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

Diagnosis: Gastrointestinal Covid. 
Treatment: Full Hospital Admission. 

The insurer denied coverage for full hospital admission. 

The denial is overturned. 

Patient is an adult with a history of atrial fibrillation, on Eliquis, hypertension, and dilated cardiomyopathy who presented to the emergency department (ED) with complaints of syncope, vomiting and diarrhea. The patient was found to be hypotensive in the ED with blood pressure (BP) 78/54. Multiple intravenous (IV) fluid boluses were given for hypotension. The patient had electrolyte imbalances - hyponatremia and hypomagnesemia. In addition, there was significant transaminitis. White Blood Cell (WBC) count was 7.2, Hemoglobin (Hgb) 14.2, Sodium 131, Magnesium 1.6, and elevated Serum Glutamic-Oxaloacetic Transaminase (SGOT) and Prothrombin Time (PT). There were no acute infiltrates on the chest x-ray. The patient had an abdominal ultrasound which revealed Hepatic Steatosis. A Covid Test came back positive. The patient was unvaccinated for Covid. 

The patient was seen by multiple specialists for his Hypotension and gastrointestinal (GI) symptoms. The Pulmonary consultant believed that the GI symptoms were related to Covid. They recommended continuation of IV fluids and treat the patient with Remdesivir IV. No steroids were recommended as the patient was not hypoxic and did not have pulmonary infiltrates. 

The patient was treated with a 3-day course of IV Remdesivir and the GI symptoms improved, and liver function tests (LFT's) decreased. Given the patient's refractory GI symptoms and presentation with hypotension and multiple electrolyte abnormalities; GI Covid was presumed to be the diagnosis. The patient was treated with IV Remdesivir for Covid and improved. The patient's blood pressure improved, and he was started on his home medications. 

Given his presentation with GI Covid and requiring treatment with IV Remdesivir admission was appropriate. 

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

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

Diagnosis: Cancer - Malignant Neoplasm
Treatment: Prescription Drugs - Tagrisso
The health plan denied the formulary exception request, Tagrisso.
The health plan's determination is overturned.

The patient is a female with metastatic adenocarcinoma of the lung with an exon 19 deletion based on next generation sequencing. The patient has received brain radiotherapy and carboplatin+pemetrexed for two cycles. Tagrisso has been recommended by the provider and is at issue in this review.

The health plan's determination is overturned in whole.

The drug recommended and under review is formulary based on its Food and Drug Administration (FDA) approval. The patient has not failed front line therapy; due to the extent of disease, the patient was treated with chemotherapy while awaiting results of a next generation sequencing panel. Tagrisso (Osimertinib) has been demonstrated to improve overall survival, progression free survival, and duration of response in this clinical scenario. It is also documented to have greater intracranial efficacy and better tolerability than chemotherapy. This approach is recommended by the peer-reviewed literature, by the authors of UpToDate, and by the National Comprehensive Cancer Network (NCCN) Guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Myeloma.
Treatment: Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (PET/CT) fusion scan.
The insurer denied Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (PET/CT) fusion scan.
The determination is overturned.

This is a patient with newly diagnosed multiple myeloma. The patient has documented bone involvement. A positron emission tomography (PET) / computed tomography (CT) scan has been recommended for initial staging and is under review for medical necessity.

PET/CT scanning using fluorine-18-labeled (18F) fludeoxyglucose (FDG) is more sensitive and specific than skeletal survey for the detection of bone lesions and may be more sensitive than a CT scan for the detection of extramedullary disease. In a study prospectively comparing PET/CT versus magnetic resonance imaging (MRI) of the spine and pelvis versus skeletal survey, PET/CT was superior to skeletal survey for the detection of bone lesions and was able to detect bone changes in sites out of the MRI field in one-third of patients. This approach is recommended by the National Comprehensive Cancer Network (NCCN), peer-reviewed literature, and by the authors of UpToDate. For these reasons, medical necessity has been established for this service.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II diabetes mellitus
Treatment: Janumet Extended Release (XR)
The insurer denied Janumet XR. 
The health plan's determination is upheld.

This is a male diagnosed with T2DM (type II diabetes mellitus) with hyperglycemia. This request is for Janumet [extended release (XR)]. As reported, he is on Janumet XR 50-500 milligrams (mg) twice daily and Jardiance 10 mg daily. He also has hyperlipidemia and obesity.

His hemoglobin (HGB) A1C was 6.2% (percent).

A formulary exception is not indicated. The formulary alternatives would be as effective.
The Dipeptidyl peptidase (DPPIV) inhibitors have similar efficacy. There are no trials showing superiority of one DPPIV inhibitor over another including linagliptin (tradjenta), saxagliptin(onglyza), vidagliptin or sitagliptin (Januvia). The American Association of Clinical Endocrinologists consensus statement regarding treatment of patients with type two diabetes recommends the use of metformin followed by the use of a DPPIV inhibitor or a GLP1 (glucagon like peptide 1) agonist. 

There are no studies showing superiority of the requested Janumet over Jentadueto. The patient can try the formulary drug.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: congestive heart failure (CHF)
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The determination is upheld. 

The patient is a male who presented to the emergency department (ED), brought by paramedics with worsening chest pain, shortness of breath and orthopnea. His symptoms started two weeks prior to presentation. The patient was not able to sleep for a few days due to chest pressure and worsening orthopnea. He usually is using 2 pillows for sleep, but lately he was sleeping in sitting position. The patient has a chronic cough. The patient was seen in the ED and was admitted for observation. 

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with a congestive heart failure (CHF) exacerbation. The patient previously underwent a work up for his CHF, and his diagnosis was established. The patient had non ischemic, possible alcoholic cardiomyopathy, and he was treated previously. His admission was due to poor compliance with fluid restriction. The patient had evidence of CHF exacerbation, based on his history. His brain (or B-type) natriuretic peptide (BNP) was elevated, but his baseline was unknown. The patient had normal BP, and his O2 (oxygen) saturation was normal on room air. His echocardiogram was similar to one that was previously done. He improved quickly on IV (intravenous) lasix.

Based on above, this patient did not have indications for inpatient admission. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Scaling and root planing
The insurer denied scaling and root planing.
The determination is overturned.

This is a male patient who presented for evaluation and treatment of all four quadrants with periodontal therapy consisting of scaling and root planing. Provided for review are previous letters of appeal and denial, full mouth radiographic images, one page of American Dental Association (ADA) claim forms, periodontal indices, and health plan language. Previous denials have been on the basis that there is not bone loss associated with the teeth to allow for scaling and root planing. At issue is the medical necessity of the planned treatment of scaling and root planing.

Yes, the requested health service/treatment of deep gum and root cleaning is medically necessary for this patient. Based on the provided radiographic images, there is bone loss in all four quadrants and thus the scaling and root planing is indicated. Based on the periodontal indices provided, the patient also has indications of active disease based on provided indices. Hence the requested treatment of scaling and root planing is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a male with a medical history of heavy alcohol use, anxiety, and depression. He presented to the emergency department with two days of epigastric pain and weeks of diarrhea. He had been drinking alcohol heavily until the night before. His vital signs were notable for a rapid heart rate of 106 beats per minute. His physical examination was notable for epigastric abdominal tenderness. His laboratory studies showed an unremarkable complete blood count, an elevated aspartate aminotransferase of 36, and an elevated lipase of 279 (upper limit of normal 78).

The computed tomography scan of the abdomen and pelvis showed acute interstitial pancreatitis involving the distal body and tail of the pancreas, with inflammatory stranding. He was treated with intravenous fluids, Morphine, Ativan, and a Librium taper. He was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol. The patient reported improvement in his abdominal pain, with no nausea and the CIWA score was 4. The patient's oral intake was restarted. He was tolerating a regular solid diet and he had used Morphine one time for pain. The patient left against medical advice.

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

The patient had acute pancreatitis, considering his abdominal pain, imaging findings, and his lipase level that was elevated above three times the upper limit of normal [1-3]. The patient was appropriately treated, with intravenous fluid administration, and had a gradual advancement of diet [3-7]. There was no persistent hemodynamic instability or other complications such as pancreatic pseudocyst, pancreatic necrosis, abscess, or sepsis, which would require a higher level of care [3-7]. He was appropriately monitored for alcohol withdrawal during the stay, and did not have any significant complications [8,9]. The interventions performed, including laboratory studies, intravenous fluids, monitoring, imaging, and gradual advancement of his diet, could have been performed in sequence after presentation without the inpatient level of care. For these reasons, the inpatient level of care is not supported.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Major Depressive Disorder. 
Treatment: Fetzima 120 mg. 

The insurer denied Fetzima 120 mg. 
The determination is upheld. 

The patient is a female with major depressive disorder and proposed treatment with Fetzima (levomilnacipran) at 120 milligrams (mg) daily. The patient has failed to sustain a response or remission, or tolerate Lexapro, duloxetine, and Latuda. Comorbid conditions include anorexia nervosa and attention deficit hyperactivity disorder (ADHD). Current medications include Adderall 5 mg daily as needed, bupropion 300 mg, and trazodone 50 mg (milligram). 

The health plan has denied coverage of Fetzima on the basis of a coverage exclusion indicating that there is no evidence that there is an advantage for Fetzima versus formulary alternatives in keeping with plan guidelines and prior authorization criteria. The correspondence from the health plan references desvenlafaxine (Pristiq) and venlafaxine (Effexor) as a formulary alternative. 

The patient's physician has requested an exception to the denial of coverage on the basis of the clinical history and treatment failure with formulary alternatives, as noted above. 

The health plan's determination is upheld in whole. 

In this case, the formulary drugs venlafaxine hydrochloride, venlafaxine hydrochloride (HCL) extended release (ER), and desvenlafaxine ER would not be considered ineffective as compared to the request for the non-formulary drug, Fetzima, and would be considered as effective as the non-formulary drug Fetzima 120 mg. Fetzima and the formulary alternatives would pose similar risks for adverse effects. 

Moreover, health plan coverage requirements are not met in this case for the requested benefit of Fetzima with regard to medical necessity and with regard to the Prescription Drug Plan. The health plan formulary alternatives, venlafaxine and desvenlafaxine, are reasonable and consistent with prevailing standards of medical practice for the treatment of the condition diagnosed in this case.
Appeal type: Formulary Exception
Decision: Upheld

Mental Health
Pharmacy/Prescription Drug

Diagnosis: Major Depressive Disorder
Treatment: Fetzima 120 mg
The insurer denied Fetzima 120 mg.
The determination is upheld.

The patient is a female with major depressive disorder and proposed treatment with Fetzima (levomilnacipran) at 120 milligrams (mg) daily. The patient has failed to sustain a response or remission, or tolerate Lexapro, duloxetine, and Latuda. Comorbid conditions include anorexia nervosa and attention deficit hyperactivity disorder (ADHD). Current medications include Adderall 5 mg daily as needed, bupropion 300 mg, and trazodone 50 mg.
The health plan has denied coverage of Fetzima on the basis of a coverage exclusion indicating that there is no evidence that there is an advantage for Fetzima versus formulary alternatives in keeping with plan guidelines and prior authorization criteria. The correspondence from the health plan references desvenlafaxine (Pristiq) and venlafaxine (Effexor) as a formulary alternative.
The patient's physician has requested an exception to the denial of coverage on the basis of the clinical history and treatment failure with formulary alternatives, as noted above. 
The health plan's determination is upheld in whole.
In this case, the formulary drugs venlafaxine hydrochloride, venlafaxine hydrochloride (HCL) extended release (ER), and desvenlafaxine ER would not be considered ineffective as compared to the request for the non-formulary drug, Fetzima, and would be considered as effective as the non-formulary drug Fetzima 120 mg. Fetzima and the formulary alternatives would pose similar risks for adverse effects.
Moreover, health plan coverage requirements are not met in this case for the requested benefit of Fetzima with regard to medical necessity and with regard to the Prescription Drug Plan. The health plan formulary alternatives, venlafaxine and desvenlafaxine, are reasonable and consistent with prevailing standards of medical practice for the treatment of the condition diagnosed in this case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Major Depressive Disorder
Treatment: Fetzima 120 mg
The insurer denied Fetzima 120 mg.
The determination is upheld.

The patient is a female with major depressive disorder and proposed treatment with Fetzima (levomilnacipran) at 120 milligrams (mg) daily. The patient has failed to sustain a response or remission, or tolerate Lexapro, duloxetine, and Latuda. Comorbid conditions include anorexia nervosa and attention deficit hyperactivity disorder (ADHD). Current medications include Adderall 5 mg daily as needed, bupropion 300 mg, and trazodone 50 mg.
The health plan has denied coverage of Fetzima on the basis of a coverage exclusion indicating that there is no evidence that there is an advantage for Fetzima versus formulary alternatives in keeping with plan guidelines and prior authorization criteria. The correspondence from the health plan references desvenlafaxine (Pristiq) and venlafaxine (Effexor) as a formulary alternative.
The patient's physician has requested an exception to the denial of coverage on the basis of the clinical history and treatment failure with formulary alternatives, as noted above. 
The health plan's determination is upheld in whole.
In this case, the formulary drugs venlafaxine hydrochloride, venlafaxine hydrochloride (HCL) extended release (ER), and desvenlafaxine ER would not be considered ineffective as compared to the request for the non-formulary drug, Fetzima, and would be considered as effective as the non-formulary drug Fetzima 120 mg. Fetzima and the formulary alternatives would pose similar risks for adverse effects.
Moreover, health plan coverage requirements are not met in this case for the requested benefit of Fetzima with regard to medical necessity and with regard to the Prescription Drug Plan. The health plan formulary alternatives, venlafaxine and desvenlafaxine, are reasonable and consistent with prevailing standards of medical practice for the treatment of the condition diagnosed in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polyarticular Juvenile Arthritis.
Treatment: Cimzia.
The insurer denied: Cimzia.
The denial is: Upheld.

The patient is a female with a history of chronic erosive rheumatoid factor (RF)+ polyarticular juvenile arthritis / seropositive rheumatoid arthritis (RA) who has previously been on adalimumab, methotrexate (weaned off for intolerance), and prednisone. She has active arthritis based on a note with right knee swelling, active synovitis of both knees by ultrasound, and left shoulder tenosynovitis by ultrasound. No further history is provided. Cimzia 200 milligrams (mg) every (q)2 weeks is being requested. The health plan determined that treatment with Cimzia does not meet medical necessity as in their view patient could instead be on the plan preferred Enbrel, Kevzara, or Xeljanz.

There is no mention of patient being pregnant or contemplating a pregnancy, which would be valid reasons for use of Cimzia use above other anti-tumor necrosis factor (TNF) drugs such as Enbrel or other treatments such as Kevzara or Xeljanz. There is also no mention of patient having a severe needle phobia which would be a concern given that Enbrel is given weekly rather than 200 milligrams (mg) every 2 weeks (or 400 mg every 4 weeks) as with Cimzia. There is also no mention of comorbid diseases such as Crohn's or a spondyloarthritis for which Cimzia might be preferable to Enbrel or interleukin (IL)-6 blockers.
The subject under review is the medical necessity for the use of Cimzia in this case.

The health plan's determination.

While a biologic disease modifying anti rheumatic drug (DMARD) or a targeted synthetic DMARD is indicated for this patient with uncontrolled polyarticular juvenile idiopathic arthritis (JIA) / rheumatoid factor (RF)+ rheumatoid arthritis (RA), Cimzia in specific is not medically necessary above other options given information provided.
The medical documents provided do not indicate a reason for Cimzia above the plan's available options (of Enbrel, Kevzara, or Xeljanz). Specifically, there is no mention of pregnancy or plans for pregnancy and no mention of comorbid diseases such as Crohn's disease for which Cimzia could be a better option in the medical records provided. While Cimzia is a reasonable next option, there is also no compelling reason why it has to be used in this situation above other anti-TNF agents such as Enbrel or other treatment such as Kevzara or Xeljanz. Compelling reasons would include pregnancy or plans for pregnancy, or the presence of other comorbidities such as Crohn's disease for which Cimzia would be superior to Enbrel.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Pressure
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is upheld.

This case involves a man with end-stage renal disease on hemodialysis, and human immunodeficiency virus (HIV), who presented to the hospital with abdominal pain. The patient missed dialysis for an entire week and was requesting dialysis. He was seen in the emergency department (ED). He complains of mild shortness of breath but no chest pain. The patient complains of epigastric pain that is constant and nonradiating. On examination, he was mildly tachycardic at a heart rate of 104 beats per minute (bpm), with some abdominal tenderness in the epigastric area but otherwise unremarkable. 

An inpatient hospitalization was not warranted in this case. 
This is a patient who was noncompliant with outpatient dialysis and was hospitalized to correct the problems of his noncompliance with hemodialysis, including hyperkalemia and mild volume overload. This is a relatively common problem usually managed under an alternate level of care with a rapid transition to ambulatory care.
The patient experienced hyperkalemia and shortness of breath due to mild volume overload because of missing dialysis for an entire week. After dialysis, the hyperkalemia resolved, the volume overload improved, and the patient stabilized. Furthermore, the patient was noncompliant with antihypertensives therapy and experienced elevated blood pressures. There is no clear evidence of hypertensive encephalopathy, acute myocardial infarction, or stroke to warrant an inpatient hospitalization. Patients with end-stage renal disease often suffer from severely elevated blood pressures, requiring a multidrug regimen to control these blood pressures. Initiation and titration of the blood pressure regimen can be completed in an alternate setting and does not require inpatient admission. There is no documentation stating the patient was on continuous infusion of an antihypertensive regimen, such as a Nicardipine drip, due to the risk of stroke or bleeding.