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

Diagnosis: Common variable immunodeficiency
Treatment: Cuvitru
The insurer denied Cuvitru.
The determination is upheld.


The patient is requesting Cuvitru and has been stable on this. He has common variable immunodeficiency (CVID). A prior denial was due to a lack of failure of the preferred products. At issue is the medical necessity of Cuvitru.
The Cuvitru is not medically necessary. The plan's formulary alternatives include Gamunex- C, Gammaked, Gammagard, Flebogamma, and Privigen. All these products are Food and Drug Administration (FDA) approved for the treatment of primary immunodeficiency disorder (PID). Per Bonilla et al, they are all reasonable for a trial and these have not been shown to be less effective than the requested product. 
There are no head-to-head studies to show that the alternatives are more effective or have less side effects.
Therefore, the Cuvitru is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post-tonsillectomy bleed
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of a tonsil bleed. She had a tonsillectomy and adenoidectomy several days prior to presentation (unclear per the records provided). She presented to the emergency department (ED) with a tonsil bleed.
She was noted to be hemodynamically stable and was tolerating oral intake well. She was admitted to the hospital. She had no recurrent bleeding. She was discharged the next day.
At issue is the medical necessity of an inpatient stay.
An inpatient stay was not medically necessary for this patient.
The patient had a post-tonsillectomy bleed. It is considered standard of care to admit a young child for observation when there is evidence of bleeding because children have overall low blood volumes and excessive bleeding can lead to significant medical complications. Based on the clinical documents the child was not actively bleeding, had normal vital signs and was in no cardiopulmonary distress. It would be considered clinically appropriate and standard of care to observe the child overnight. However, the care could have been provided at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient hospital

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

The patient is a male brought to the emergency department (ED) by emergency medical services after a witnessed seizure at school. He came from the Dominican Republic two months prior. He had one seizure there and reportedly had normal head imaging. He had one other seizure a month prior. He was not on anti epileptics or any other medications. He says that he felt dizzy with blurry vision prior, then witnesses saw him fall and have alternating stiffness and posturing for about seven minutes followed by a post-ictal period. He denied drugs or alcohol, fevers, recent illnesses. His vital signs were normal, he appeared well, and his physical exam, including neuro and mental status exam, were normal except for right cheek laceration. Urine toxicology screen was normal, Covid was negative, glucose was normal, and complete blood count (CBC) was normal.

The the inpatient hospital admission was not medically necessary. The patient was stable following a witnessed seizure, his third in two months. He had returned promptly to baseline. He had a computed tomography (CT) scan after his first seizure, which was reportedly normal. His labs were normal. His physical exam, including neurologic and mental status exams, was normal. His labs were normal. There was no concern that he had an infectious, toxic, metabolic, or other ongoing process to manage. He was administered Keppra. in the ED. He appears to have been admitted to expedite an Electroencephalogram (EEG) and Magnetic Resonance Imaging (MRI) that could be done as an outpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intermittent right upper extremity swelling and rash. 
Treatment: Computed Tomography (CT), for Neck, (70491) with Contrast Dye, (71260), CT Chest with Dye (74177). 

The insurer denied the Computed Tomography CT, for Neck, (70491) with Contrast Dye, (71260), CT Chest with Dye (74177). 

The denial is upheld. 

The patient in this case is a man who presented with symptoms of intermittent right upper extremity swelling and rash, for which he was treated with topical treatment and antibiotics. He had an elevated ANA (antinuclear antibody). CBC (complete blood count) testing that is provided does not reveal significant ongoing abnormalities. There was no lymphadenopathy on exam. CT (computed tomography) scans are requested to look for evidence of lymphoma. 

No, the Computed Tomography  for Neck, (70491) with Contrast Dye, (71260), computed tomography Chest with Dye (74177) are not medically necessary.
This patient had symptoms mostly confined to the right arm and hand. He did not have other significant symptoms or physical exam findings. There was no palpable abnormality and also no CBC (complete blood count) abnormalities that would indicate the presence of underlying lymphoma. His right upper extremity symptoms of intermittent swelling and rash are not typical symptoms of lymphoma. He had no symptoms or abnormalities involving the neck, chest, abdomen or pelvis based on review of records. Therefore, the CT (computed tomography) scans in this case are not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis. 
Treatment: Taltz. 

The insurer denied the Taltz. 
The denial is overturned. 

The patient is a woman with severe plaque psoriasis affecting more than 15% body surface area who has tried and failed Otezla, Skyrizi, Stelara, Enstilar, clobetasol, mometasone, triamcinolone, and tacrolimus. Her co-morbidities include hypertension, hypercholesterolemia, pre-diabetes, anemia, and gout. 

Yes, the requested Taltz is medically necessary. 

Taltz is indicated for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. The patient has severe psoriasis that has failed multiple treatments. She is a candidate for systemic therapy. Cosentyx has a greater number of possible adverse events. Side effects of Cosentyx that are different from Taltz include diarrhea, oral herpes, hives, tonsillitis, oral thrush, impetigo, inflammatory bowel disease, ear infection, eye infection or inflammation (conjunctivitis), increased liver transaminases, and low white blood cell count (neutropenia). These drugs have not been directly compared in clinical studies. However, one review of studies of plaque psoriasis found that Taltz was more effective than Cosentyx at reducing symptoms of psoriasis. 

In the meta-analysis of studies with active comparators, PASI (Psoriasis Area and Severity Index) 90 response rates were 12.7% [95% confidence interval (CI) 5.519.8], 10.0% (95% CI [confidence interval] 2.118.0) and 11.2% (95% CI [confidence interval] 3.219.1) higher and PASI (Psoriasis Area and Severity Index) 100 response rates were 11.7% (95% CI [confidence interval] 5.917.5), 12.7% (95% CI [confidence interval] 6.019.4) and 13.1% (95% CI [confidence interval] 6.319.9) higher for ixekizumab compared with secukinumab using BU (Bucher), SG (Signorovitch) total and SG (Signorovitch) separate methods. Ixekizumab had higher PASI (Psoriasis Area and Severity Index) 90 and PASI (Psoriasis Area and Severity Index) 100 responses at week 12 compared with secukinumab using adjusted indirect comparisons. Taltz is medically appropriate and necessary for this patient. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin disease/skin ulcer. 
Treatment: Oxygen treatment/hyperbaric oxygen. 

The insurer denied oxygen at high pressure. 
The health plan's determination is overturned. 

The patient is a male with a left gluteal ulcer. He has suffered from recurrent full-thickness ulceration and prior abscess to this area, requiring hospitalization. The ulceration did heal; however, it reoccurred. He has been receiving advanced wound care including serial debridement's, offloading, topical collagens and antimicrobials, absorbent dressings, and advanced negative pressure wound therapy with continued chronicity and deterioration in wound size measurements. 

The oxygen at high pressure is medically necessary for this patient. The Milliman Care guidelines (MCG) are met in this case. The patient has had positive wound cultures which were treated both topically and systemically. Offloading has included a gel air chair cushion, group 2 pressure relieving bed support surface, and aggressive repositioning schedule to prevent pressure. His nutritional status has been optimized during his treatment. He has received these therapies over 30 days with continued wound chronicity and lack of improvement. He meets all of the MCG guidelines for HBO(Hyperbaric oxygen) for management of the diabetic related gluteal ulcer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myasthenia Gravis
Treatment: Vyvgart
The insurer denied Vyvgart.
The determination is upheld.

The patient was diagnosed with refractory myasthenia gravis. Treatment with Vyvgart is the subject of this review. The patient has tried and failed prednisone and azathioprine. The drug was initially denied by the plan because the patient has not tried and failed mycophenolate mofetil, methotrexate, or cyclosporine. The provider indicated that these drugs were not appropriate due to risk of renal impairment.
At issue is whether the Vyvgart is medically necessary.

Vyvgart is not medically necessary. The drug was denied because the member has not tried and failed one of the following drugs: cyclosporine, tacrolimus, mycophenolate mofetil, and/or methotrexate. The provider indicated that these drugs were contraindicated because of the patient's history of chronic kidney disease and malignancy. However, only treatment with cyclosporine and methotrexate are contraindicated in renal impairment. In renal disease, the use of mycophenolate mofetil and tacrolimus should proceed with caution. Compendia and prescribing information also indicate that azathioprine carries a similar caution in chronic kidney disease and prior malignancy. However, the patient is treated with this medication. As such, the patient does not have an absolute contraindication to the available alternatives of mycophenolate mofetil or tacrolimus. In addition, mycophenolate mofetil is generally considered a first-line medication for treatment of myasthenia gravis (as a steroid sparing agent), whereas Vyvgart is considered a second-line agent due to a lack of long-term outcomes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: White glass with gold crown; tooth 30 and 31.
The insurer denied white glass with gold crown; tooth 30 and 31.
The determination is overturned.


The patient presented for evaluation and treatment of teeth number (#) 30 and 31. Provided for review are previous letters of appeal and denial, full mouth radiographic images and a narrative from her provider. At issue is the medical necessity of the planned treatment of porcelain fused to noble metal crowns for teeth #30 and 31 (2752).

Yes, based on the provided documentation, teeth #30 and 31 have decay that resulted in significant loss of tooth structure and there is a need for restoration of the teeth with crown restorations as direct restorations are not possible.
Therefore, the entire treatment of porcelain fused to noble metal #30 and 31 (2752) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness and Shortness of Breath; Anemia. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient in this case is a male who presented to the emergency department  with complaints of fatigue and weakness. The week before this visit he had outpatient labs which revealed a hemoglobin of 4.7 grams per deciliter (g/dl).  He did not go to the emergency department (ED) at that time but went they day he was admitted because he was feeling more fatigued and had increasing shortness of breath. He had noted no active bleeding on the day before he presented.  The patient's hemoglobin was 4.8 grams per deciliter. 

The patient was admitted to the hospital for transfusion and further evaluation. Vital signs were unremarkable. Hematology and gastroenterology were consulted while he was hospitalized and he was transfused two units of packed red blood cells following admission.  Hemoglobin was improved to seven grams per deciliter on day two. The patient was seen by gastroenterology on day two and it was recommended that he have an esophagogastroduodenoscopy (EGD) and colonoscopy.  The patient wanted to have those tests done as an outpatient.  Computed tomography (CT) scan was done while the patient was in the hospital and no acute findings were identified.  The patient was discharged to home. 

No, the proposed inpatient admission was not medically necessary. 

This patient had severe anemia but was hemodynamically stable. He had no coronary ischemia or any evidence of impaired organ function.  He had no evidence of active bleeding, and notably his hemoglobin had remained stable in the week between the initial blood test showing anemia and his hospitalization.  He could have been transfused and discharged following that without admission.  No intervention was taken during his hospital stay that clearly required him to be in the hospital.  Given the above considerations, the hospitalization in this case was not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic Hypersomnia With Long Sleep Time. 
Treatment: Xywav. 

The insurer denied the Xywav. 
The denial is overturned. 

The patient is a female with diagnosis of idiopathic hypersomnia. The service under review is Xywav. 

This service was denied coverage by the health plan as not medically necessary, because the preferred medication (Xyrem) was not tried and failed and there was no documentation to support the diagnosis (i.e. [that is] sleep study). This decision is being appealed, stating that Xywav is standard of care and is the only medication FDA (United States Food and Drug Administration) approved for this indication. Medical history includes idiopathic hypersomnia. 

Yes, the requested Xywav is medically necessary. 

The relevant clinical practice guideline by the American Academy of Sleep Medicine [ref 1] states that several medications can be used for the treatment of idiopathic hypersomnia in adults, including sodium oxybate. These guidelines do not distinguish between the two forms of oxybate (Xyrem vs. Xywav). These guidelines list several other treatment options: modafinil, clarithromycin, methylphenidate, and pitolisant.

According the FDA [ref 2] Xywav is indicated for the treatment of idiopathic hypersomnia (IH) in adults. None of the other treatments listed above has FDA indication for this diagnosis. 

Other medications have been used off-label for years for treatment of idiopathic hypersomnia, but Xywav is the first drug to be approved in the US (United States) for this indication [ref 3]. 

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The plan denied the use of the only medication that is approved by the FDA for treatment of idiopathic hypersomnia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-abdominal pain. 
Treatment: Inpatient hospital stay. 

The health plan denied the inpatient stay. 
The reviewer has upheld in whole the health plan's determination. 

This is a patient with a history of idiopathic thrombocytopenic purpura (ITP), who presented to the emergency department (ED) due to abnormal liver function tests. The patient was complaining of some mild epigastric and right flank pain for several weeks intermittently. She also had mild nausea but no diarrhea, dysuria, or hematuria. Home medications include Atarax, omeprazole, and Promacta for ITP. Per the ED assessment, the patient has elevated liver function tests (LFTs), a known adverse reaction of Promacta. Due to right upper quadrant discomfort, they obtained a right upper quadrant ultrasound, gastrointestinal (GI) consultation, and a rescreen for hepatitis. A computed tomography (CT) scan of the abdomen and pelvis showed no acute disease. The right upper quadrant ultrasound showed gallbladder sludge and tiny stones without cholecystitis or biliary dilation. The LFTs improved as well. The gastroenterologist assessed the patient. Promacta was stopped on admission. A hematology consultation was obtained, who agreed with the current work-up. Overnight, asymptomatic bradycardia was noted, and a 2D echocardiogram showed no significant findings. Thyroid function tests were normal. The patient had been taking between 4 and 8 Tylenol per day, four times per week, which made them concerned about Tylenol toxicity and initiated the patient on Mucomyst. 
Inpatient stay is not medically necessary for this patient. The patient was admitted for elevated liver enzymes and nonspecific abdominal discomfort. Acute cholecystitis and choledocholithiasis were ruled out. The lab abnormalities were attributed to Promacta. The patient did not have refractory ITP, as the platelet counts remained in the 360,000 range, significantly higher than any concerning thrombocytopenia level. It was quickly determined by both hematology and gastroenterology that Promacta is the culprit and should be discontinued, the elevation of liver enzymes more than three times the baseline range. Determination to stop this medication was made within 24 hours of hospitalization. Regarding the bradycardia the patient was asymptomatic. The echocardiogram was completely normal, and thyroid function tests were also unremarkable. The rest of the work-up performed in the hospital can be accomplished under a lower level of care and does not necessitate inpatient admission. The patient has no evidence of hepatic encephalopathy, spontaneous bacterial peritonitis or ascites, significant coagulopathy, elevated prothrombin times, or international normalized ratio (INR); no history of alcoholic hepatitis. There is no evidence of hepatorenal syndrome or hepatic vein occlusion. Evaluation in the hospital failed to reveal serious causes of nausea and vomiting, such as bowel obstruction, acute cholecystitis, acute pancreatitis, ileus, or intraabdominal infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pregnancy.
Treatment: Intrauterine Insemination (IUI) Cycle. 
The insurer denied Intrauterine Insemination (IUI) Cycle. 
The health plan's determination is overturned. 

The patient is a woman who underwent superovulation (SO) with intrauterine insemination (IUI) for infertility. She subsequently conceived a child with this cycle.

The Intrauterine Insemination (IUI) Cycle was medically necessary for this patient.  This patient had reassuring ovarian reserve testing and had the opportunity to try to conceive with IUI. Though success rates are relatively low in this age group, with appropriate screening (such as an evaluation of ovarian reserve) and limited attempts (as success usually happens within the 1st 1-2 cycles if it going to work), this can be a reasonable step in fertility treatment in women over 40 years of age. This patient has an ongoing pregnancy from this cycle which shows that this was an appropriately selected patient for IUI.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath with Phlegm or Mucus
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a male with history of COPD (chronic obstructive pulmonary disease) and CHF (congestive heart failure). He presented to the ER (emergency room) with productive cough and SOB (shortness of breath).

The patient was diagnosed with COPD exacerbation and was started on IV (intravenous) antibiotics and IV steroids. The patient was admitted to acute hospital level of care. The patient received IV steroids, IV antibiotics, and nebulizations.

The acute inpatient admission was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

No, the inpatient admission was not medically necessary.

The patient received standard treatment for COPD exacerbation, which included steroids, antibiotics, and nebulizations. The patient improved significantly with ER level of care and continued to receive similar treatment. The patient did not require any additional oxygen. The patient's SOB improved within 24 hours. The patient was tolerating diet and was ambulating. Since the patient's condition improved rapidly with ER treatment, the lower level of care would be safe and effective, and the inpatient admission was not medically necessary

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain
Treatment:  Inpatient Hospital Stay

The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient has a past medical history (PMH) of morbid obesity, asthma, hypertension (HTN), diabetes mellitus type 2 (DM2), seizure disorder (d/o), bipolar d/o, and major depressive disorder (MDD) who was admitted with complaints of (c/o) dizziness, abdominal pain, nausea, and vomiting. Vital signs were notable for a blood pressure (BP) of 185/105. The physical exam was notable for tachycardia and left upper quadrant (LUQ), left lower quadrant (LLQ) and right costovertebral angle (CVA) tenderness, bilateral lower extremity (LE) edema. Lab work was notable for hyperglycemia and a creatinine of 1.31. A chest x-ray (CXR) showed no acute pathology. The patient was diagnosed with abdominal pain and treated with supportive therapy with biochemical work-up, intravenous fluids (IVF), anti-emetics, and antacids. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an inpatient level of care.
This patient presented to the emergency department (ED) with c/o abdominal pain and was found to have hyperglycemia. The patient was hemodynamically stable, responded to insulin therapy, and there was no diabetic ketoacidosis (DKA), acute mental status change, end stage renal disease (ESRD), sepsis, acute cerebrovascular accident , acute myocardial infarction (MI) or significant complications, and she did not have any evidence of acidosis as the patient had a normal serum bicarbonate and potential of hydrogen (pH). Hyperglycemic patients presenting to the ED with a blood glucose less than (<) 600 can be appropriately managed at a lower level of care. For the abdominal pain, the patient did not have associated high-risk features, such as severe renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, and did not have pyelonephritis, an ascending infection, unstable vital signs, or immunosuppression. The patient presented with abdominal pain and hyperglycemia, was treated and responded to IVF, anti-emetics, insulin therapy, and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.