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

Diagnosis: Perirectal abscess 
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is an adult male who had an inpatient hospital admission.  There was a history of status post superficial fistulotomy, anal warts, and debridement of intramural rectal abscess.  The patient presented to the hospital with rectal pain and drainage x (times) 3 weeks.  Vital signs on the patient noted blood pressure 136/92, pulse of 110, temperature of 98.7 degrees F (Fahrenheit), and respirations of 18.  Laboratory results noted white blood cells of 8.8, sodium of 134, magnesium of 1.3, hemoglobin of 12.9, and hematocrit of 37.3.  There was a plan to rule out perirectal abscess versus fistula. 
Computed tomography (CT) of the abdomen noted rectal wall thickening.  There was a 3.6 x 1.3 x 1.2 centimeters (cm) horseshoe shaped posterior perianal abscess at the level of the anorectal junction, in a similar location to the prior magnetic resonance imaging (MRI).  A fistula tract was difficult to delineate.  The patient had a general surgery consult and was started on intravenous (IV) antibiotics and fluids.  The patient was admitted and there was a plan for exploration under anesthesia.  The patient underwent a surgical intervention.  There was aspiration of small amount of air/fluid with no fistula seen.  Small internal hemorrhoids were noted.  The patient was deemed appropriate for discharge with oral antibiotics and follow-up.

Per the cited reference, admission to the hospital may be indicated when there is hemodynamic instability that is not readily corrected by appropriate treatment and for conditions for which observation care has failed or is not considered appropriate.  In this case, the patient presented to the hospital with concerns of perirectal abscess versus fistula.  It was argued that the inpatient hospital stay was medically necessary for the patient based on severity of symptoms and persistence of symptoms despite initial aggressive management.  However, the documentation did not detail hemodynamic instability that did not respond to appropriate treatment.  The patient did not have persistent or severe symptoms that could not be managed at observation level of care. 

Based on the above, the insurer's denial must be upheld.  The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Childbirth. 
Treatment: Full Hospital Admission - Neonatal Intensive Care Unit (NICU). 
The insurer denied Full Hospital Admission - Neonatal Intensive Care Unit (NICU). 
The health plan's determination is overturned. 

The female patient was born by vaginal delivery at 41 weeks' estimated gestational age to a primigravida mother. Mild shoulder dystocia was noted during the delivery. She was noted to have a nuchal cord x1 and was initially floppy but responded to routine newborn resuscitation. Her Apgar scores were 7 and 8 at one and five-minutes of age. Her birth weight was 3.93 kilograms. 
The infant was initially admitted to the newborn nursery, but she had a dusky episode and drop in oxygen saturation to the high 80's during which she turned red and the saturation was then in the low 80's. She was noted to possibly be breath holding. The neonatologist was consulted, and the infant was transferred to the Neonatal Intensive Care Unit at approximately 6 hours of life for further stabilization and management. 

The requested Inpatient Hospital Admission-Neonatal Intensive Care Unit (NICU) was medically necessary for this patient. 
 
On day 1, the patient was hemodynamically stable; mild grunting/subcostal retractions on admission that resolved without intervention; chest x-ray consistent with retained lung fluid. A head ultrasound was obtained and was read as normal. Magnetic resonance imaging (MRI) of brachial plexus obtained. Oxygen saturation was 99% in room air at admission. Temperature instability was noted and the neonate was in the incubator.
On day 2, the patient was hemodynamically stable, breathing unassisted on room air; ad lib feeding in an open crib; and diagnosed with Erb's palsy. 
On day 3, there were no changes. The plan was to monitor for apnea, bradycardia, desaturation events for 3 days. Critical congenital heart disease screen was passed; Hepatitis B vaccine was given. Hearing screen passed. 
On day 4, there were no changes; echocardiogram showed patent foramen ovale and no patent ductus arteriosus; medically stable for discharge to home with the parents.
During the dates in question, the infant met inpatient criteria for Admission-Neonatal Intensive Care Unit secondary to the criteria: temperature instability, meconium stained amniotic fluid and polycythemia. A lower level of care was not appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient is an adult female with a diagnosis of sickle cell disease (SCD). The patient was admitted for anemia, fatigue, shortness of breath (SOB), and weakness. The physical examination showed scleral icterus, pale skin, and protruded abdomen with palpable splenomegaly. Lab testing was done revealing a very low hemoglobin level of 5.3 grams per deciliter (g/dL), and a very low hematocrit level of 14.5, and a high creatinine level of 2.1 milligrams per deciliter (mg/dL). The request is for inpatient admission, which is under medical necessity review.

The admission is appropriate due to the level of the anemia that would require several units of blood to be transfused, kidney dysfunction, a symptomatic patient, and significant symptoms that cannot all be assumed to be related to an uncomplicated anemia. In a patient with a history of prior multiple transfusions, it cannot be assumed that the hemoglobin (Hb) level will sufficiently rise and requires monitoring. Transfusions require about eight hours to complete.      

"Red cell transfusions remain a mainstay of therapy for patients with sickle cell disease (SCD), but pose significant clinical challenges. Guidance for specific indications and administration of transfusion, as well as screening, prevention, and management of alloimmunization, delayed hemolytic transfusion reactions (DHTRs), and iron overload may improve outcomes." (Chou, S. T., et al. 2020).

"Sickle cell disease (SCD) is a red blood cell (RBC) disorder caused by a single nucleotide substitution in the -globin allele on chromosome 6 that results in sickle hemoglobin (HbS).1,2 At low oxygen concentrations, HbS polymerizes, causing RBCs to distort into a crescent or sickle shape (Figure 1). These fragile, sickled RBCs lead to recurrent, severe pain and to progressive damage in nearly every organ system. Transfusion of RBCs mitigates, treats, or prevents a variety of complications of SCD (Table 1). Through RBC transfusion therapy, the burden of sickled cells is reduced, allowing for improved oxygen-carrying capacity and perfusion throughout the vascular system.1-3 RBCs can be delivered via simple transfusion or exchange transfusion." (Han, H., Hensch, L., & Tubman, V. N. 2021). 

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

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

This is a female patient with a history of Hodgkin's lymphoma and recently diagnosed type 1 diabetes who presented to the emergency department for an insulin refill and referral to endocrinology. She had blurry vision, variable glucose levels with hyperglycemia, polyuria, polydipsia, and weight loss. She was unable to fill her Tresiba insulin as it was not covered by insurance. She was diagnosed with vaginal candidiasis and treated with fluconazole.  She was treated with intravenous fluids and admitted to medicine. Her subcutaneous insulin doses were adjusted. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.
The patient presented with minimal hyperglycemia with a glucose of 197 milligrams per deciliter (mg/dL) without acidosis. Her carbon dioxide (CO2) level and potential hydrogen (pH) level were normal and her urine ketones were negative. The patient did not have acute renal failure or dehydration or significant electrolyte abnormality. She was hemodynamically stable. Her outpatient insulin regimen was known and her insulin doses were adjusted. Therefore, no, the requested inpatient stay was not medically necessary based on Milliman Care Guidelines (MCG) 26th Edition Endocrinology Diabetes. There was no medical indication for admission outside of these criteria. This patient had vaginal candidiasis, which does not require inpatient treatment. She did not have diabetic ketoacidosis. She required assistance with filling her insulin prescription and with scheduling an endocrinology appointment, neither of which required an inpatient admission. Therefore, the requested inpatient stay was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: low back pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

This adult female with a history of morbid obesity (BMI (Body mass index)=53) had an acute episode of low back pain and was unable to walk and do her activities of daily living (ADLs).  She was transported by ambulance to the Emergency Room and was given Intravenous (IV) Morphine which did not reduce her pain and caused nausea.  She was admitted and given non-steroidal anti-inflammatory (NSAIDs) and oral opiates.  Admission noted acetaminophen and prn (as needed) lidocaine patches. A magnetic resonance image (MRI) was ordered, and an Epidural steroid injection was administered on Day 4 of her admission. The MRI showed spinal stenosis, ligamentum flavum hypertrophy and resolution of previously documented herniated disc.

The patient had RED Flags symptoms and was administered intravenous opiates initially. However, was subsequently switched to oral medications and by Day 3 the progress note states "pain much improved, previously not able to sit straight up. Now able to walk with improved pain. Pending open MRI today than steroid injection."  

Clinical practice guidelines (1) support admission when there are Red Flag symptoms.
Casazza (2) reviewed concerning symptoms (Red Flags) that should prompt aggressive treatment.  The patient had motor weakness in being unable to ambulate:
"Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis), major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and suspected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required."

However, the full in-patient hospital Admission was not medically necessary.  As noted by Day 3 the patient was improved, ambulating with improved pain.  It was NOT medically necessary to remain an inpatient while awaiting magnetic resonance imaging (MRI) and an Epidural Steroid injection while taking oral medications.  

Based on the above, the insurer's denial must be modified. 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 inpatient admission for 3 days is substantiated. However, continuing admission after three days is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male. The patient presented with right lower back pain radiating into the right leg with right leg weakness. The patient presented after a workplace injury. The patient presented to the emergency department where an x-ray and computed tomography (CT) scan were performed. The patient represented to the emergency department and was admitted and then discharged the next day.

The proposed treatment is not medically necessary.

The documentation provided does not demonstrate any significant findings that would warrant the acute inpatient hospitalization of this patient. While there is documentation that the patient had pain, there is insufficient evidence that the patient had significant findings that warranted acute inpatient hospitalization. These would include significant pain, requiring intravenous pain medication, significant neurological deficit, or other findings that warranted this type of hospitalization. Therefore, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numbness, weakness, and dizziness
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She has a past medical history of hypertension, obesity, and hyperlipidemia. She presented to the emergency department with the complaints of left lower extremity numbness, weakness, and dizziness. At presentation, the patient had sensory deficits and weakness of her left lower extremity. Vital signs were stable. Computed tomography (CT) scan was negative for acute pathology. Her National Institutes of Health (NIH) Stroke Scale score was 1. She was admitted for further evaluation. Subsequent magnetic resonance imaging (MRI) of the brain was negative for acute stroke.

The Inpatient admission was not medically necessary.

The patient presented with left lower extremity symptoms. She had a stroke scale of 1, negative computed tomography scan, and stable vital signs. Current standard of care guidelines does not support acute inpatient admission for NIH (National Institutes of Health) Stroke Scale score of 1 (1). The monitoring, diagnostic studies, and treatment could have been provided at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Localized-related (focal) (partial) idiopathic epilepsy
Treatment: Aptiom 600 milligram (mg) tablet
The insurer denied the request for Aptiom 600 mg tablets.
The health plan's determination is upheld.

The patient is a female who is diagnosed with localized-related (focal) (partial) idiopathic epilepsy and epileptic syndromes. Treatment with Aptiom 600 milligram (mg) tablets is the subject of this review. The drug was denied because the patient has not tried and failed three formulary alternatives including Carbamazepine extended release, Celontin, Clobazam, Clonazepam, Clorazepate, Diazepam, Divalproex Sodium extended release and delayed release, Felbamate, Fycompa, Gabapentin, Lacosamide, Lamotrigine, Lamotrigine Extended Release, Levetiracetam, Levetiracetam Extended Release, Oxcarbazepine, Phenobarbital, Phenytoin, Phenytoin Extended Release, Pregabalin, Primidone, Rufinamide, Tiagabine, Tapir, Valproate, Valproic Acid, Vigabatrin, Xcopri, or Zonisamide. The provider appealed this determination.

The patient has tried and failed to formulary alternatives including Levetiracetam and Oxcarbazepine. There is no documentation that the patient has tried and failed any of the remaining formulary agents. There is no compelling evidence that all of the old formulary alternatives would not be as effective as the nonformulary drug or would have adverse side effects for treatment of the patient's localization related epilepsy.
There are limited studies that directly compare Aptiom to other anticonvulsants. In one meta-analysis, seizure control was similar for Aptiom, Fycompa, and Limpet (Lacosamide). Many of the formulary alternatives are recognized as treatment for focal seizures or localization related epilepsy. Additionally, the physician notes that the patient is treated with Oxcarbazepine and a similar drug is desired; however, there is no documentation that the patient has tried and failed Carbamazepine or Carbamazepine extended-release. This drug is in the same family as Aptiom and Trileptal (Oxcarbazepine). The provider notes that Oxcarbazepine is being discontinued due to dizziness; however, dizziness is one of the most common side effects of Aptiom. The health plan's determination is not changed after review of the additional records.

The health plan's determination is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Migraine Headaches
Treatment: Qulipta 60 Milligram Tablet
The insurer denied: Qulipta 60 Milligram Tablet
The denial is overturned.

The patient is an adult female with chronic migraines. She is currently on Qulipta via samples and that has been effective. She has not tried Aimovig, Emgality or Ajovy due to needle phobia. She had previously tried Topamax, amitriptyline, Depakote and Inderal with side effects. The provider is requesting Qulipta. The request was previously denied as the patient had not tried and failed or is intolerant of all formulary alternatives.

The health plan should cover the proposed Qulipta.

Qulipta should be covered. Needle phobia is a valid reason for this patient not trying any of the other anti-calcitonin gene-related peptide (CGRP) medications given that they are injections. The patient has already found success with Qulipta which is a oral preventative anti-calcitonin gene-related peptide medication for migraines. The patient already meets American Headache Society anti-calcitonin gene-related peptide guidelines for starting anti-calcitonin gene-related peptide medication as she has tried and failed or was intolerant to at least two oral preventative medications and therefore formulary alternatives that are not anti-calcitonin gene-related peptide medications would not be appropriate.
Appeal type: Formulary Exception
Decision: Overturned

Digestive System/Gastrointestinal
Pharmacy/Prescription Drug

Diagnosis: Chronic Idiopathic Constipation
Treatment: Motegrity (prucalopride) 
The insurer denied Motegrity (prucalopride).
The determination is overturned.

This is a medically complex child, with chronic lung disease (CLD), cystic periventricular leukomalacia (PVL) (GRADE 1 Intraventricular hemorrhage (IVH)), spontaneous bowel perforation (cecal) with multiple complication and surgical interventions (bowel resection of ascending colon, cecum, ileocecal valve (ICV) and 10 centimeters (cm) of ileum) ileostomy times (x) 2 status/post (s/p) reversal with ileum connected to transverse colon); immature ganglion cells on rectal biopsy (with normal ganglion cells noted on repeat surgical path), gastroesophageal reflux disease, gastrostomy (G)-tube dependence with chronic recurrent abdominal distention, feeding intolerance, emesis and severe malnutrition currently on cyproheptadine and erythromycin with ongoing abdominal distention( on intermittent rectal decompression) resulting in feeding intolerance subsequent failure to thrive with suboptimal response to current promotility medications. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Motegrity (prucalopride) or would have adverse effects.

Linzess would not be appropriate in this case as the patient as it is reported to have a potential for causing severe diarrhea and dehydration in this patient's age group. 
Though a prior study by Hyman et al showed effectiveness of Lubiprostone in treating functional constipation, a recent study in pediatric patients by Beninga et al did not demonstrate significant effectiveness of Amitiza over placebo in children with functional constipation. This patient is medically complex and has gastrointestinal dysmotility which makes it less ideal for this patient who has both upper gastrointestinal and lower gastrointestinal dysmotility. No recent studies have shown the efficacy of the Lubiprostone on upper gastrointestinal motility which is a significant issue in this medically complex child. 
Recent studies by Hirsch et al showed the utility of prucalopride in children with refractory upper gastrointestinal symptoms including reflux and feeding intolerance. In this study, they showed that approximately (~) 50 percent (%) of all the children reported improvement in symptoms at their first follow up appointment with feeding difficulty improving in 79 % and constipation in 64%. Winter et al also showed significant improvement in constipation for children treated with prucalopride.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Acute stress reaction
Treatment: Xanax
The insurer denied: Xanax
The denial is overturned.

This case involves an adult male who is prescribed Xanax extended release (XR) for the treatment of acute stress reaction (revenue code F43.0). The health plan has denied authorization for coverage of Xanax indicating that this medication is non-formulary and that at least three alternative formulary medications, diazepam, clonazepam, lorazepam, alprazolam or oxazepam, must have been tried and failed due to lack of efficacy or tolerability issues/adverse effects. The request for Xanax is considered not medically necessary under the plan per the health plan policy and criteria for a formulary exception.
The appeal is based on clinical judgment and the Food and Drug Administration (FDA) indicated use for the treatment of the condition diagnosed in this case. The appeal indicates that the patient has been successfully treated with brand Xanax since 2011 with a positive therapeutic response and tolerability without adverse effects. The appeal notes that the patient had failed treatment with alprazolam, clonazepam/Klonopin, and lorazepam prior to treatment with brand Xanax. The issue under review and reason for referral is Brand Xanax (alprazolam).

The health plan should cover the proposed treatment with Xanax.

In this case, three formulary drugs have been tried and failed as required under the plan indicating that the patient meets plan criteria for a formulary exception. Moreover, the remaining formulary alternatives would not be as effective as the requested non-formulary drug which has been effective since 2011 without adverse effects, and, the remaining formulary alternatives, oxazepam and diazepam, would pose risk for adverse effects for this patient. In summary, three formulary drugs have been ineffective for this patient due to adverse effects and a switch from the non-formulary drug to one of the two remaining formulary alternatives would not be as effective as the requested non-formulary drug. Additionally, the health plan's requirements for a coverage exception are met in this case, and the approval for continuing the requested treatment as proposed is reasonable, in the patient's best interest and reflects sound medical judgment in keeping with New York State instruction for this review and prevailing standards of medical practice, as well as the scientific literature, referenced below.