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

Diagnosis: Symptomatic microcytic anemia.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of anemia, fibroids, methadone-dependency, and hypertension (HTN) and was admitted with complaints of (c/o) lightheadedness and vertigo without respiratory distress, pale skin. Her vital signs on admission were unremarkable, with a normal blood pressure (BP) and pulse. The physical exam was notable for non-ill appearing, non-toxic appearing. Lab work showed a hemoglobin of 4.4 and hematocrit of 15.6. The patient was diagnosed with symptomatic microcytic anemia and treated with intravenous fluids (IVF) and blood transfusion times (x) 3. The patient was discharged in stable condition. At issue is whether the inpatient stay was medically necessary.

The hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the emergency department (ED) with c/o lightheadedness and vertigo without respiratory distress. The patient was found to have a low hemoglobin with a known history of uterine bleeding with fibroids, but had no history of hematochezia, hematemesis, or melena. The patient received three units of packed red blood cells (PRBCs), symptomatically improved, and was discharged home in stable condition. The patient did not have hemodynamic instability, persistent orthostasis, evidence of active bleeding in the ED (such as frequent episodes of hematemesis, melena, or bright red blood per rectum (BRBPR), coagulopathy, or known esophageal varices. This patient could have been safely observed and received diagnostic work-up, consultation and transfusion at a lower level of care.
Regarding the Milliman Care Criteria, the patient did not have hemodynamic instability, active hemolysis, active bleeding that cannot be controlled at a lower level of care, severe or persistent altered mental status (AMS), recurrent syncope, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low-platelet count, acute renal failure, heart failure, chest pain, myocardial ischemia, dyspnea not responsive to treatment, or need for pulmonary artery catheter monitoring or urgent inpatient surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Dupixent 300MG/2ML SC SOPN. 
The denial is overturned. 

This is a male patient with a history of atopic dermatitis. He has tried topical steroids and methotrexate. Tacrolimus was tried as well but he had infections. Dupixent has been recommended by his provider.
At issue is the medical necessity of Dupixent 300 milligrams (MG)/2 milliliters (ML) subcutaneous (SC) solution pen injector (SOPN).

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Dupixent 300MG/2ML SC SOPN is medically necessary for this patient
Dupixent is indicated for treatment of moderate-to-severe atopic dermatitis not adequately controlled with topical prescription therapies age 6 and older. The safety and efficacy of Dupixent was established in three randomized, double-blind, placebo controlled pivotal studies by Wollenberg et al. The populations in these trials included adults that had atopic dermatitis for at least 3 years and had involvement of 10% of the body surface area. The study entrants were also previously uncontrolled by topical therapies. In all studies, the primary endpoint was a score of 0 (clear) or 1 (almost clear) on the Investigator's Global Assessment (IGA) and a reduction of 2 points from baseline to week 16. In the SOLO-1 trial, the primary endpoint was met in 38% of subjects in the Dupixent group versus 10% of subjects in the placebo group. In the SOLO-2 trial, the primary endpoint was achieved in 36% of subjects in the Dupixent group versus 18% in the placebo group. 
According to Beck et al (2014), "Patients treated with dupilumab had marked and rapid improvement in all the evaluated measures of atopic dermatitis disease activity. Side-effect profiles were not dose-limiting." 
Per Draelos, Z.D., et al 2019 "Topical therapies are the cornerstone of atopic dermatitis (AD) management, beginning with emollients and moisturizers as first-line therapies. Topical corticosteroids (TCSs), which suppress antigen processing and proinflammatory cytokine release in immune cells, are first-line anti-inflammatory therapies. Second-line therapies include topical calcineurin inhibitors (TCIs), which inhibit calcineurin-dependent activation of T cells. TCIs are recommended for AD unresponsive to TCSs, for situations in which TCS use is inadvisable, and for proactive maintenance (application 23 times weekly to flare-prone areas)."
Dupixent received recent United States Food and Drug Administration (FDA) approval for ages 6 and up. In this case, the patient has tried first line therapies for atopic dermatitis and Dupixent is necessary.
Therefore, the requested health service/treatment of Dupixent 300MG/2ML SC SOPN is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a boy with asthma who presented to the emergency department with respiratory distress.

He was well until 1 day prior to presentation when he began to sneeze and cough. He also complained of a sore throat at that time. That evening he awoke with coughing and respiratory distress and had one episode of post-tussive emesis. He was given albuterol twice with only temporary relief. Due to the persistence of his respiratory distress, he was brought to the emergency department for care.

In the emergency department, he was febrile to 38.6 degrees Celsius and was noted to be in acute distress with tachypnea (respiratory rate of 42) as well as accessory muscle use and wheezing. His oxygen saturation was noted to be 92% (percent) on room air.

The inpatient hospital admission was medically necessary for this patient.

Children with asthma who have respiratory distress on arrival and who have little improvement after initial therapy with beta-agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and poor aeration. Hospitalization is also indicated for patients who require beta-agonist therapy more often than every four hours.

This patient had insufficient improvement after aggressive treatments in the emergency department and initially required beta-agonist therapy every 3 hours. Therefore, inpatient hospital admission for ongoing treatment and monitoring was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Other- neurogenic thoracic outlet
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

Patient with no past medical history (PMH) was admitted with complaints of (c/o) right arm pain, weakness, and numbness, with similar symptoms occurring six months prior with negative work-up. Vital signs were unremarkable. Physical exam on admission showed no focal neurologic deficits. Lab work was unremarkable. Imaging studies, computed tomography (CT) scan of the head showed no acute intracranial process, possible right posterior fossa atrioventricular (AV) fistula, magnetic resonance imaging (MRI) study of the brachial plexus was normal, computed tomography angiography (CTA) scan extremities showed poor perfusion in several right upper extremity (RUE) arteries. Neurology evaluated the patient and noted that arteriovenous fistula (AVF) would not explain her symptoms, even if present, and patient was discharged for neurological and vascular work-up as an outpatient. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with possible transient ischemic attack (TIA) and treated with radiological and biochemical work-up, as well as vascular work-up for RUE findings. The patient was discharged in stable condition.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o right arm pain, weakness, and numbness not associated with persistent focal neurologic findings. The patient's ABCD2 (TIA stroke risk calculator) score was 3, indicating a low risk for recurrent risk of stroke (approximately (~)1% at 7 days), suggesting that a lower level of care was appropriate for this patient. In addition, the eventual diagnosis of TIA/cerebrovascular accident (CVA) was not confirmed by neurology but was eventually diagnosed with neurogenic thoracic outlet and brachial plexopathy. Further suggestion that this patient was appropriate for a lower level of care is that the patient did not have a crescendo TIA, head CT was negative, no known extracranial embolic source such as atrial fibrillation or artificial heart valve, known carotid stenosis, or hypertensive encephalopathy. The patient received thorough work-up and expert consultations while remaining clinically stable, and these interventions could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary embolism
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned.

The patient is a female who initially presented to the emergency department with concerns for chest pain. Pertinent history included a pulmonary embolism treated with Eliquis and colon cancer status/post (s/p) sigmoidectomy actively treated with chemotherapy. Initial vital signs revealed a temperature of 97.8 degrees Fahrenheit, heart rate (HR) 100, blood pressure (BP) 150/86, respiratory rate (RR) 24, and peripheral capillary oxygen saturation (SpO2) 98% (percent) on room air. An electrocardiogram (EKG) revealed sinus tachycardia at 104 beats per minute (bpm). Initial laboratory testing revealed a white blood cell count (WBC) of 4.2, hemoglobin (HGB) 14.1, platelets (Plt) 194, blood urea nitrogen (BUN) 12, Cr (creatinine) 1.1, Na (sodium) 132, K (potassium) 3.9, carbon dioxide (CO2) 23, Glucose 423, and Troponin high sensitivity (HS) negative. Chest radiograph was unremarkable. A computed tomography (CT) angiogram of chest revealed extensive pulmonary embolus in the distal right main pulmonary artery extending into numerous branches and segmental pulmonary embolus in the left lower lobe. 

Based on the clinical documentation provided, evidence based literature, and standards of care, the acute inpatient hospital stay was medically necessary.

The patient had a simplified pulmonary embolism severity index of 2 (malignancy, systolic BP < [less than] 100), which would classify as high risk (8.9% risk of death in 30 days).

A pragmatic evaluation was published in the Journal of Thrombosis and Hemostasis which investigated the safety of treating patients in the outpatient setting who presented acutely with symptomatic pulmonary embolism. The results showed that at least 50% of patients presenting acutely with symptomatic pulmonary embolisms can be treated as outpatients. The patients did not have serious comorbid conditions and did not have tachycardia, hypotension, or hypoxia requiring oxygen therapy. [1] In this particular situation, the patient would not have been a candidate for outpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Short Stature.
Treatment: Norditropin 5mg/milliliter (mg 1.5mg) Pen (code J2941).
The insurer denied the Norditropin 5mg/ milliliter (mg 1.5mg) Pen (code J2941).  
The denial is upheld.

The patient is a male with a stable height at 12% measured by the Pediatric Endocrinologist, although there is a previous history of being 50% approximately seven years ago and 25% approximately two years ago.

The patient's testes were < [less than] 4cc (cubic centimeters) (TS [tanner stage] 1). Predicted height of 5'6", compatible with an MPH (mid-parental height) of 5'5.5" (Mother 59", Father 67.5"). Labs showed normal CBC (complete blood count), chemistries, thyroid, Celiac, LH (luteinizing hormone)/FSH (follicle stimulating hormone)/testosterone. IGF-1 (insulin-like growth factor 1) was 125, and IGFBP-3 (insulin-like growth factor binding protein 3) 3.03. GH (growth hormone) stimulation with arginine/clonidine showed a peak GH (growth hormone) of 12.9 (> [greater than] 10). An older brother was treated with GH (growth hormone) for genetic SS (short stature). No CT (computed tomography)/MRI (magnetic resonance imaging) of the pituitary was performed.

No, the requested Norditropin is not medically necessary.

The patient did not have GH (growth hormone) Deficiency. The patient's peak GH (growth hormone) on stimulation testing was >10. The patient therefore did not meet the minimal standard for a diagnosis of Idiopathic Short Stature (ISS), since the height was not < [less than] - [negative] 2SDS (standard deviation score), measuring at the 12% on visits to the Pediatric Endocrinologist. The patient was appropriately prepubertal with a normal bone age yielding a predicted height commensurate with the MPH (mid-parental height). The general lab did not reveal any other medical diagnosis.

Therefore, given the above, the requested Norditropin is not medically necessary.

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

The data provided revealed a lack of justification for the medical necessity for GH (growth hormone) replacement, warranting denial of Norditropin.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell (SS) disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

In the documentation given for review it shows the patient has sickle cell (SS) disease. He presented to the emergency room (ER) with myalgias and sickle cell pain crisis. He was given intravenous (IV) fluid, pain medications, and oxygen. He refused testing and treatment and left against medical advice (AMA). He was afebrile.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. As noted above, the patient presented to the ER with myalgias and sickle cell pain crisis. He was given IV fluids, pain medications, and oxygen. He was afebrile. The patient refused testing and treatment and left AMA. The plan's denial was appropriate, in this case.      

As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018)

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

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

Diagnosis: Osteoporosis

Treatment: Evenity (romosozumab-Aqqg)

The insurer denied coverage for Evenity (romosozumab-Aqqg)

The denial is upheld

The patient is a female with a history of osteoporosis and low trauma fracture (right femoral neck and bilateral wrist). There is no history of prior osteoporosis therapy. Treatment with Evenity is requested.

For the initial treatment of osteoporosis in postmenopausal women, oral bisphosphonates are recommended (Grade 2B). Oral bisphosphonates are recommended as initial therapy because of their efficacy, and the availability of long-term safety data. For most postmenopausal women with osteoporosis, either alendronate or risedronate are recommended as the initial choice of bisphosphonate (Grade 2B).

Anabolic therapy (like Evenity) is not recommended because of subcutaneous route of administration, and long-term safety concerns (algorithm 1). Note that there are multiple concerns about treatment with Evenity because it is indicated for only one year because clinical experience is limited and the long-term side effects uncertain. In addition, Evenity may increase the risk of myocardial infarction, stroke and cardiovascular death.

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

Evenity (romosozumab-Aqqg) is not considered medically necessary for this patient.

The insurer's denial of coverage for Evenity (romosozumab-Aqqg) is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Idiopathic Constipation.
Treatment: Formulary exception for Motegrity, pre-service.
The insurer denied the Formulary exception for Motegrity, pre-service.
The denial is overturned.

The patient is a female with chronic idiopathic constipation. She has failed Amitiza and Linziess. Her provider is requesting treatment with Motegrity.

Yes, the health plan should cover the formulary exception for Motegrity.
In order for criteria for Motegrity to be met, the patient must have tried and failed 2 preferred alternatives Amitiza and Linzess. Per the appeal, the patient has failed Amitiza and Linzess. Therefore, criteria for Motegrity is met, and the formulary exception for Motegrity should be covered by the health plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease, hypothyroidism, and osteoarthritis.
Treatment:  PCA (personal care assistance) service, 7 days per week 2-12 hours, split shift (168 hours/week).

The insurer denied coverage for PCA service, 7 days per week 2-12 hours, split shift (168 hours/week).  The denial is upheld.

This is a female with Alzheimer's disease, hypothyroid and osteoarthritis. She lives alone in a private residence. The plan approved PCA live in service 7 days/week. She is requesting PCA service, 7 days per week 2-12 hours, split shift (168 hours/week), which is currently under review. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as severely impaired. She is unable to formulate a plan or activate personal emergency response system (PERS). She requires extensive assistance for personal hygiene, upper body dressing, walking and toilet transfers. She is bladder incontinent and frequently bowel incontinent. Maximal assistance is required for personal hygiene and lower body dressing. The patient has the appropriate safety items to assist with mobility including stair lift, bed rails, gait belt, lift recliner, and shower chair. The patient has severe cognitive deficits and significant functional impairments that support the medical necessity of PCA services 7 days x 24 hours (live-in). However, her condition and functional needs are not at a level or unpredictable as to require the requested continuous care split shift; 24 hours, 7 days/week. This physician would also agree the patient requires 24-hour monitoring. However, safety monitoring under PCA does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided. The patient's health and safety can be appropriately provided and maintained by the authorized live-in 24 hours PCA services. 

From a physical medicine and rehabilitation perspective, the requested PCA service, 7 days per week 2-12 hours, split shift (168 hours per week) is 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 personal care aide (PCA) service 7 days per week 2-12 hours split shift (168 hours per week) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: Inpatient Admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a morbidity obese male with history of chronic lymphocytic leukemia (CLL), atrial fibrillation status post ablation, and umbilical hernia repair.  The patient underwent robotic assisted laparoscopic radical prostatectomy and bilateral pelvic lymph node dissection for prostate cancer.  He was noted to have 350 to 400 cubic centimeters of estimated blood loss with operative report showing the patient tolerated the procedure well.  He was hemodynamically stable and admitted postoperatively. The patient was cleared for surgery from cardiology and hematology/oncology without specific inpatient requests or monitoring. 

The patient was noted to remain hemodynamically stable with pain controlled. On the same day, the patient was noted to have no issues postoperatively, and his pain was well controlled.  He was tolerating liquids. The patient was tolerating clear liquids, passing gas, and his diet was advanced. The patient's hematocrit dropped from 46.7 to 37.2. Repeat hematocrit in the afternoon was 34.5. The patient was noted to have clear urine with no signs of bleeding. His pain was well controlled, he was tolerating a regular diet, and ambulating. The Jackson-Pratt (JP) drain was removed; he was stable for discharge to home. 

The patient's inpatient admission was denied for not medically necessary. 

No, the proposed inpatient hospital admission was not medically necessary. 

This male with history of atrial fibrillation status post ablation, chronic lymphocytic leukemia (CLL), and umbilical hernia was cleared for robotic assisted laparoscopic radical prostatectomy.  He was cleared for surgery from cardiology and hematology/oncology (without any special postoperative care recommendations) and underwent robotic assisted laparoscopic radical prostatectomy without complication. The patient was noted to be doing well at completion of the procedure.  He was tolerating liquids and passing gas the same day after the procedure. The patient's hematocrit did decrease but he did not require blood products and was hemodynamically stable. The following day the patient's diet was advanced, and he was noted to be ambulating with well controlled pain. The Jackson-Pratt was removed and the patient was discharged to home. 

This patient received short term monitoring and was discharged to home within 24 to 48 hours of his procedure. He remained hemodynamically stable and did not require any additional monitoring/care related to his co-morbidities.  Thus, this patient's postoperative care met the criteria for observation services. 

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

The patient's surgery was uneventful and there were no specific additional care requirements related to the patient's co-morbidities. He remained hemodynamically stable, with pain well controlled, and diet advanced without difficulty.  He was discharged to home the day after his procedure.