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

Diagnosis: Sepsis secondary to urinary tract infection (UTI)

Treatment inpatient stay

The insurer denied coverage for inpatient stay

The denial is upheld

This is a male patient with past medical history of renal cell cancer, chronic kidney disease, benign prostatic hyperplasia (BPH) who presented to the emergency department (ED) with complaint of fever, frequency, pyuria. The patient found to have sepsis secondary to UTI as well as acute kidney injury (AKI). He was given intravenous (IV) fluids, IV Meropenem in the ED. Foley catheter placed; the patient was admitted to general medical services. His symptoms and labs improved. Foley was removed. The patient was stable for discharge home on oral antibiotics. 

Per Milliman Care Guideline (MCG) Health 25th (UTI), patient fails to meet clinical indications for admission to inpatient care. The patient only took one bacterium tab as out-patient before presenting to ED with fever. He had a pan sensitive Klebsiella UTI, so this was not a multiple drug resistant organism. The patient was on self-catheterization for neurogenic bladder, so his urine will always reflect some bacterial colonization from the repeated manipulation of inserting and removing catheter on a daily basis. Per MCG (25th) Urologic Disease, the patient fails to meet clinical indications for admission under "Urinary retention requiring inpatient cure" which includes hemodynamic instability, AKI requiring inpatient care. The patient did not have positive blood cultures, no evidence of ureteral blockage, pyonephrosis, or emphysematous pyelonephritis. 

The inpatient stay was not considered medically necessary for this patient.

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 stay rendered is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: migraines

Treatment: Aimovig 140 mg/mL autoinjector

The insurer is denied coverage for Aimovig 140 mg/mL autoinjector

The denial is overturned. 

This female patient has a history of migraines

This combination is medically necessary for improved migraine control for the patient and is supported by the following evidence:  
 
"In the context of migraine, headache depends on activity in unmyelinated C- and thinly myelinated delta fibers (A) in the Dura. Botox selectively inhibits activation and sensitization of the unmyelinated C- but not thinly myelinated A-fibers. Humanized calcitonin gene-related peptide (CGRP) monoclonal antibodies, inhibit A- but not C-type neurons in the trigeminal ganglion therefore a combination treatment that blocks both the C- (OnabotulinumtoxinA) and the A- (CGRP monoclonal antibodies and CGRP receptor antagonists) meningeal nociceptors may be more effective than a monotherapy that blocks only one of these pathways." (Burstein, et al. 2020) 
 
Botox and CGRP antibodies work by different mechanisms of action to enhance more effective headache control. The decision should therefore be overturned and approved.

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

The carrier's denial of coverage for the Aimovig 140 mg/mL autoinjector is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: gastrointestinal (GI) bleed

Treatment: inpatient level of care

The insurer is denied coverage for inpatient level of care

The denial is overturned. 

This female patient has a history of mitral valve regurgitation with valve repair, hypertension, and hyperlipidemia.

The patient presented to the ED with symptomatic anemia. She has significant comorbidities including a recent cardiac surgery. In addition, she's on anticoagulation. These are situations where mortality is high with upper GI bleeding. Admissions and aggressive management of upper GI bleed is warranted.

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

The carrier's denial of coverage for the inpatient level of care is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcer with an associated adherent clot. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

The patient presented with epigastric pain and vomiting. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The hemoglobin was 14.8 and went down to 12.7. intravenous (IV) Famotidlne and antiemetics were ordered. A computed axial tomography (CAT) scan showed gastric thickening and an endoscopy was advised. An endoscopy was performed. A duodenal ulcer was found with an adherent clot. Intravenous (IV)proton pump inhibitor therapy (PPI) therapy for 72 hours was given. He was transferred to the intensive care unit (ICU) as it was felt that there was a high risk of bleeding. 

This patient had an active ulcer with an associated adherent clot. It was classified as Forrest 28 indicating recent hemorrhage from the site. Milliman Care Guidelines (MCG) guideline M-180 lists Indications for admission for Upper Gastrointestinal Bleeding. An indication for admission is having a peptic ulcer with high-risk endoscopic features. An adherent clot is listed as a high-risk endoscopic feature. 

The patient had an active ulcer with an adherent clot suggesting recent bleeding and a high risk of rebleeding. He was sent to the ICU and was given IV PPI therapy for 72 hours. In view of the high-risk endoscopic feature, he met the clinical criteria for admission for Upper Gastrointestinal (Gl) Bleeding from an ulcer. The health care plan did not act with sound medical judgement. An inpatient admission was medically necessary. 

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 admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Disruptive Mood Dysregulation, Oppositional Defiant Disorder, attention deficit disorder (ADHD), and Reactive Attachment Disorder.

Treatment continued admission at a residential level of care.

The insurer denied coverage for continued admission at a residential level of care.

The denial is upheld.

The patient was admitted to this inpatient mental health residential treatment due to mood and behavioral symptoms including physical and verbal aggression, extreme behaviors, explosive mood, and kicked objects when frustrated. She reportedly had a diagnosis of Disruptive Mood Dysregulation, Oppositional Defiant Disorder, attention deficit disorder (ADHD), and Reactive Attachment Disorder. 

The  Milliman Care Guidelines (MCG) Residential-Behavioral Health Level of Care- Psychiatry guidelines report that one needs to have continued danger to self or others still in the form of auditory hallucinations contributing to suicide or serious harm to self or paranoid delusions or auditory hallucinations contributing to risk of homicide or serious harm to others or persistent thoughts of suicide or serious harm to self or homicide or serious harm to others that cannot adequately be monitored at a lower level of care, or moderately or severe psychiatric or behavioral symptoms requiring 24 hour daily treatment or serious dysfunction in daily living. 

As of date in question, there were no medical records for review that provided enough specific evidence to support that she only required 24 hour inpatient residential treatment or that he could not be treated in a less restrictive level of care then. There were no records reporting suicidal or homicidal ideation, plan, or intent, psychotic symptoms, self-injurious, aggressive, threatening, or severely agitated behavior, substance use, manic episodes, severe depression, or inability to care for her basic needs. There were no reports of specific reported identifiable and quantifiable treatment goals that could only be achieved in a 24 hour residential treatment setting or that could not be achieved in a less restrictive setting or specific evidence that she was still considered a danger to self or others, and had no reports in the medical records provided that he had significant behavioral or mood symptoms requiring 24 hour treatment. 

It appeared that the health care plan acted reasonably, with sound medical judgment, and in the best interests of the patient then.

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

Diagnosis: Syncope, cerebrovascular accident with hemiparesis, seizure disorder and depression

Treatment: Continued long-term custodial care

The insurer denied coverage for continued long-term custodial care.

The denial is overturned.

The patient has multiple chronic medical problems including syncope, cerebrovascular accident with hemiparesis, seizure disorder and depression. He has impaired cognition and requires 24-hour supervision for safety.  The patient was admitted to rehabilitation and nursing center and approved for custodial coverage.  Under review is the medical necessity of continued long-term custodial care onward.

The clinical records clearly demonstrate the patient's ongoing need for custodial care.  He has multiple medical problems, cognitive deficits, poses a significant falls risk and requires 24-hour supervision.  He has neither friends nor family to care for him in a home sitting.  His clinical condition is much the same as it has been during the approved time (by the insurer) of his long term custodial care.  Long term custodial care remains the best and most appropriate level of care for the patient from a given date onward.  

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical probability, continued long-term custodial care is medically necessary.

Based on the above, the medical necessity for the continued long-term custodial care onward is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee pain
Treatment: Knee Arthroplasty (27447) and Inpatient Hospital Admission 
The insurer denied the Knee Arthroplasty (27447) and Inpatient Hospital Admission
The denial is overturned

The patient is a male with bilateral knee pain. He was evaluated and reported previous treatments received (consultations, stem cell injections, medications, ice). He reported swelling, buckling and stiffness. He had difficulty with stairs, i.e., he would take one step at a time. He was found to have joint line tenderness, and effusion. Imaging reports were osteochondral defects to both knees. Surgery was recommended for both knees.

Imaging reports were that of osteochondral defects, osteophytes, joint space narrowing and effusion.

Yes, the Knee Arthroplasty (27447) and Inpatient Hospital Admission are medically necessary.
The medical records were consistent, showing pathology to the patient's knees. There were subjective complaints, physical findings and imaging studies showing a condition to require surgical management. A pain generator had been defined. Conservative treatments had been attempted. There was functional loss. The best option would be surgical intervention.

A pain generator had been defined. There was pathology which most likely would not respond to additional nonoperative management. Guidelines for Surgery had been met.

See AIM guidelines:

Bicompartmental or tricompartmental joint damage or destruction due to osteoarthritis, inflammatory disease or other chronic conditions when ALL of the following requirements have been met:
1)	Imaging evidence of significant joint destruction and cartilage loss, defined as modified Outerbridge grade III - IV or Kellgren-Lawrence grade 3  4. MET. There was joint space narrowing, osteophytes and joint destruction.

2)	Knee arc of motion greater than 50 degrees. MET

3)	Failure of at least 3 months of non-surgical conservative therapy. MET. There was documentation of stem cells and medications.

4)	Functional limitation secondary to knee pathology which interferes with the ability to carry out age-appropriate daily activities. MET. The patient could not do stairs nor walk normally.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis

Treatment: Otrexup

The insurer denied coverage for Otrexup

The denial is overturned.

This case involves a female who has been recommended to utilize Otrexup to treat her rheumatoid arthritis. The letter of medical necessity indicated she was prescribed this medication which she has been utilizing and feeling well without stiffness, pain or swelling. She has remained 100% (percent) adherent to therapy without any side effects. Prior to that she has trialed and failed oral methotrexate as well as injectable methotrexate, prednisone, diclofenac, and leucovorin. The physician indicated it was recommended she continued to utilize the requested therapy which has been safe and effective for this patient.

Otrexup (methotrexate) injection is a folate analog metabolic inhibitor indicated for the management of patients with severe, active rheumatoid arthritis (RA) and polyarticular juvenile idiopathic arthritis (PJIA), who are intolerant of or had an inadequate response to first-line therapy. This patient has trialed and failed oral methotrexate as well as injectable methotrexate (given she could not correctly utilize the vial and syringe and inject herself), prednisone, diclofenac, and leucovorin. The physician indicated it was recommended she continued to utilize the requested therapy which has been safe and effective for this patient as it is an auto injector. Therefore, as she has had benefit with use and a trial and failure of other medication, the use of Otrexup is medically necessary. 

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

The insurer's denial of coverage for Otrexup is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: acne

Treatment: Retin - A

The insurer is denied coverage for Retin - A

The denial is upheld. 

This female patient has a history of acne.

The patient has not been shown to have an intolerability or limitation which prevents the use of multiple other concentrations of tretinoin gel. According to the provided documentation formulary alternatives are available which would not be inferior to the requested medication. As such, the request for Retin-A micro 0.06% pump gel is not considered medically necessary based on the information provided.  

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

The carrier's denial of coverage for the Retin - A is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP).

Treatment: Truvada 200-300 OR TABS

The insurer is denied coverage for Truvada 200-300 OR TABS

The denial is upheld. 

This male with no medical history.

It is unclear from medical records what specific side effects the patient was experiencing with the generic tenofovir disoproxil fumarate with emtricitabine (TDF/FTC). There are no specifics indicated in the clinical documentation submitted. According to the insurance carrier, a requested non-formulary medication may be approved if separate individual components have been tried and failed due to adverse events such as rash, nausea, vomiting, anaphylaxis that is thought to be due to active ingredient.

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

The carrier's denial of coverage for the Truvada 200-300 OR TABS is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hand pain.
Treatment: Peripheral Nerve Stimulator.
The insurer denied the Peripheral Nerve Stimulator.
The denial is upheld.

The patient is a female with a chief complaint of neck, thoracic, low back, and CRPS (complex regional pain syndrome) of the right hand pain.  The CRPS (complex regional pain syndrome) pain is noted to have started after carpal tunnel repair.  History is significant for allodynia, color changes, swelling, and muscle fasciculations.  EMG (electromyelogram) shows improvement in median sensory latency and similar motor responses compared to the previous study.  MRI (magnetic resonance imaging) of the wrist is significant for adequate decompression of the carpal tunnel.  History is further significant for diabetes and tobacco dependence.  The patient is taking gabapentin for pain control.  Assessment is median neuropathy and recommendation is for PNS (peripheral nerve stimulation) with SPRINT.

Provider appealed denial as stating the provider felt it was medically necessary for patient suffering from hand when all other attempts to alleviate pain have failed.

No, the peripheral nerve stimulator is not medically necessary.
The use of peripheral nerve stimulation for any indication, including CRPS (complex regional pain syndrome) is considered to be unproven.  The quality and quantity of the data in the current peer-reviewed scientific medical literature is inadequate to establish the clinical utility and efficacy.

A review of the treatment of CRPS (complex regional pain syndrome) with peripheral nerve stimulation over 30 years of 165 patients with peripheral nerve simulators implanted found 29 patients continue to use their PNS (peripheral nerve stimulator).  The authors conclude PNS (peripheral nerve stimulator) is a useful modality to improve function and reduce long-term pain in selected patients with CRPS (complex regional pain syndrome).  However, this study is quite limited in size.

More studies are needed to establish the clinical utility, efficacy, and safety of PNS (peripheral nerve stimulator). As such, at this time, this procedure is considered unproven and therefore not medically necessary. In addition the clinical notes reviewed do not show this patient has tried other treatments for her condition including but not limited to, physical therapy, injections (i.e. stellate ganglion blocks, peripheral nerve blocks, other), other medications, and/or spinal cord stimulation for her condition.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypothyroidism
Treatment: Tirosint
The health plan denied the request for the prescription drug Tirosint. The health plan's determination is overturned.

This is a female with hypothyroidism status-post gastric bypass. She has been on Tirosint. A request for continuation of Tirosint is under review. She has tried and failed Levothyroxine, Armour Thyroid, and Nature-Thyroid. A request for continuation of Tirosint is under review.

I overturn in whole, the health plan's determination for Tirosint, as this request is medically necessary in this clinical situation, as outlined above.

This request is for Tirosint for the treatment of hypothyroidism. This patient has been stable on Tirosint. She has tried and failed Armour Thyroid, Nature-Thyroid, and Levothyroxine in the setting of decreased absorption status-post gastric bypass. The American Thyroid Association recommend avoiding switching between brands or generics as switching can cause hyperthyroidism or hypothyroidism, as any particular dose is not equivalent from brand to brand or generic to generic. Given this patient is stable on Tirosint, the American Thyroid Association supports the medical need for this patient to continue on Tirosint over the formulary alternatives Levothyroxine capsules, Synthroid, Levo-T, Levoxyl, and Unithroid, as these alternatives may cause hypothyroidism or hyperthyroidism.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia. 
Treatment: Vraylar (cariprazine). 

The insurer is denied coverage for Vraylar (cariprazine). 

The denial is overturned. 

This female had psychotic symptoms including auditory hallucinations, paranoid, and disorganized thinking, was hearing voices, and also using cocaine. She has a diagnosis of schizophrenia-paranoid type and cocaine use disorder. The patient had positive toxicology for cocaine and tetrahydrocannabinol (THC). It was reported that she tried multiple antipsychotic medications including Risperidone, Invega, Olanzapine, Aripiprazole, and Haldol. She reportedly was taking Topiramate for cocaine urges. She also reportedly took Buspirone. It was reported that she gained weight when taking Invega and that the other antipsychotic medications including Risperidone, Olanzapine, Aripiprazole, and Haldol were ineffective. It was reported that she was given samples of Vraylar (Cariprazine) 1.5 mg (milligrams) per day and then prescribed Vraylar (Cariprazine) 1.5 mg per day to treat her psychotic symptoms of schizophrenia. 
  
According to the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia it reports that antipsychotic medications are the treatment of choice for psychotic symptoms of schizophrenia. Vraylar is considered one of the antipsychotic medications for the treatment of psychotic symptoms of schizophrenia and is considered Food and Drug Administration (FDA) approved. 
  
This reviewer disagrees with the decision to deny coverage for Vraylar (Cariprazine) 1.5 mg for treatment of schizophrenia as this patient tried several formulary antipsychotic medications including Risperidone, Invega, Olanzapine, Aripiprazole, and Haldol and had lack of efficacy for Risperidone, Olanzapine, Aripiprazole, and Haldol, and had reported side effects of weight gain with Invega. She reportedly took Aripiprazole for schizophrenia without effect. It was reported that it was again being tried for depression in addition to Vraylar for schizophrenia and Topiramate for cocaine urges. This patient had a Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 diagnosis of Schizophrenia so the use of Vraylar for this patient was considered medically necessary, standard, and appropriate treatment. 

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. Vraylar (Cariprazine) 1.5 mg per day for the treatment of schizophrenia is medically necessary for this patient. 

The insurer's denial of coverage for Formulary Exception for Vraylar (cariprazine) is overturned. Medical necessity is substantiated.