendation of Grade B for lumbar fusion for intractable low back pain without stenosis or spondylolisthesis. Lumbar fusion or a comprehensive rehabilitation program incorporating cognitive therapy are recommended as treatment alternatives for patients with chronic low back pain that is refractory to traditional conservative 2-level degenerative disc disease without stenosis or spondylolisthesis (multiple Level II studies). It is recommended that lumbar fusion be performed for patients whose low-back pain is refractory to conservative treatment (physical therapy or other nonoperative measures) and is due to 1- or 2-level degenerative disc disease without stenosis or spondylolisthesis (multiple Level II studies). (1)

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for spinal fusion is overturned. Medical Necessity is substantiated.