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

Diagnosis: Gastroenteritis
Treatment: Inpatient Stay
The insurer denied the requested inpatient stay as not medically necessary. The denial is upheld. 

This is the case of a previously healthy male who presented to the emergency department (ED) with non-radiating abdominal pain, diarrhea, and vomiting x 5 episodes. Symptoms began the day of presentation, and multiple family members have had similar illness. A review of symptoms (ROS) was negative for fever, dyspnea, or chest pain.
The ED vitals included a temperature of 37C., a heart rate (HR) of 155 beats per minute (bpm), a respiratory rate (RR) of 18/minute, a blood pressure (BP) of 132/84 millimeters of mercury (mmHg), and an oxygen saturation of 100%. A physical exam was notable for dry mouth, a soft abdomen without masses, and tenderness throughout the abdomen. Labs showed a white blood cell count (WBC)=15.3 with 88 neutrophils (segs) and 4 lymphs, a hemoglobin=16.3, platelets=290, a sodium=141, a potassium=4.1 hemolyzed, a chloride=106, a carbon dioxide (CO2)=21, a blood urea nitrogen (BUN)/Creatinine= 20/1.0, and a Glucose=133. A computed tomography (CT) scan of the abdomen and pelvis showed no obstruction, a 4mm (millimeter) calcification in the right lower quadrant (RLQ) with a normal appearing appendix, a small amount of fluid around the gallbladder without stones, and suggestion of diarrhea and gastritis. The patient received intravenous fluids (IVF) and Zofran, Lorazepam, Toradol, and Acetaminophen. He continued to have abdominal pain (improved from 10/10 to 2/10) and failed an oral challenge, so the decision was made to admit him to the hospital for further management of gastroenteritis.
At issue is whether the inpatient hospital stay was considered medically necessary for this patient.

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

The patient required additional treatment beyond the ED; however, this could have been accomplished at an alternate level of care versus full inpatient admission.
This otherwise healthy male presented to the ED with acute gastroenteritis and abdominal pain in the setting of multiple family exposures to similar. The patient was tachycardic on arrival to the ED. Work-up revealed normal electrolytes and a CT of the abdomen and pelvis was reassuring for no acute surgical process. The patient's pain improved with pain medications, but some symptoms remained. Therefore, given the patient's age, medical condition, and stable nature, he could have safely and effectively been treated at an alternate level of care with anticipated discharge within 24 hours.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hyperkalemia.
Treatment: Lokelma 5 grams Powder for suspension.
The insurer denied coverage for Lokelma 5 grams Powder for suspension.
The denial is overturned.

This patient has a history of ischemic heart failure and reduced ejection fraction, valvular heart disease status post mechanical mitral valve and left ventricular assist device placement. Left ventricular assist device (LVAD) was removed due to bacteremia and patient was listed for heart transplant. Additional history includes hyperkalemia not responsive to polystyrene sulfonate oral suspension that resolved following treatment with Lokelma. Documents submitted by the provider states that formulary alternatives failed to control potassium levels. 

This patient suffers from hyperkalemia and severe left ventricular dysfunction requiring guideline directed medical therapy.  Hyperkalemia is defined as potassium levels above 5.0 milliequivalents per liter (mEq/L) and is frequently noted in patients with heart failure. Hyperkalemia is associated with increased levels of all-cause mortality in patients with heart failure. (Reference 1) In studies of patients with heart failure and hyperkalemia, Lokelma allowed for sufficient reduction in potassium levels to allow for titration of guideline directed medical therapy and a concurrent improvement in left ventricular function. (Reference 3) This patient clearly benefits from Lokelma therapy and documentation submitted states that formulary alternatives were not efficacious. In conclusion, the formulary drug is not efficacious, and the requested drug is more effective than the formulary alternative.

The insurer's denial of coverage for Formulary Exception for Lokelma 5 grams Powder for suspension is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Overactive bladder
Treatment:  Gelnique 10% Gel
The insurer denied the  Gelnique 10% Gel
The denial is upheld

This female with overactive bladder has requested coverage for Gelnique 10% gel. Tolterodine, trospium and Myrbetriq did not have prior benefit.  

The rationale for denial was "Formulary alternative(s) are darifenac in extended-release;
oxybutynin; oxybutynin extended-release; solifenacin; tolterodine extended-release; tolterodine tablet; Toviaz; trospium; trospium extended release. Requirement: 3 in a class with 3 or more alternatives, 2 in a class with 2 alternatives, or 1 in a class with only 1 alternative. Please refer to your plan documents for a complete list of alternatives."

No, the health plan should not cover the proposed treatment. The patient has not tried three formulary alternatives. Per American Urological Association "Guideline Statement 11 If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a 3-adrenoceptor agonist may be tried. Clinical Principle."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain - colitis.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

Patient is a female with past medical history significant for hemorrhoids, cervical human papillomavirus (HPV) and asthma who presented to the emergency department with complaints of abdominal pain, headaches, and bloody diarrhea with bright red blood per rectum for 4 days. 

Vitals on presentation included: Temperature-98.3 Fahrenheit, Blood Pressure-104/77, Heart Rate-130, Respiratory Rate-18, oxygen saturation-98%. Laboratory results showed: white blood cell (WBC)-12.3, hemoglobin-13.2, hematocrit-38.5, creatinine-0.83, glucose-119. 

Patient was empirically started on antibiotics (ciprofloxacin and metronidazole) for possible infectious diarrhea. Computed Tomography scan of abdomen/pelvis showed pancolitis which may be infectious or inflammatory etiology. Infectious Diseases was consulted. Stool polymerase chain reaction (PCR) panel was negative for infectious etiology. Patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged home following a three-day hospital stay. 

According to medical records, patient presented with abdominal pain that was different from her menstrual pain, as well as bloody diarrhea that resolved the day prior to presentation. She was afebrile, normotensive and laboratory results were notable only for a mildly elevated WBC. Gastroenteritis panel was negative for infectious etiology. Based on above findings, patient met criteria for observation level of care. Patient was not immunocompromised, was hemodynamically stable, and did not meet criteria for acute care hospitalization.  

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

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

Diagnosis: Atopic dermatitis.
Treatment: Dupixent.
The insurer denied coverage for Dupixent.
The denial is overturned.

The patient is a female with a diagnosis of severe atopic dermatitis affecting more than 10% total body surface area (TBSA). The patient has failed therapy with topical steroids, tacrolimus, elidel, and eucrisa. The patient has exhausted topical therapies and requires systemic treatment. The requested medication is Dupixent.  

Based on the standard of care, Dupixent is medically necessary for this patient. The patient has failed all reasonable topical options for the treatment of her atopic dermatitis. Her disease is severe and requires systemic therapy. The use of traditional oral immunosuppressive is not Food and Drug Administration (FDA) approved for atopic dermatitis and carry a significantly higher risk of complications and adverse side effects for a child compared to FDA approved Dupixent. The decision is reversed and the use of Dupixent is approved.  

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 Dupixent is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: General Debility and Weakness, Seizure. 
Treatment: Continued Long Term Custodial Care. 

The insurer denied the Continued Long Term Custodial Care. 
The denial is upheld. 

The patient is a male with history of general debility and weakness secondary to seizure, status epileptics and was in acute hypoxia and hypercapnia respiratory failure, was intubated and later extubated. 

The patient has a past medical history of depression, anxiety, substance abuse, seizure, peripheral neuropathy, cervical stenosis, bipolar disorder, etc.  Prior to admission, he was independent with all activities of daily living (ADLs) and living in a homeless shelter on the fifth floor with an elevator. 

The patient was independent with all activities of daily living (ADLs) including feeding, dressing, bathing, tilting, ambulation and was discharged from physical therapy (PT) and occupational therapy (OT). The patient refused to be discharged back to the homeless shelter. 

No, the proposed treatment was not medically necessary. 

The requested continued stay in a long-term custodial care facility was not medically necessary because the patient was independent with all activities of daily living (ADLs) including feeding, dressing, bathing, tilting, and ambulation.  In addition, the patient was discharged from physical therapy (PT) and occupational therapy (OT). He refused to be discharged back to the homeless shelter. 

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

The health plan has acted reasonably in this instance, and its decision was with sound medical judgment which was in the best interest of the patient because as stated above, the patient was independent with all activities of daily living (ADLs) including feeding, dressing, bathing, tilting, and ambulation.  He was discharged from physical therapy (PT) and occupational therapy (OT). He refused to be discharged back to the homeless shelter.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, congestive heart failure
Treatment: Personal Care Aide (PCA) Level 2 Services, Live-in Per Diem, 24 Hours Per Day, 7 Days Per Week
The insurer denied the Personal Care Aide (PCA) Level 2 Services, Live-in Per Diem, 24 Hours Per Day, 7 Days Per Week
The denial is overturned

The patient is a female with a past medical history of Alzheimer's dementia, congestive heart failure (CHF) and depression.  Currently, she is taking an Exelon patch and Prozac.  She is also taking Abilify.  The patient is on pureed food and is at risk of aspiration because of vocal cord dysfunction.  She needs help and supervision while eating.  She also needs supervision with toileting and is at risk of falls.  The patient frequently forgets taking her medication.  She needs 24-hour supervision for her safety.

The patient is requesting an increase in Personal Care Aide (PCA) services to live-in per diem.

Yes, the proposed Personal Care Aide (PCA) services live-in per diem are medically necessary.
The patient is on pureed food and is at risk of aspiration because of vocal cord dysfunction.  The patient needs help and supervision while eating.  She also needs supervision with toileting and is at risk of falls. The patient has urinary and bowel incontinence.  She has muscle weakness and decreased balance.  The patient frequently forgets taking her medication.  She needs 24-hour supervision for her safety.  The plan approved Personal Care Aide (PCA services 6.5 hours per day, 7 days per week (45.5 hours per week total)  is not enough as she needs constant supervision while eating and taking her medications. This patient has significant functional and cognitive decline.  She has unsteady gait and also has dysphagia. She is at risk of falls.  The patient needs increased Personal Care Aide (PCA) services to ensure safety and get the help that she needs.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient
This patient has significant functional and cognitive decline.  She has unsteady gait and also has dysphagia. She is at risk of falls.  The patient needs increased Personal Care Aide (PCA) services to ensure safety and get the help that she needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fracture; decay. 

Treatment: D2740 Porcelain Crown, D2950 Core Build-up Including Pins, Teeth and /or Quad 19. 

The insurer denied the D2740 Porcelain Crown, D2950 Core Build-up Including Pins, Teeth and /or Quad 19. 

The denial is upheld. 

The patient is a male with lower left molar (tooth #19) filled with a large amalgam restoration. Decay was noted in the neighboring teeth (#18, #20). Per dentist's notes, there is a lingual fracture in tooth #19, recurrent decay, and the patient is symptomatic. The dentist requested a crown and core build-up for tooth #19. 

Review of the submitted intraoral photograph and x-ray show tooth #19 has a very large and deep amalgam restoration. 

There was no medical or dental history provided for the patient. There were no study models provided nor close-up intraoral photograph of tooth #19. There was no description of the patient's symptoms.

The core build-up and crown for tooth #19 were denied coverage by the health plan, because the "tooth does not appear to have decay or injury. The dental plan only covers crowns, inlays, onlays, and veneers when needed due to decay or injury and when the tooth cannot be restored with a routine filing. This tooth appears to have sufficient tooth structure remaining to provide adequate support and retention for an indirect restoration." This denial is being appealed. 

No, the requested treatment of crown and core build-up for tooth #19 is not considered medically necessary at this time. 

While the submitted intraoral photograph and panoramic x-ray show tooth #19 has a very large and deep amalgam restoration, there is no indication on these documents that there is recurrent decay or a lingual fracture. It is not possible to determine this level of detail from the provided photograph. A close-up intraoral photograph of tooth #19 would better show if there is loss of marginal integrity of the existing restoration or if decay is present; similarly, a bitewing x-ray could better show if decay is present. There was no description of the patient's symptoms-- so it cannot be determined that the patient has cracked tooth syndrome or any other indication for treatment with a crown. Based on review of the clinical documentation, there is no medical need at this time for a crown for tooth #19. 

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

The health plan applied sound judgment by utilizing the submitted x-ray and photograph, as well as the explanation for treatment letter provided by the dentist.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID-19 (coronavirus disease 2019).
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld.

The patient is a male with a history of hypertension (HTN), COVID-19, hyperlipidemia (HLD) and hypothyroidism. The patient presented to the emergency department (ED) with complaints of difficulty breathing when lying down flat in bed. The patient also reported symptoms of orthopnea and paroxysmal nocturnal dyspnea (PND) for a few days. The patient received the COVID-19 vaccine a few days prior.

At presentation to ED the patient's vital signs were as follows: Temperature 98.1, Heart rate (HR) 68, Respiratory rate (RR) 18, Blood pressure (BP) 169/95, and oxygen (O2) saturation was 97% on room air (RA). The patient was in no acute distress (NAD). There was no jugular venous distension (JVD) noted.  His lungs were clear. His CVS (cardiovascular system) was noted as normal. The patient was awake and alert upon a non-focal neurological exam.

The patient was admitted to telemetry with a diagnosis of COVID-19 and a possible new onset of congestive heart failure (CHF). 

This patient was treated with 20 mg (milligrams) intravenous (IV) Lasix. He remained stable after admission. He was afebrile with O2 saturation of 97-98 % on room air (RA). A myocardial infarction (MI) was ruled out (R/O) by serial EKG's (electrocardiograms) and Troponins. 

The patient did not have any evidence of CHF. COVID-19 was asymptomatic. There was no hypoxia or pneumonia. O2 saturation was 97-98% on RA. The patient was afebrile and did not receive any specific treatment for COVID. He was discharged home the same day with directions for follow up in the outpatient setting. His symptoms were ascribed to an upper respiratory infection (URI).

This patient did not need acute inpatient hospitalization. He could have been placed in observation status. The patient's symptoms were likely from an URI. He did not need any specific COVID-19 related treatment that required acute inpatient hospitalization. No signs of (congestive heart failure) were noted. He was seen and cleared by Cardiology. The patient did not have any evidence of Acute MI or cardiac ischemia.

The patient was stable for discharge after evaluation and treatment in the ED. The patient was discharged home after a few hours in the hospital on oral medication.

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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: TTE (transthoracic echocardiogram). 
The insurer denied coverage for TTE.
The denial is upheld. 

This female patient presented to a cardiologist complaining of new symptoms of chest pain that is exacerbated by left arm movement. She has a past medical history of palpitations that were due to ventricular premature beats on electrocardiogram. Office notes clearly state that palpitations were first noted 2.5 years earlier and symptoms have become less frequent. Physical examination revealed normal heart rate and regular rhythm and no cardiac abnormalities were noted. The only medication that the patient was taking was pantoprazole. No Holter monitor or electrocardiogram result was submitted for review. An echocardiogram was performed and revealed a preserved left ventricular ejection fraction without any valvular abnormality. An exercise stress test was performed and revealed no evidence of ventricular ectopy on electrocardiography. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. This patient had a history of palpitations and premature ventricular beats that was first evaluated 2.5 years earlier. The patient history clearly noted an improvement in symptoms. 

The AHA (American Heart Association) and ASE (American Society of Echocardiography) appropriate use criteria for echocardiography classify routine echocardiography for infrequent palpitations as "I" inappropriate. (1). Patients with frequent premature ventricular beats are at risk for developing cardiomyopathy and echocardiography upon initial evaluation is indicated. (2). This patient had no evidence of significant ectopy noted on exercise ECG (electrocardiogram) testing. In conclusion, echocardiography for infrequent palpitations that were first evaluated 2.5 years prior to presentation was not medically necessary for this patient. 

The insurer's denial of coverage for transthoracic echocardiogram (TTE) is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Alopecia
Treatment:  Xeljanz 10 mg (milligrams) tablets, pre-service
The insurer denied the Xeljanz 10 mg tablets, pre-service.
The denial is overturned.

The patient is a female diagnosed with alopecia areata (AA) with 50% (percent) loss on the scalp, has tried and failed topical, intralesional and oral steroid and has now been prescribed Xeljanz. The request for Xeljanz was denied by insurance so the provider is appealing the denial.

There are no FDA (Food and Drug Administration) approved medical treatment options for AA. However, there are several studies that show efficacy of Xeljanz in treating this medical disease of the immune system.

There are no FDA-approved treatments for this condition of AA. The patient has tried and failed standard treatment options. Current medical studies show that Janus kinase (JAK) inhibitors such as Xeljanz can be used to treat this medical disease.

Liu, L., et al writes "The successful reversal of the distortion of appearance that
characterizes alopecia areata leads to improvement in psychosocial functioning. In the broader context of appropriate and essential medical care, the treatment of alopecia areata satisfies the definition of medical necessity and is merited, by objective measures, in the same way that treatment of other chronic dermatoses, such as atopic dermatitis and psoriasis, is merited."

As stated in Gilhar, A., et al, "the US Food and Drug Administration has accepted
clinical studies with Janus kinase inhibitors for alopecia areata by the so-called investigational new drug process, which implies a favorable risk benefit ratio assessment."

Strazzulla, Lauren C., et al writes "The Janus kinase/signal transducers and activators of
transcription pathway is upregulated in alopecia areata but not in normal hair follicles".

Per Ibrahim O., et al, "Janus kinase inhibitors have been shown to attenuate the
inflammatory cascade associated with alopecia areata. Our results indicate that tofacitinib is efficacious in the treatment of alopecia areata. Although small, our cohort achieved greater median improvement in SALT (Severity of Alopecia Tool) scores than reported in previously published studies (50.5% vs 21%). This outcome may be related to our higher doses, longer duration of therapy, and patients' shorter duration of current disease episode. In addition, our results demonstrate lack of durability of effect after the discontinuation of therapy, a finding similar to that in other studies."

Hogan, S., et al concludes "The majority of patients experienced hair regrowth, ranging
from less than 5 percent to 100 percent regrowth during the study. This is consistent with other studies, suggesting disease duration might not predict patient response, but rather a pathophysiological mechanism might be involved. Our study is limited by its small sample size, precluding detailed subgroup analyses. Larger, randomized, controlled trials are needed to explore such variations in regrowth. Nevertheless, our results suggest Janus kinase inhibition might serve as an effective treatment modality for alopecia areata."