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

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

The patient is a female who presented to the emergency department (ED) with chest pain. Her chest pain was described as continuous squeezing chest pain, 5/10, radiating to the left shoulder and across her chest. It was associated with palpitations. The pain was worse with exertion. The chest pain started 6 days prior to presentation.
The patient went to see her primary care provider, and, after the discussion with cardiologist, she was sent to the ED. Her past medical history was significant for hypertension, hyperlipidemia, irritable bowel syndrome.
In the ED, her blood pressure (BP) was 118/77, heart rate was 84 beats per minute (BPM), respiratory rate was 17 and she was afebrile. O2 (oxygen) saturation was 97%(percent) on room air. Her physical examination revealed regular heart rate, clear lungs bilaterally, soft abdomen and unremarkable neurologic exam.
Her electrocardiogram (ECG) revealed incomplete RBBB (right bundle branch block) and early repolarization. Her troponin was 4.2, her bilirubin was elevated to 1.7. The patient was admitted to the monitored unit.

The Inpatient Hospital Admission was not medically necessary for this patient.
This patient presented with chest pain concerning for acute coronary syndrome. But some of the features of her chest pain were not in favor for cardiac origin, such as continuous pain for days. The patient's cardiac enzymes, ECG and echocardiogram did not support the diagnosis of acute coronary syndrome. Her stress nuclear test was normal.
In summary, it was appropriate to monitor the patient on telemetry for 24 hours in the hospital setting for evaluation of new onset of chest pain. However, as her cardiac enzymes were negative, serial ECG and echocardiogram were unremarkable, and her stress test was normal, the inpatient level of care was not indicated. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Narcolepsy
Treatment: Xyrem
The insurer denied Xyrem.
The health plan's determination is overturned.

The patient is a male with narcolepsy. Continued treatment with Xyrem is the subject of this review. The drug was previously denied because the patient had not tried and failed Sunosi. Records indicate that the patient is treated by a neurologist and the diagnosis of narcolepsy is confirmed by a sleep study. The provider indicates that the patient has now tried and failed Sunosi. The patient is also on stimulant medications. 

Xyrem is medically necessary for this patient.

Xyrem is Food and Drug Administration (FDA) approved and literature supported for the treatment of narcolepsy. This drug is typically reserved for people with severe or refractory narcolepsy. The records demonstrate that the patient has severe narcolepsy. The patient has previously tried and failed Sunosi and continues on the stimulants of Vyvanse and armodafinil. Despite these stimulants, the patient continues to have excessive daytime sleepiness. In clinical trials, Xyrem was shown to decrease both excessive daytime sleepiness and cataplexy. The patient was previously using this medication to good effect and there was no medical reason to discontinue therapy in favor of a formulary drug. As such, the use of Xyrem is medically necessary as the patient has an approved condition and has failed other possible treatment alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a history of epilepsy. He was diagnosed with juvenile absence epilepsy for which he was treated with ethosuximide. He had no further GTC (generalized tonic-clonic) seizures until he had a GTC seizure at school. The seizure had a duration of 60-90 seconds and stopped spontaneously. As a result of the seizure activity, he bruised his forehead, but had no other injuries. Postictally, he was confused, vomited once, had generalized weakness, and a headache. He was taken to the emergency room (ER), where he was awake and interactive, and where his postictal symptoms gradually resolved. It was discovered by his treating physicians in the ER that he had been non-compliant with his ethosuximide. In the ER, multiple tests were run, including a complete blood count (CBC), basic metabolic panel (BMP), urine drug screen, creatine kinase (CK), electrocardiogram (EKG), head computed tomography (CT), and cervical (C)-spine CT scan, all of which were normal or negative. He was admitted to the hospital, where he was treated with ethosuximide and underwent a video electroencephalogram (EEG), which was abnormal and revealed generalized irregular spike and wave complexes at 3-5 hertz (Hz), with duration of 2 seconds. He had no further seizures while in the hospital. He was discharged to home on the combination of ethosuximide and levetiracetam. At issue is the medical necessity of an inpatient hospital stay.

The admission to the hospital was not medically necessary. The patient had a known seizure disorder and had a seizure. He could have been observed in the ER and discharged to home. The EEG could have been obtained as an outpatient. The inpatient hospital stay was not medically necessary.

When a patient with known epilepsy has a GTC seizure, it may be justified for that patient to be seen in the ER. This is true if the patient's epileptic seizures are usually absence seizures and not GTC seizures. However, if the seizure stops spontaneously and the patient is medically stable with vital signs and level of consciousness that return to normal, then it is not necessary to admit that patient to the hospital. The patient can be observed in the ER for a period of time and then discharged to home. This is true if it becomes evident that the patient has been noncompliant with his prescribed medications. The patient can receive a dose of the anticonvulsant and be discharged to home. This patient had a known seizure disorder and had a seizure that stopped spontaneously. He could have been observed in the ER for a period of time, treated with an anticonvulsant, and discharged to home.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Idiopathic short stature (ISS)
Treatment: Norditropin
The insurer denied Norditropin.
The health plan's determination is upheld. 

The patient is a female who is seeking continuation of growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). Her mother's height is 5 feet 2.75 inches while her father's height is 5 feet 8 inches. Her sister was diagnosed with growth hormone deficiency (GHD) and treated with GH. Her maternal uncle was also diagnosed with GHD and treated with GH. Her growth chart shows her height below and parallel to 5%tile (percentile) while her weight was at 10%tile. She has been evaluated in the pediatric endocrinology clinic and her evaluation has shown normal celiac screen, thyroid function test, growth factors, karyotype and SHOX (short-stature homeobox gene) gene testing. She also underwent GH stimulation testing and her peak GH response was 10.5 after Arginine and Clonidine. 

Norditropin is not medically necessary for this patient.

In the absence of pretreatment height SDS (standard deviation score) and growth velocity, it is unclear whether this patient qualifies for GH treatment under the indication of ISS. The appeal letter from her endocrinologist says pretreatment height was less than 2%tile which can simply be 2.06 SD (standard deviations) below the mean for age (not 2.25 SD below the mean for age). Also, growth velocity is meaningful only if it provides duration of the growth velocity (as growth velocity over a short period of time does not necessarily reflect actual annual growth).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a female with a past medical history significant for chronic obstructive pulmonary disease (COPD), tobacco use disorder, hypertension, type 2 diabetes mellitus, hyperlipidemia, seizure disorder, bipolar disorder, schizophrenia, and anxiety who presented to the emergency department with complaints of shortness of breath and productive cough. The patient had a small amount of whitish sputum. She also endorsed associated chest tightness at times, not related to activity or cough. The review of systems was negative for fever, chills, rigors, palpitations, sweating, and lightheadedness. 

The patient was admitted to the hospital with a diagnosis of acute respiratory distress secondary to chronic obstructive pulmonary disease (COPD) exacerbation, hypomagnesemia, hypercalcemia, and lactic acidosis that was attributed to recently initiated treatment with metformin. During the hospital stay, the patient received treatment with intravenous fluids due to lactic acidosis. The treatment with metformin was discontinued. During the hospital stay, the patient remained afebrile and hemodynamically stable. She was discharged home the next day after admission.

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary for this patient. The patient presented to the hospital with complaints of shortness of breath and a productive cough. The patient was hemodynamically stable and had a respiratory rate of 18 breaths/minute and oxygen saturation of 98% on room air. This patient likely had mild COPD exacerbation. During the hospital stay, the patient's respiratory rate remained normal, and she never required supplemental oxygen. Furthermore, on the physical exam, the patient was in no respiratory distress, had no rales, rhonchi, or wheezing, and did not use accessory muscles. The chest x-ray did not demonstrate any infiltrates or effusions.
This patient had lactic acidosis, which was most likely related to the use of Metformin. The treatment of lactic acidosis required discontinuation of Metformin and hydration. This patient had hypomagnesemia that was not critical and could have been repleted overnight. Taking into consideration all these facts, the admission at a lower level of care status was the most appropriate, given the clinical circumstances.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Formulary Exception for Proair RespiClick (albuterol). 

The insurer denied coverage for Formulary Exception for Proair RespiClick (albuterol). 

The denial is upheld. 

The patient is a teenager with a history of moderate persistent asthma and the main trigger for her symptoms are exercise and exertion. There are no medical records or pulmonary function tests results submitted with this appeal to approve Proair RespiClick.  It should be noted that there is no medical record documentation to support the appeal for this non formulary medication. 

The alternative bronchodilator medications on formulary will provide suitable alternative treatment for this patient's symptoms of asthma which are caused by exercise and exertion. If the alternative therapeutic bronchodilator metered dose inhaler medications are administered according to asthma guidelines, then asthma control should not be adversely affected. 

Proair RespiClick is a dry powder inhalation device which administers a bronchodilator medication to provide relief of asthma symptoms. This medication can be administered prior to exercise to control asthma symptoms such as coughing and shortness of breath. 

Ongoing monitoring of clinical symptoms and lung function by pulmonary function testing will be important to assess the impact of switching from Proair RespiClick to the alternative bronchodilators on the formulary. 

The main goals of asthma management are to optimize control of asthma symptoms and reduce the risk of asthma exacerbations, while minimizing medication adverse effects. The four essential components of asthma management are patient education, control of asthma triggers, monitoring for changes in symptoms or lung function, and pharmacologic therapy. 

The goals of chronic asthma management may be divided into two domains: achieving good control of asthma-related symptoms and minimizing future risk (asthma exacerbations, suboptimal lung function, adverse effects of medication). The patient's own goals should be incorporated into decision-making regarding asthma management. 

The formulary drugs are not expected to cause adverse effects. 
 
The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication. 

The formulary drug is not expected to be ineffective. The not formulary drug is not expected to be more effective that the formulary alternatives. 

The carrier's denial of Request for Formulary Exception for Proair RespiClick (albuterol) to treat asthma is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: benign prostatic hyperplasia (BPH)
Treatment: waterjet ablation of the prostate (0421T)
The insurer denied: waterjet ablation of the prostate (0421T)
The denial is: Upheld

The patient is a male with a diagnosis of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. Associated symptoms include urinary retention. Prior failed therapy includes finasteride and tamsulosin.
The subject under review is whether transurethral waterjet ablation of the prostate is likely to be more beneficial for this patient than any standard treatment.

The proposed waterjet ablation of the prostate is not likely to be more beneficial than any other standard treatment for the patient.
The first line therapy for management of BPH includes medical therapy. This includes alpha blockers, 5 alpha reductase inhibitors, phosphodiesterase inhibitors and anticholinergic medication. The standard of care for management of patients with BPH not responding to medical therapy is transurethral resection of prostate. In patients with very large glands (greater than [>] 100 cubic centimeter [cc], as in this patient), Holium Laser Enucleation of the Prostate (Holep) and simple prostatectomy are considered standard of care.
The proposed treatment is not likely to be more beneficial for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: benign prostatic hyperplasia (BPH)
Treatment: waterjet ablation of the prostate (0421T)
The insurer denied: waterjet ablation of the prostate (0421T)
The denial is: Upheld

The patient is a male with symptomatic prostate enlargement. He has a 157 milliliter (ml) gland, retention of urine, with failed voiding trials despite maximal medical therapy utilizing finasteride and tamsulosin. Aquablation was recommended for surgical treatment. The subject under review is whether the requested procedure is likely to be more beneficial for the patient's condition than any standard treatment.

No, the proposed treatment is not likely to be more beneficial for this patient.  Robotic waterjet therapy is endorsed by the American Urological Association (AUA) for glands between 30 and 80 cubic centimeters (cc) in size. The current studies in literature which tout use in larger glands are supported by the device manufacturer. Other authors have noted that long term data regarding novel prostate therapies is lacking; studies comparing the efficacy of this procedure against current standard of care for large glands have not been done.(2)
Current Cochrane analysis states, "Based on short-term (up to 12 months) follow-up, the effect of Aquablation on urological symptoms is probably similar to that of transurethral resection of the prostate (TURP) (moderate-certainty evidence). The effect on quality of life may also be similar (low-certainty evidence). We are very uncertain whether patients undergoing Aquablation are at higher or lower risk for major adverse events (very low-certainty evidence). We are very uncertain whether Aquablation may result in little to no difference in erectile function but offer a small improvement in preservation of ejaculatory function (both very low-certainty evidence). These conclusions are based on a single study of men with a prostate volume up to 80 milliliters (mL) in size. Longer-term data and comparisons with other modalities appear critical to a more thorough assessment of the role of Aquablation for the treatment of lower urinary tract symptoms (LUTS) in men with BPH."
Literature is unsure about long term efficacy. Many of the published studies are supported by device manufacturer.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: benign prostatic hyperplasia (BPH)
Treatment: waterjet ablation of the prostate (0421T)
The insurer denied: waterjet ablation of the prostate (0421T)
The denial is: Upheld

The patient is a male with benign prostatic hyperplasia (BPH) and urinary retention who has requested coverage for treatment with the "Aqua Beam" Transurethral Waterjet Ablation" of the prostate. He has tried tamsulosin and finasteride. The prostate volume was 157 grams. The office note states that he has been in retention for about 7 weeks. The subject under review is whether the requested procedure is likely to be more beneficial for this patient than any standard treatment for his condition.

No, the requested procedure is not likely to be more beneficial for the patient than any standard treatment. The procedure in question is Transurethral Waterjet Ablation of the prostate.
Transurethral Waterjet Ablation of the prostate has been studied for men with prostate volumes of up to 150 grams. This patient's prostate was 157 grams. The attending physician (AP) would need to provide supportive data for his prostate volume to support the use of this procedure in this case.
The Water II trial was a prospective multicenter study of men with larger prostates--
"Materials and methods: Between September-December 2017, 101 men with moderate-to-severe BPH symptoms and prostate volumes of 80-150 cubic centimeter (cc) underwent an ultrasound-guided robotically executed Aquablation procedure in a prospective multicenter international clinical trial (WATER II). Baseline, procedural and follow up parameters were recorded at baseline and scheduled postoperative visits. Herein we report 2-year safety and efficacy for this cohort.
Results: Mean prostate volume was 107 cc (range 80-150 cc). Mean International Prostate Symptom Score (IPSS) improved from 23.2 at baseline to 5.8 at 2 years (17-point improvement, probability [p] less than [< ].0001). Mean IPSS quality of life improved from 4.6 at baseline to 1.1 at 2 years (p < .0001). Maximum urinary flow increased from 8.7 to 18.2 cc/second. Two subjects underwent a repeat procedure for BPH symptoms over the 2-year follow up period. By 2 years or study exit, all but 2 of 74 subjects stopped taking alpha blockers. Similarly, all but 4 of 32 subjects stopped taking 5-reductase inhibitors.
Conclusions: Two-year prospective multicenter follow up demonstrated that the Aquablation procedure is safe and effective in the treatment of men with lower urinary tract symptoms (LUTS) due to BPH and prostates 80-150 cc with durable treatment efficacy, acceptable safety profile and a low retreatment rate."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Otitis Media
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Overturned

The patient is a female who presented to the emergency department with fever and vomiting for 5 days.
She was well until 5 days prior to presentation when she developed a fever to 103 Fahrenheit (F). She took acetaminophen but her fever continued. She also developed emesis. She was taken to her primary doctor and was diagnosed with bilateral otitis media. She was prescribed amoxicillin at that time, but she was unable to keep the medication down due to vomiting. She continued to vomit 3-4 times per day and had decreased wet diapers. She was also crying when her hands and feet were touched and was not wanting to stand or hold her bottle. She was therefore brought to the emergency department for care.
In the emergency department she had a heart rate of 122 beats per minute (bpm) and she was found to have bloody discharge in her ear canals. She was given Zofran and Amoxicillin, but she was unable to swallow the medication. She was therefore given intramuscular (IM) Ceftriaxone and was admitted for further care.
In the hospital she was found to have a bulging right tympanic membrane. she was continued on IM Ceftriaxone and her intake and output were monitored. She has no further episodes of emesis, and she she was felt to be stable for discharge to home with follow-up as an outpatient. The inpatient admission is under review.

The requested inpatient admission was medically necessary for this patient. This is a patient who presented with otitis media, fever, and vomiting for 5 days. She continued to have symptoms despite appropriate treatment as an outpatient and was vomiting several times per day. She had decreased wet diapers and was unable to tolerate liquids in the emergency department. She therefore required inpatient admission for ongoing treatment with parenteral antibiotics (IM Ceftriaxone) as well as close monitoring with additional treatments as needed. While she improved quickly after admission, this could not have been anticipated ahead of time.
According to the Milliman Care Guidelines, Head and Neck Disease, hospitalization is indicated for patients with a complicated infection when antibiotic treatment has failed. This patient continued to have fever and deterioration despite appropriate treatment as an outpatient and had ongoing fever and vomiting and decreased wet diapers. Complications of otitis media can include extension of the infection including mastoiditis and meningitis. This patient was also at risk for dehydration due to continued vomiting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied: Dupixent
The denial is: Upheld

The patient is a female with atopic dermatitis, treated with topical steroids and topical calcineurin inhibitors. Patient has a hemophilic disorder (factor eleven [XI] hemophilia) and oral immunosuppressants are best avoided per the appeal letter. The provider wants to treat the patient with Dupixent. The health plan requires a trial and failure to systemic immunosuppressants.

The health plan's determination is upheld.

The treatment with Dupixent is not medically necessary for this patient.
The health plan requires a trial and failure to systemic immunosuppressants. Systemic medications such as cyclosporine can also be used in atopic dermatitis. While oral immunosuppressive medications may not be specifically Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis, their use is considered standard and well supported in the medical literature. No contraindication was seen for cyclosporine with hemophilia. Therefore, Dupixent is not medically necessary.