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

Diagnosis: nephrolithiasis
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a female with a past medical history remarkable for diabetes, hypertension, diverticulitis, and coronary artery disease, who was admitted for left flank pain and vomiting. Review of system was negative for additional symptoms.
The patient was afebrile, described as awake, alert, and not in acute distress. Her blood pressure was 129/78, pulse rate of 89, respiratory rate of 14, and oxygen saturation of 97% on room air. Physical examination was remarkable for left lower abdominal tenderness.
Laboratory evaluation demonstrated a sodium of 137, potassium 4.4, chloride of 99, carbon dioxide (CO2) of 26.5, blood urea nitrogen (BUN) of 25, creatinine of 1.36, glucose of 311, white blood cell count (WBC) of 10.3, HGB (hemoglobin) of 13.3, Hematocrit (HCT) of 40.4, and platelet of 258. A computed tomography (CT) scan of the abdomen revealed 1.1 centimeter (cm) left ureteral pelvic junction calculi and nonspecific bowel wall thickening.
The patient was admitted for intractable left flank pain due to nephrolithiasis, acute kidney injury, and obstructive uropathy. 

The inpatient admission was medically necessary. The care could not have been safely rendered at a lower level of care.
The patient was admitted for pain requiring IV (intravenous) hydration and urgent procedural intervention for relief of urinary obstruction. The patient presented with acute kidney injury and necessitated inpatient admission for relief of obstruction and monitoring of renal function. Renal stones are common problems that results in emergency department (ED) admissions, and many cases may end up requiring only conservative therapy and outpatient management. However, there are certain cases where nephrolithiasis can result in renal obstruction, which could cause permanent renal damage if treated inadequately. The patient presented with clinical symptoms of renal colic with laboratory/imaging findings consistent with acute kidney injury in a setting of a ureteral stone. Urgent urologic intervention is warranted in patients with severe pain and acute kidney injury. The likelihood of stone passage decreases for stones larger than 4 millimeter (mm), therefore surgical intervention was warranted for the patient, as close observation or conservative treatment would have been sub-optimal.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep Vein Thrombosis, Suicide attempt
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay
The determination is overturned.

The patient had attempted suicide and had been admitted to the hospital for critical management. In the course of her care, she developed bilateral lower extremity deep vein thromboses (DVT) and was treated with Lovenox and then Apixaban. Once she stabilized, she was transferred to the psychiatry service. While in the behavioral health unit, she developed worsening right leg pain and swelling. She was transferred from the behavioral health unit to the hospital inpatient status. Admission orders included constant monitoring based on suicide precautions, telemetry and anticoagulation with Eliquis. The right leg Doppler study  showed extensive deep vein thrombosis.
The psychiatry note states that there was a high probability of recurrent severe depression/suicidal attempt if the patient were to be discharged and that she was not safe for discharge . The vascular surgery service consulted and directed treatment with regard to the deep vein thrombosis (DVT). The patient had normal vital signs. Treatment was continued with leg elevation, Eliquis, telemetry and monitoring. She was discharged from the inpatient setting and transferred back to the psychiatry unit. At issue is the medical necessity of an inpatient stay.

Yes. An inpatient level of care was appropriate and medically necessary for this patient with acute DVT progression of the right leg and a recent suicide attempt that necessitated amputation of her hand and subsequent surgery. Admission orders included constant monitoring based on suicide precautions, telemetry and anticoagulation with Eliquis. It was reasonably expected that her care would span a period of at least 48-hours. The treating psychiatry service also advised that there was a high probability of recurrent severe depression/suicidal attempt if the patient were to be discharged and that she was not safe for discharge. The most appropriate level of care in this case was inpatient status with subsequent transfer back to the mental health unit. 
Based on the clinical needs for close/constant monitoring and treatment for progression of the right leg DVT an inpatient stay was the most appropriate. A lower level of care would not have been consistent with generally accepted standards of care given her comorbid mental health diagnosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient had abdominal pain and was found on the operative report to have a stuck appendix with purulent fluid and on pathology to have intact serosa but with purulence and serositis. There was concern for possible Meckel's diverticulum, so during the surgery, the bowel was evaluated. Her white blood cell count (WBC) was elevated on admission to 17, she had a lactic acidosis (1.9), and her heart rate was elevated to 116; all of these are worrisome for sepsis She required post operative intravenous (IV) antibiotics (Rocephin and Flagyl) and fluids. She was discharged on by mouth (PO) antibiotics.
At issue is the medical necessity of an inpatient stay.

Yes, it is medically necessary for intravenous (IV) antibiotics, IV fluid resuscitation. She had repeat labs and her WBC improved but was still elevated. Purulent appendicitis or appendicitis with serositis is not an outpatient procedure meaning that the patient cannot go home after the procedure and will require IV antibiotics and fluids This is not uncomplicated simple appendicitis. However, patients with gangrenous appendicitis can be placed on a pathway for expeditious discharge and a study in 2019 indicated no increased risk of infection or readmission (ref 1)-what would be most appropriate in this setting would be extended stay. Per reference 1, the average length of stay (LOS) for gangrenous appendicitis patients decreased from 2.5 to 1.4 days (probability [p] less than [<] 0.001) and antibiotic doses decreased from 5.2 to 1.3 (p < 0.001). Only one gangrenous appendicitis patient required readmission, and one patient in each group developed a superficial infection; there were no postoperative abscesses. Per references 2 and 3, care delivered was within American practice standards
This was a complicated appendicitis without rupture and does not fit the diagnosis of acute uncomplicated appendicitis This patient required IV antibiotics as well as fluids. Sepsis can occur in appendicitis and this patient demonstrated an elevated WBC and elevated lactate and tachycardia; those are the risk factors dictating the need for safe care in a monitored setting. InterQual data about a risk of venous thromboembolism in children is not applicable- kids rarely get venous thromboembolism (VTE) so applying this in this setting is not appropriate. Outpatient stay is not appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient had abdominal pain and was found on the operative report to have a stuck appendix with purulent fluid and on pathology to have intact serosa but with purulence and serositis. There was concern for possible Meckel's diverticulum, so during the surgery, the bowel was evaluated. Her white blood cell count (WBC) was elevated on admission to 17, she had a lactic acidosis (1.9), and her heart rate was elevated to 116; all of these are worrisome for sepsis She required post operative intravenous (IV) antibiotics (Rocephin and Flagyl) and fluids. She was discharged on by mouth (PO) antibiotics.
At issue is the medical necessity of an inpatient stay.

Yes, it is medically necessary for intravenous (IV) antibiotics, IV fluid resuscitation. She had repeat labs and her WBC improved but was still elevated. Purulent appendicitis or appendicitis with serositis is not an outpatient procedure meaning that the patient cannot go home after the procedure and will require IV antibiotics and fluids This is not uncomplicated simple appendicitis. However, patients with gangrenous appendicitis can be placed on a pathway for expeditious discharge and a study in 2019 indicated no increased risk of infection or readmission (ref 1)-what would be most appropriate in this setting would be extended stay. Per reference 1, the average length of stay (LOS) for gangrenous appendicitis patients decreased from 2.5 to 1.4 days (probability [p] less than [<] 0.001) and antibiotic doses decreased from 5.2 to 1.3 (p < 0.001). Only one gangrenous appendicitis patient required readmission, and one patient in each group developed a superficial infection; there were no postoperative abscesses. Per references 2 and 3, care delivered was within American practice standards
This was a complicated appendicitis without rupture and does not fit the diagnosis of acute uncomplicated appendicitis This patient required IV antibiotics as well as fluids. Sepsis can occur in appendicitis and this patient demonstrated an elevated WBC and elevated lactate and tachycardia; those are the risk factors dictating the need for safe care in a monitored setting. InterQual data about a risk of venous thromboembolism in children is not applicable- kids rarely get VTE so applying this in this setting is not appropriate. Outpatient stay is not appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, ischemic heart disease.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This patient has a history of ischemic heart disease, hypertension (HTN), diabetes mellitus (DM) and chronic kidney disease. He presented to the hospital for elective cardiac catheterization as part of a staged revascularization procedure. The patient initially presented with chest pain and underwent right carotid artery (RCA) percutaneous coronary intervention. Cardiac catheterization was performed via right radial artery approach and revealed a patent stent in the RCA, diffuse disease of the left anterior descending (LAD) artery, 80 percent occlusion of the first obtuse marginal artery and a 90 percent occlusion of the second obtuse marginal artery. Drug eluting stents were placed in the first and second obtuse marginal arteries. No perioperative complications were noted, and the patient was discharged the following day.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference 1-4).  Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care (Reference 4).  In conclusion, inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Colitis

Treatment: Mesalamine 400 milligrams OR (oral route) CPDT (community pharmacy development team)

The insurer denied coverage for Mesalamine 400 milligrams OR CPDT

The denial is upheld.

The patient was having abdominal pain. A computed axial tomography (CAT) scan showed thickening of the colon. A colonoscopy revealed inflammatory changes. Biopsies showed chronic colitis. She was treated with antibiotics but continued to have symptoms. Her physician has advised that she go on mesalamine.

The American College of Gastroenterology guideline on Management of Crohn's Disease in Adults discusses treatment of mild to moderately severe disease. It advises that Sulfasalazlne is effective in treating of symptoms. Oral mesalamine has not been consistently shown to be of benefit for active disease such as in this clinical scenario.

This patient has segmental colitis and there is a concern about inflammatory bowel disease (IBD), Mesalamine has been shown to be useful for ulcerative colitis but less so for this patient's diagnosis/disease. However, there is no recommendation that mesalamine is more effective for a segmental colitis as compared to the formulary alternatives. The formulary medications Include mesalamine extended release and Sulfasalazine. If her physician feels that mesalamine is indicated for this segmental colitis, she could have been treated with the mesalamine extended release which is on the formulary.

The patient has been offered formulary alternatives for a segmental colitis. Since Mesalamine extended release and Sulfasalazine have not been tried and failed, the health care plan acted reasonably and with sound medical judgment. Mesalamine 400 mg capsules are not medically necessary.

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

The insurer's denial of coverage for Mesalamine 400 milligrams OR CPDT is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Optic Neuritis

Treatment Gammagard 10 grams (gm)/100 injection (inj)

The insurer denied coverage for Gammagard 10 grams (gm)/100 injection (inj)

The denial is upheld

The patient has hereditary optic atrophy and bilateral optic neuritis. Visual acuities were count fingers in the right eye (OD) and 20/200 in the left eye (OS).  Diagnosis of optic neuritis was noted, with patient having bilateral vision loss.  Plan was for intravenous immunoglobulin (IVIG) infusions.  It was noted that the patient was referred by ophthalmology for IVIG infusions for optic neuritis and will start monthly IVIG.  High-dose steroid administration like that with methylprednisolone is typically used as first-line treatment for acute optic neuritis.  There is no documentation in the medical records that the patient has tried, has intolerance to, or contraindication to the use to corticosteroids.

There is currently no evidence in the literature that intravenous immunoglobulin (IVIG) is more effective than corticosteroids.  High-dose steroid administration is usually used as first-line treatment for acute optic neuritis.  In patients who do not respond to steroids and continues to have vision loss, IVIG are alternative immunomodulatory therapies that may offer additional benefit for acute optic neuritis treatment (Altunrende, Horton).

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

The insurer's denial of coverage for Formulary Exception for Gammagard 10 grams (gm)/100 injection (inj) to treat optic neuritis is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertriglyceridemia. 
Treatment: Fenofibrate Capsules 130mg. 

The insurer denied fenofibrate capsules 130mg. 
The determination is upheld. 

The patient has a history of diabetes, obesity and hypertriglyceridemia requesting coverage for fenofibrate micronized 130 milligram (mg) capsules.
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug , or would have adverse effects. 

Based on a thorough review of the information provided and a review of the medical literature as cited in the reference below, there is no evidence that the formulary fenofibrate products will be or have been ineffective, would not be as effective as the non-formulary drug (fenofibrate micronized 130 mg capsules), or would have adverse effects. All of these products are essentially interchangeable. There is no evidence that the patient tried and failed the formulary medications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Rubraca. 
The denial is upheld.

The patient is a male with metastatic pancreatic cancer. The patient has progressive disease following treatment with FOLFIRINOX. The patient has a germline PALB2 mutation. Rubraca has been recommended and is under review for medical necessity.

The health plan's determination is upheld.

The benefit of rucaparib (Rubraca) in this clinical scenario remains the subject of ongoing investigation in a number of trials including, but not limited to, National Clinical Trial (NCT) 04171700. Neither the National Comprehensive Cancer Network (NCCN) nor the author of UpToDate recommend the use of this agent in this clinical scenario. While there is data to support poly adenosine diphosphate (ADP) ribose polymerase (PARP) inhibition in patients such as this, the literature supporting that approach is based on research done with another agent, olaparib; it is not clear that these are interchangeable. For these reasons, medical necessity cannot be established for this service.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 Diabetes Mellitus.
Treatment: Formulary exception for Januvia.
The insurer denied the Formulary exception for Januvia.
The denial is overturned.

The patient is a female with type 2 diabetes. The request for Januvia is under review. The prior request was denied by the health plan, as approval on criteria requires a trial and failure, intolerance, or contraindication to Tradjenta. The attending physician is appealing this determination as the patient has been stable on Januvia. The patient has previously tried Tradjenta.

Yes, the health plan should cover the Formulary exception for Januvia.
This request is for Januvia for the treatment of type 2 diabetes. The prior authorization indicates that the patient has tried the formulary alternative Tradjenta. This patient is stable on Januvia therapy. Without Januvia, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: complete traumatic metacarpophalangeal amputation of the right index finger
Treatment: Custom High Definition Passive Functional Aesthetic Silicone Prosthesis: Artificial Finger, with Prosthetic Shrinker. 
The insurer denied Custom High Definition Passive Functional Aesthetic Silicone Prosthesis: Artificial Finger, with Prosthetic Shrinker. 
The health plan's determination is overturned. 

This is a female who was diagnosed with a complete traumatic metacarpophalangeal amputation of the right index finger. The injury occurred when the patient's finger was caught in a leash when the dog took off. Under review is the request for a Custom High Definition Passive Functional Aesthetic Silicone Prosthesis: Artificial Finger, with Prosthetic Shrinker(s). The request was denied by the health plan as the requested artificial finger exceeds basic health needs, there are alternative prosthetic fingers that can treat the condition, the requested codes did not match the requested item, and cosmetic and reconstructive procedures are not covered.

Custom High Definition Passive Functional Aesthetic Silicone Prosthesis: Artificial Finger, with Prosthetic Shrinker(s) is medically necessary for this patient.
In this case, the patient sustained a complete traumatic metacarpophalangeal amputation of the right index finger and has functional deficits including difficulty holding and grasping objects and typing. The patient has been recommended for a silicone prosthesis to improve function and cosmesis. The article cited below from the Disability and Rehabilitation Journal states that silicone prosthesis for finger amputation of the upper limb play an important role in process of adaptation to amputation and improve the amputee's quality of life. Rehabilitation of a finger deformity with a silicone prosthesis offers psychological, functional, and aesthetic advantages. In consideration of the available information, Custom High Definition Passive Functional Aesthetic Silicone Prosthesis: Artificial Finger, with Prosthetic Shrinker(s) is medically necessary and appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Trauma
Prosthetics (Devices)

Diagnosis: complete traumatic metacarpophalangeal amputation of the right index finger
Treatment: Custom High Definition Passive Functional Aesthetic Silicone Prosthesis: Artificial Finger, with Prosthetic Shrinker. The health plan's determination is overturned. 

This is a female who was diagnosed with a complete traumatic metacarpophalangeal amputation of the right index finger. The injury occurred when the patient's finger was caught in a leash when the dog took off. Under review is the request for a Custom High Definition Passive Functional Aesthetic Silicone Prosthesis: Artificial Finger, with Prosthetic Shrinker(s). The request was denied by the health plan as the requested artificial finger exceeds basic health needs, there are alternative prosthetic fingers that can treat the condition, the requested codes did not match the requested item, and cosmetic and reconstructive procedures are not covered.

Custom High Definition Passive Functional Aesthetic Silicone Prosthesis: Artificial Finger, with Prosthetic Shrinker(s) is medically necessary for this patient.
In this case, the patient sustained a complete traumatic metacarpophalangeal amputation of the right index finger and has functional deficits including difficulty holding and grasping objects and typing. The patient has been recommended for a silicone prosthesis to improve function and cosmesis. The article cited below from the Disability and Rehabilitation Journal states that silicone prosthesis for finger amputation of the upper limb play an important role in process of adaptation to amputation and improve the amputee's quality of life. Rehabilitation of a finger deformity with a silicone prosthesis offers psychological, functional, and aesthetic advantages. In consideration of the available information, Custom High Definition Passive Functional Aesthetic Silicone Prosthesis: Artificial Finger, with Prosthetic Shrinker(s) is medically necessary and appropriate for this patient.