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

Diagnosis: Opioid Withdrawal.

Treatment: Inpatient Hospital Admission.

The insurer denied coverage for Inpatient Hospital Admission.

The denial is overturned.

This is a patient admitted to the hospital for treatment of opioid withdrawal. The patient had opioid withdrawal symptoms including nausea and vomiting as much as 20 to 30 times, cold sweats, tachycardia, diarrhea, abdominal pain, poor oral intake, and had a Clinical Opiate Withdrawal Score (COWS) as high as 19. The patient had been drinking codeine a few times per day, taking 2 Percocet pills per day, and smoking cannabis 10 times per day. The patient also has a history of alcohol use. Patient had electrolyte abnormalities including a low potassium of 3.2, CO2 of 19, and bilirubin of 1.6. The patient received detoxification medication for opioid withdrawal including intravenous (IV) Methadone, IV antiemetics, IV Toradol, IV fluids, and Clonidine. Patient continued to have opioid withdrawal until the date of discharge.
  
The medical records provided enough specific evidence to support that the patient required this level of care. The American Psychological Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance, puts patients at high risk for complicated withdrawal. These patients are candidates for inpatient detoxification treatment. There was a recommendation from the medical team for inpatient substance treatment, but the patient declined. The patient was hemodynamically stable and not considered in further withdrawal at day of discharge. The medical records support that patient was at risk for more severe opioid withdrawal due to the large amount of daily opiate use and was at risk for overdose. Chart reports of inpatient medical issues included severe abdominal pain and electrolyte abnormalities and the patient required and received treatment for detoxification. 

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease). 
Treatment: LINX Procedure. 

The insurer denied: LINX Procedure. 
The denial is overturned. 

The patient is an adult male with long-standing reflux. He has failed medication off and on for many years. The patient has a small-to-moderate-size hiatal hernia. EGD (esophagogastroduodenoscopy) shows esophagitis. Manometry is within normal limits. DeMeester is 108. The request for the LINX system. 

The health plan should cover the LINX procedure. 

Literature regarding the use of the LINX system in GERD (gastroesophageal reflux disease) patients demonstrated that it has been shown to be effective. The use of the LINX has been approved by the FDA (United States Food and Drug Administration). This patient has undergone and failed multiple rounds of medication for his GERD (gastroesophageal reflux disease). He has recurrent symptoms, normal manometry, and a very high DeMeester score. The LINX system has been used in patients with hiatal hernias as well, with good outcomes and safety. Buckley et al. even showed similar outcomes between large and moderate size hiatal hernias with using the LINX system. This patient would benefit from the use of the LINX device. 

The LINX procedure is more beneficial. The LINX system has been shown to help decrease the incidence of gas bloat syndrome in comparison to standard laparoscopic fundoplication. This has been shown in 2 articles from Skubleny et al. and Reynolds et al. This is beneficial in patients with mild to moderate GERD (gastroesophageal reflux disease).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This is a young adult female diagnosed with diabetic ketoacidosis. This request is for inpatient hospital admission.
The patient presented to the emergency department with complaints of generalized weakness, congestion, sore throat. The patient has a history of insulin-dependent diabetes. The patient was tachycardic at 110 beats per minute. She had dry mucous membranes. Glucose was 431. Potential of hydrogen (pH) was 7.22 with a partial pressure of carbon dioxide (PCO2) of 24 and a base excess of -18 at a bicarbonate of seven. Urine ketones were large. The anion gap was 22. The patient was started on intravenous fluid and an insulin infusion. The patient was found to be positive for influenza A. The patient had pre-renal acute kidney injury with a creatinine of 1.07. The patient was started on Tamiflu. The patient's anion gap closed overnight. The note from day #1 reports that the patient was transitioned overnight to the home diabetes regimen of basaglar 38 units, and an insulin to carbohydrate ratio of one to seven grams and an insulin sensitivity factor of one to 25, target ten.

The proposed inpatient hospital admission was medically necessary.

Hospitalization for diabetic ketoacidosis (DKA) is universally medically necessary. Patients with diabetes and diabetic ketoacidosis (DKA) initially generally require intensive care unit (ICU) level care until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring intensive care unit level care. Most hospitals admit patients with diabetic ketoacidosis (DKA) to the intensive care unit due to rules regarding level of service with every one-hour blood draws and nursing rules. This patient was admitted for treatment of diabetic ketoacidosis in the setting of influenza. The patient met the accepted criteria for diabetic ketoacidosis. The patient required acute inpatient admission for an insulin infusion and improvement of the anion gap and treatment of the acute kidney injury. The requested admission is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD). 
Treatment: Daytrana. 

The insurer denied: Daytrana. 
The denial is upheld. 

The patient is an adolescent male diagnosed with attention deficit hyperactivity disorder (ADHD). He has tried and failed Vyvanse, which caused weight loss. He also failed Adderall as it did not improve his symptoms. It is noted in the appeal application that the patient has sensory issues and a medication that is chewable would contribute to compliance. 

The health plan should not cover the proposed treatment. 

The patient has not tried and failed enough formulary alternatives. There is no reason why the patient cannot try the alternatives, which are all effective in treating attention deficit hyperactivity disorder (ADHD). No justifiable rationale was provided as to why the patient cannot be tried on the alternatives, which may be just as effective as Daytrana. It was noted on the appeal application that the patient has sensory issues and a medication that is chewable would contribute to compliance; however, the statement is vague and there is not documentation detailing this statement. It is not known what sensory issue the patient is experiencing. Therefore, the request is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD).
Treatment: Quillivant XR (extended release).
The insurer denied: Quillivant XR (extended release).
The denial is: Overturned

The patient is a male who has been diagnosed with attention deficit hyperactivity disorder (ADHD) combined subtype. A physician letter describes that the patient has been successfully treated with Quillivant (methylphenidate extended release suspension). He has had an excellent response to the medication, with minimal side effects. At issue in this case is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The health plan's determination is overturned.

The records indicate that the patient has tolerated Quillivant suspension very well, with excellent results. Most importantly, the medication has been available, and there is no indication that he has had to miss doses of medication due to the nationwide shortage of multiple types of stimulant medication. At present, multiple stimulant medications are unavailable or on backorder. It will be highly disruptive to the patient's treatment if his Quillivant is discontinued and he has to have multiple trials of formulary listed medications, particularly as there is no guarantee that any of the listed medications are currently available. As an example, one group of medications listed above by the health plan as a formulary approved alternative, Methylphenidate Hydrochloride Extended Release Oral Presentations is currently listed as being in short supply by the national pharmacy association American Society of Health System Pharmacists (ASHP). Quillivant is the most appropriate medication for the patient. The medication is available, is not listed as being in short supply, and has been proven to be effective and well tolerated. There is no guarantee that any of the formulary alternatives will be available, effective treatment, or tolerated by the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension
Treatment: Formulary exception for Toprol XL (extended release)
The insurer denied the formulary exception for Toprol XL.
The denial is upheld.

The patient is an adult female with a submitted diagnosis of hypertension. The request is for formulary exception for Toprol XL (extended release). According to the submitted PA (prior authorization) request form, the patient tried and failed metoprolol XL generic due to intolerance from GI (gastrointestinal) side effect. The request for coverage has been denied by the health plan based on formulary requirements. The denial is being appealed.

The health plan should not cover the formulary exception for Toprol XL.

There is no submitted information that only Toprol XL can treat this patient's hypertension to establish that it is medically necessary for this patient. A number of clinical trials have shown that blood pressure control is the most important determinant of benefit from antihypertensives. At the same level of blood pressure control, most antihypertensives provide the same level of cardiovascular benefit. The authors of the 2017 ACC/AHA (American College of Cardiology/American Heart Association) guideline on the treatment of hypertension have concluded, among others, that the amount of blood pressure reduction is the major determinant of improvement in cardiovascular risk in patients with hypertension, not the choice of antihypertensive drug. The patient in this case tried and failed just one formulary drug, generic metoprolol XL due to GI intolerance. While metoprolol XL has been ineffective for this patient, the other beta-blockers available would be as effective as the requested non-formulary drug and may not have adverse effects for this patient. Neither the patient nor the physician have submitted documentation to substantiate that Toprol XL is the only tolerated beta-blocker that controls this patient's hypertension and is more effective than the 
other formulary antihypertensive choices available to this patient, which have published and time proven efficacy and safety for her medical condition. Therefore, the health plan should not cover the requested formulary exception.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/ Kidney Disorder
Treatment: Inpatient Hospital Stay

Diagnosis: Genitourinary/ Kidney Disorder - Prostate Problem
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

The patient is a male with a history of coronary artery disease, hypertension, hyperlipidemia, chronic kidney disease (CKD), and benign prostatic hyperplasia (BPH). He presented for cystoscopy and transurethral resection of the prostate. He underwent the procedure. There were no intraoperative or postoperative complications. Postoperatively he was admitted for continuous bladder irrigation (CBI) which was discontinued the next morning. He was eventually discharged home the same day.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient admission was not medically necessary for this patient.
A majority of patients who undergo transurethral resection of prostate can be discharged within 24 hours of the procedure. The procedure was an elective scheduled procedure. The patient did not have any significant risk factors which increase the risk of post-operative complications. His post-operative course was essentially normal without any significant complications or issues with pain control. An alternate level of care for this patient's clinical presentation and post-operative course would have been the safe, effective, generally accepted standard, and the most appropriate treatment option. Admission status may be changed if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Immune thrombocytopenic purpura (ITP)
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient is an adult female with medical diagnosis of rash. The patient went to the emergency room (ER), with a diffuse rash over the entire body and increased redness in the right third digit. A pyogenic granuloma was removed from it and C-reactive protein (CRP) was elevated. Her platelet count was noted at 30,000. The patient was given 2 grams (g) of intravenous (IV) Ancef and 75 milligrams (mg) of oral (PO) prednisone. The patient was hemodynamically stable but was admitted for care. Hematology was consulted over the case. The patient was placed on a prednisone taper. Her platelets improved. The patient was discharged after a period of hemodynamic stability.

The patient was hemodynamically stable and with a platelet count of 30,000, high enough that spontaneous bleeding was not expected. There was, granted, a diffuse petechial rash on the lower extremities. The patient was previously started on Bactrim for ten days pre-procedure at a Wound Care center, then had continued on Bactrim since the procedure. No other IV medications were given in the hospital after admission.      

The platelet count was not excessively low, there were no signs of active bleeding and Bactrim could have been the cause of thrombocytopenia.  Later, the patient's platelet count improved to 43,000. 

"Immune thrombocytopenic purpura (ITP) is an autoimmune pathology characterized by a low platelet count, purpura, and hemorrhagic episodes caused by antiplatelet autoantibodies. The diagnosis is typically made by the exclusion of the known causes of thrombocytopenia. Immunoglobulin G (IgG) autoantibodies sensitize the circulating platelets. It leads to accelerated removal of these cells by antigen-presenting cells (macrophages) of the spleen, and sometimes the liver or other components of the monocyte-macrophage system. Bone marrow compensates the platelet destruction by increasing platelet production. ITP most often occurs in healthy children and young adults within a few weeks following a viral infection. Certain drugs can also cause immune thrombocytopenia indistinguishable from ITP. Most children have spontaneous remission within a few weeks or months, and splenectomy is rarely needed. However, young adults rarely have spontaneous remissions necessitating splenectomy within the first few months after diagnosis. According to current evidence, this activity will review the most common causes of ITP and outline an interprofessional treatment approach." (Justiz, et al., 2022)

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

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

Diagnosis: Deep bite, crowding
Treatment: Braces (D8080) and Monthly Visits (D8670)
The insurer denied the braces (D8080) and monthly visits (D8670).
The denial is overturned.

The patient is a middle childhood female. The request is for orthodontic benefits and monthly follow up visits. The patient has a Class II canine occlusion, deep bite, severe upper and lower crowding, and blocked out upper left and right permanent canines. The prior denial was due to rescoring the handicapping index to 22.

The proposed braces and monthly visits are medically necessary.

The patient's upper left and right permanent canines are totally "blocked out" of the arch, meaning that they do not touch teeth next to them or underneath them. Without the canines in their proper position, there can be no canine guidance. Canine guidance is when the canines guide the lower jaw's motion during the chewing cycle. When there is canine guidance, the upper and lower teeth glide along each other harmoniously. Without the guidance, multiple teeth can bang into or grind against each other, creating a traumatic occlusion. This will, over time, cause tooth fractures and/or loosening of teeth. The canines need to be in their proper positions to prevent this problem. Orthodontic treatment is needed to correct this. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chordoma of the lumbar vertebrae 3 (L3) of the spine
Treatment: Intracytoplasmic sperm injection (ICSI) and assisted hatching
The insurer denied: Intracytoplasmic sperm injection (ICSI) and assisted hatching
The denial is upheld

The patient is an adult female who was diagnosed with chordoma of the lumbar vertebrae 3 (L3) of the spine. The plan is to proceed with in vitro fertilization for fertility preservation prior to cancer treatment. The provider requested coverage for in vitro fertilization, intracytoplasmic sperm injection (ICSI), and assisted hatching. Collection of eggs with freezing was approved by the health plan; however, intracytoplasmic sperm injection (ICSI), and assisted hatching were denied and are the subject of this review.

Intracytoplasmic sperm injection (ICSI) and assisted hatching are not medically necessary.

As part of education and informed consent before cancer therapy, healthcare providers should address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss fertility preservation options and/or to refer all potential patients to appropriate reproductive specialists. Sperm and embryo cryopreservation as well as oocyte 
cryopreservation is considered standard practice and are widely available. Fertility preservation options in females depend on patient age, diagnosis, type of treatment, presence or participation of a male partner and/or patient preferences regarding the use of banked donor sperm, time available, and the likelihood that cancer has metastasized to her ovaries. 
This is a patient being treated for a chordoma and is at risk of developing ovarian failure. The standard of care is to proceed with in vitro fertilization and oocyte or embryo cryopreservation. 
Since the patient is married, embryo cryopreservation may be the best option. Therefore, in vitro fertilization is medically appropriate and standard of care. Note, however, that in the absence of a male factor, there is no indication for intracytoplasmic sperm injection (ICSI) in this patient. 
Intracytoplasmic sperm injection (ICSI) for nonmale factor has not been proven to help the odds of a successful pregnancy. Intracytoplasmic sperm injection (ICSI) for this patient is not medically necessary.
A Cochrane review concluded that despite significantly improved odds of clinical pregnancy, there is insufficient evidence to determine any effect of assisted hatching (AH) on live birth rates. Currently, there is insufficient evidence to recommend assisted hatching. According to the American Society of Reproductive Medicine (ASRM): Laser-assisted hatching (AH) should not 
be routinely recommended for all patients undergoing in vitro fertilization (IVF). There are insufficient data to make a recommendation for selected groups, such as patients with poor prognosis. (Strength of evidence: B/C; strength of recommendation: moderate.) 
In summary in vitro fertilization for this patient is medically appropriate and standard of care; however, there is no indication for intracytoplasmic sperm injection (ICSI) or assisted hatching.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 1 Diabetes
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

The patient is a male with type 1 diabetes on insulin pump. The patient presented with hypoglycemia. He felt weak upon waking at 3 p.m. His mother came into his room, and he was lethargic. Emergency medical services was called and his initial fingerstick was 60 milligrams per deciliter (mg/dL). Glucose improved to greater than (>) 100 mg/dL after dextrose (D) 50 was given. In the emergency department, the patient was alert and oriented x 3 (person, place, time). Glucose was 60 mg/dL at 9:20 p.m., repeat 115 mg/dL 11:02 p.m. The patient underwent chest x-ray and computed tomography (CT) of the abdomen and pelvis in the emergency department, which were unremarkable. His insulin pump was discontinued, and he was started on insulin sliding scale. Endocrinology was consulted. The patient was resumed on insulin pump and recommended insulin pump setting changes and use of continuous glucose monitor in conjunction with his pump. The subject under review is the medical necessity for inpatient admission.

The inpatient admission was not medically necessary. This patient was admitted with hypoglycemia in the setting of known type 1 diabetes on insulin pump therapy. He was alert and oriented at the time of his initial physical exam. He had a glucose of 60 mg/dL in the emergency department which responded to treatment without loss of consciousness or seizure activity. He was hemodynamically stable. He had a known cause of hypoglycemia. He did not have other complicating factors such as renal failure or infection. Therefore, the patient's inpatient admission was not medically necessary.