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

Diagnosis: Saddle embolus of pulmonary artery without acute cor pulmonale.
Treatment: Eliquis.

The health plan denied Eliquis.  The health plan's determination is overturned.

The patient is a male with a history of hypertension and ulcerative colitis who was admitted to the hospital with shortness of breath after being diagnosed with a pulmonary embolism. He was started on direct oral anticoagulants (DOAC), apixaban (Eliquis) for treatment of his pulmonary embolism. He followed with his primary care physician who prescribed the same medication given to him from the hospital discharge, as he was advised to stay on it. 

At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug (Eliquis), or would have adverse effects.

I overturn, in whole, the health plan's determination.

The formulary drug of Xarelto will be equally effective but has a slightly higher risk of adverse effects as compared to Apixaban, per the current published literature. The formulary drug of Warfarin is less effective and has a higher risk of adverse events as compared to Apixaban (Eliquis) based on current published literature. [1-3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CHF (congestive heart failure)
Treatment: Inpatient admission 
The insurer denied: Inpatient admission 
The denial is upheld

The patient is an adult female. She was hospitalized for CHF (congestive heart failure). She presented to the ED (emergency department) for evaluation of cough and SOB (shortness of breath). Her PMH (past medical history) is pertinent for known CHF (congestive heart failure) with LVEF (left ventricle ejection fraction) of 20% and tobacco abuse.

The patient's vital signs revealed O2 (oxygen) saturation of 97% on RA (room air). EKG (electrocardiogram) showed AFib (atrial fibrillation). Chest x-ray reported vascular congestion. BNP (brain natriuretic peptide) was 753. Troponin panel was negative. Treatment included IV (intravenous) Lasix 80 mg (milligrams) x 1 dose and she was discharged on Lasix 20 mg (milligrams) PO (by mouth) daily.

This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient approved at the Observation level of care.

The inpatient admission was not medically necessary.
Based on the peer-reviewed medical literature, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism, aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management.

In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care she received for uncomplicated, mildly decompensated chronic LV (left ventricle) systolic HF (heart failure) is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted records and the current CHF (congestive health failure) guidelines, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Inpatient stay 
The insurer denied coverage for the inpatient stay.
The denial is overturned.

The patient was seen by her doctor for follow up for seizures. She noted that the patient had 3 breakthrough seizures since the last visit which were associated with loss of awareness and head jerking. She noted that the patient was on Keppra and Vimpat. On a prior visit she noted that the patient's seizure frequency was 2-3 a month. The patient had a video EEG (electroencephalogram) which did not capture episodes except for a mild episode of eye flicker and a dizzy feeling which did not have an EEG correlation. The background EEG did not show any definitive epileptiform discharges and the possibility of psychogenic non-epileptic seizure was raised. 

The plan was to admit the patient to the epilepsy monitoring unit (EMU) for video-EEG for characterization of her spells and to lower the Keppra. There was a progress note during EMU admission. It was noted that the targeted spells were the ones associated with spaciness, head jerking, or loss of awareness. It was noted that the plan was to reduce the dose of Keppra more. It was noted that no seizures or clinical events were recorded and that the overnight EEG was normal. 

The patient was seen by a doctor who noted that the patient had events of feeling spacey. She noted that the patient had no events overnight. She noted that the patient had no seizures or clinical events recorded overnight, that the plan was to discharge the patient and to restart Keppra and Vimpat. There was a discharge summary which noted the discharge summary of focal seizure. It was noted that the patient was admitted and had video EEG monitoring and no events or seizures were captured during the admission.

The EMU admission was medically necessary as there was some suspicion about psychogenic seizures.

"The indications for admission to the EMU include differential diagnosis of paroxysmal spells, characterization of seizure types, presurgical epilepsy evaluations, seizure quantification, monitoring medication adjustment in a safe setting, and differentiation between seizures and side effects. We conclude that the appropriate use of this specialized testing can lead to an early and correct diagnosis in a variety of clinical circumstances. The EMU evaluation is considered the gold standard test for the definitive diagnosis of epilepsy and seizure-like spells." (Shih, J. J. et al. 2018).
"An electroencephalogram (EEG) is an essential tool that studies the brain's electrical activity. Despite the development of more advanced imaging techniques, an EEG remains an essential paraclinical tool for seizure evaluation." (Rayi, A. et al. 2022).                                                         

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 inpatient stay is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy 0.5mg (milligrams)
The insurer denied coverage for the Wegovy 0.5mg.
The denial is overturned.

The patient required weight management for obesity. She started an exercise and restricted calorie program and has been in a weight management program with behavior modifications. Her starting BMI (body mass index) was 30.5. After being treated with Wegovy her BMI dropped to 24. 

UpToDate has an article titled "Obesity in Adults: Drug Therapy." The article states that a number of medications are approved by the FDA (Food and Drug Administration) for the treatment of obesity in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those with a BMI over 30 or a BMI over 27 with related comorbidities. Semaglutide is a GLP-1 (glucagon-like peptide 1) agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction, as well as improvement in glycemia and lipids. It has also demonstrated cardiovascular benefits. 

This patient met criteria for starting Wegovy. She had a BMI over 30 and she has been involved in a behavior modification program. Wegovy is approved by the FDA for the long-term treatment of obesity. It can be used for as long as it remains beneficial for the patient in maintaining weight loss and is not causing intolerable side effects. 

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 0.5 milligrams (mg) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: abdominal pain

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

The patient presented with abdominal pain for 1 week. She was afebrile and with stable vital signs. She had abdominal guarding but no peritoneal signs. A computed tomography scan (CT) scan was read as a distended gallbladder with pericholecystic fat stranding consistent with acute cholecystitis. The patient's white blood cell count (WBC) count was 19.2. intravenous (IV) antibiotics were given. The leukocytosis improved. She was referred to the clinic for an elective cholecystectomy. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (MCG (Milliman Care Guidelines) M-555) include having acute cholecystitis with systemic signs of inflammation. The patient requires having upper abdominal pain, systemic signs of inflammation, and a planned interval cholecystectomy. 

This patient had upper abdominal pain with guarding and leukocytosis. A WBC count over 10,000 is an indicator of a systemic sign of inflammation. In addition, a cholecystectomy was not done during the admission, but an interval cholecystectomy was planned. The patient met MCG criteria for an inpatient admission under Gallbladder or Bile Duct Inflammation or Stone.

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 the inpatient admission services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal - Chronic Idiopathic Constipation.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Linzess.
The denial is upheld. 

This patient is a female with a history of chronic idiopathic constipation. She has tried and failed numerous therapies. She has been recommended for Linzess (linaclotide).
At issue is the medical necessity of Linzess 145 microgram (MCG) oral (OR) capsules (CAPS).

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

The requested health service/treatment of Linzess 145MCG OR CAPS is not medically necessary for this patient.
Linzess is United States Food and Drug Administration (FDA) approved for the treatment of irritable bowel syndrome with constipation (IBS-C) and for chronic constipation in adults. The safety and efficacy of Linzess in pediatric patients has not been established. Per Di Lorenzo, Carlo, et al, in children with constipation, no clear improvement over placebo was observed for Linzess.
According to Baaleman, Desiree F., et al: "Nearly half of children with IBS-C benefited from linaclotide, but adverse events were relatively common. Further prospective, controlled studies are needed to confirm these findings and to identify which patients are most likely to benefit from linaclotide." Linzess is currently undergoing a clinical trial to assess its safety and efficacy in pediatric patients and to identify the proper dosing. (3) No conclusion can be made from this study as the results are not published yet. There are no other supportive studies for using Linzess in children. Given the lack of adequate scientific support for using this medicine in children, medical necessity cannot be established.
Therefore, the requested health service/treatment of Linzess 145MCG OR CAPS is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypotension

Treatment personal care assistance (PCA) services, level II, 12 hours per day, 7 days per week, total 84 hours per week,

The insurer denied coverage for personal care assistance (PCA) services, level II, 12 hours per day, 7 days per week, total 84 hours per week,

The denial is upheld

This is a patient who has cognitive deficits. The family is requesting personal assistance in the home, as he is needing medication management. He is at risk for hypotension and falls without proper medication administration. Medications include Meloxicam. Multiple antipsychotic medications were recently discontinued.

For months, your health care service is approved for: Personal Care Assistance services, Level II, 6 hours per day 7 days per week, total of 42 hours per week."

Personal care worker logs indicate the patient does require assist, for self-care tasks such as dressing, and grooming; as well as for transfers. He is noted to need assistance for bathing, upper and lower dressing. No issues with bed mobility.

The UAS (Uniform Assessment System) - ATSP (Aide Task Service Plan) summary shows an MMSE (Mini-Mental State Examination) score of 18/30. Notes patient is minimally impaired, uses assistive device for walking. The patient is continent of bladder and bowel and management noted as self.  Personal care assistance (PCA) services, level II, 12 hours per day, seven days per week, for a total of 84 hours per week, is not considered medically necessary for this patient. The assigned hours 6/day can be adjusted to best meet the needs of the patient.

Based on the medical data reviewed, there is a lack of significant objective deficit, sufficient to warrant this degree of home healthcare services at this time. As such, this request for additional PCA service hours per week, above what is approved by the plan, is not medically necessary.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for personal care assistance (PCA) services, level II, 12 hours per day, 7 days per week, total 84 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hypercholesterolemia and hypertriglyceridemia.
Treatment:  Icosapent ethyl (Vascepa).
The insurer denied coverage for icosapent ethyl (Vascepa).
The denial is upheld. 

This is a patient with a past medical history of hypertension and hyperlipidemia. On examination, blood pressure was 152/95 millimeters of mercury (mmHg). No abnormal findings were noted. The patient was treated with metoprolol, amlodipine, lisinopril and atorvastatin 20 milligrams (mg) daily. Lipid panel revealed hypercholesterolemia and hypertriglyceridemia: Total cholesterol 240mg/deciliter (dl), triglycerides (TG) 222mg/dl, low-density lipoprotein (LDL) 168mg/dl, high-density lipoprotein (HDL) 28mg/dl.

The American Heart Association (AHA) defines moderate elevation of TG levels as those between 200-400mg/dl. (Reference 1) The guidelines recommend intensive statin therapy for the treatment of moderate to severe hypertriglyceridemia as well as Omega 3 fatty acid treatment. (Reference 2) There have been conflicting trial results demonstrating the efficacy of omega 3 fatty acids in reducing atherosclerotic cardiovascular disease (ASCVD) risk in those with hypertriglyceridemia. However, these findings were largely due to differing patient enrollment and differing doses of omega 3 fatty acids. The REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial) was a prospective double blind placebo controlled trial that enrolled patients with high cardiovascular risk. All patients had statin resistant hypertriglyceridemia. Among patients with elevated triglyceride levels despite the use of statin, the risk of ischemic events and cardiovascular death was significantly lower in the patients treated with Vascepa. (Reference 3) Current AHA guidelines recommend the use of Vascepa in patients with cardiovascular risk or established cardiovascular disease. Provided documentation does not demonstrate a history or risk of ASCVD.

In conclusion, Vascepa is not medically necessary for this gentleman with no history of diabetes and no history of ASCVD.  

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

The insurer's denial of coverage for icosapent ethyl (Vascepa) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal occlusion.
Treatment: D8080 Braces and D8670 Monthly Visit.
The insurer denied the D8080 Braces and D8670 Monthly Visit.
The denial is overturned.

The patient is an adolescent male with class I skeletal occlusion. The patient has a class II canine occlusion. He also has a deep bite and multiple anterior teeth in crossbite. The denial was due to the patient's having a handicapping index score of 13.

The proposed braces and monthly visit are medically necessary.

The patient has two anterior teeth (#11 and #27) in crossbite with gingival attachment loss. These are both automatic qualifiers according to the handicapping index scale.  When teeth are in crossbite they are much more prone to fracturing and/or loosening due to the extra forces placed on them. Orthodontic treatment is needed to correct their position. Monthly visit will allow for follow-up to make sure the treatment is on track.
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient with palpitations. She was evaluated in the emergency room. Premature ventricular complexes were noted on an electrocardiogram (EKG). She complained of palpitations with activity such as running for a bus as well as at rest. She had prior stress testing and exercise frequent premature ventricular contraction (PVCs) were noted, not suppressed with exercise. She was noted to be in ventricular bigeminy on EKG at times. She took CalMag tablets with no relief of symptoms. She also had a trial of metoprolol with no improvement in symptoms. 

She was referred to electrophysiology and underwent electrophysiologic testing and radiofrequency catheter ablation. The PVCs were mapped to the inferior basal right ventricle just below the tricuspid valve. The procedure was uncomplicated. She was discharged home. At issue is the medical necessity of an inpatient stay. 

The requested inpatient stay was not medically necessary for this patient. The patient had an idiopathic ventricular tachycardia with focus located in the right ventricle. 
She had an uncomplicated electrophysiologic study and catheter ablation. There were no post procedure complications. Hospitalization is generally at a lower level of care for an uncomplicated catheter ablation, including ventricular tachycardia (VT) ablation with right-sided ablation, based on current guidelines, referenced below. An inpatient hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute myocardial infarction.
Treatment: Inpatient admission. 
The insurer denied coverage for the inpatient admission.
The denial is overturned.

This is a case of an adult who presented to the hospital complaining of chest pain at rest for more than an hour. Upon arrival to the hospital vital signs showed a heart rate of 54 and a blood pressure 153/108. No abnormal findings were noted on physical examination. A 12-lead electrocardiogram (EKG) revealed sinus rhythm with ST (interval on a EKG) segment elevation in the inferior leads. Serum blood testing revealed elevated troponin at 3.6 nanograms/milliliter (ng/ml). Toxicology screen was positive for tetrahydrocannabinol (THC). The patient underwent urgent cardiac catheterization. Findings demonstrated a left ventricular ejection fraction of 45%, mild disease of the mid-left anterior descending artery with diffuse spasm of the vessel. The patient was admitted to the hospital and treated with nitroglycerin. The patient signed out against medical advice and went home.

This patient presented with an acute myocardial infarction due to vasospasm. The left ventricular ejection fraction was depressed, and HEART (History, EKG, Age, Risk factors, and troponin) score placed the patient in the high-risk category, consistent with a high risk of future cardiac events (1, 2). The patient was admitted and ultimately signed out against medical advice. Based on the high-risk score using both the HEART and TIMI (Thrombolysis in Myocardial Infarction) risk stratification, admission for further evaluation and work up was medically necessary. 

Risk assessment of patients presenting with chest pain and ST changes on EKG was performed by Sanchis et al. (3). Using their risk stratification schema, this patient would have a high risk of future myocardial infarction or death within one year. 

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

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

Diagnosis: Fever, nasal congestion, and cough.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission. 
The denial is overturned.

The patient is a female child born with no significant history. She presented to the emergency department with three days of fever, nasal congestion, and cough.

In the emergency room, the patient did not appear dehydrated, but on bladder scan had low urine noted. The patient subsequently was noted to have a low oxygen saturation of 89% on room air and required a normal saline bolus as well as 2 liters of oxygen. The patient was also being treated for an acute otitis media; however, the ear was not evaluated appropriately in the emergency department. Due to the patient's oxygen requirement, the patient was admitted, and IV (intravenous) antibiotics were given to continue treatment of the ear infection. Once the patient was able to take good oral fluids and demonstrated appropriate oxygen saturation without external support, the patient was discharged with follow-up care planned.

The inpatient admission was medically necessary.

The patient demonstrated poor oxygen saturation with an 89% value at room air. The patient also demonstrated decreased hydration levels with a low volume with the bladder scan. The bacterial pneumonia diagnosis was questionable, as the ear was not appreciated on exam. Therefore, the bacterial pneumonia diagnosis was not necessarily proven. The x-ray also did not demonstrate a consolidated focal lesion, also lending to a diagnosis of viral pneumonia. Irrespective of these facts, the patient demonstrated a requirement of oxygen to maintain basic life functioning, as such the admission was medically necessary.