Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine

Treatment Ubrelvy (ubrogepant).

The insurer denied coverage for Ubrelvy (ubrogepant).

The denial is upheld.

The patient has multiple medical problems and migraine. She was unable to tolerate Topamax. She received an Aimovig injection in the office and was prescribed Ubrelvy. This was denied because it is nonformulary. The Neurologist appealed because he considers triptans, beta blockers and valproate relatively contraindicated because of her other medical problems (Wolff-Parkinson-White syndrome, asthma, obesity, respectively). However, there is no reason she cannot take the formulary drug Nurtec, which is nearly identical to Ubrelvy. 

As summarized in UpToDate "A meta-analysis of available trials found that pain resolution by two hours was likelier with either rimegepant-Nurtec- (relative risk [RR] 1.8, 95% [percent] confidence interval [CI] 1.5-2.1) or ubrogepant -Ubrelvy (RR 1.6, 95% CI 1.3-1.9) than placebo. Ubrogepant received US [United States] Food and Drug Administration (FDA) approval for the treatment of acute migraine in adults and rimegepant received similar FDA approval."

The insurer's denial of coverage for Formulary Exception for Ubrelvy (ubrogepant) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Corneal edema. 
Treatment: Acthar Gel 80Unit/ML. 

The insurer denied the Acthar Gel 80Unit/ML. 
The denial is upheld. 

The patient is a female with keratitis and corneal edema for whom coverage of Acthar Gel is the subject of review. Reportedly, the patient has experienced corneal transplant rejection which would not be reversed with oral prednisone with which the patient experiences severe blood sugar elevation. The provider requests coverage of Acthar to help prevent corneal graft rejection and need for repeat surgery. 

Upon appeal, it is identified that the patient underwent Descemet's stripping endothelial keratoplasty (DSEK) for corneal edema felt likely secondary to Axenfeld-Rieger anomaly. However, the patient starting experiencing rejection quickly within four months of surgery. Treatment with oral prednisolone and topical steroids (prednisolone and Durezol) was attempted with only minor improvement.  The corneal graft ultimately failed.  The patient needs to undergo repeat corneal transplantation but needs immunosuppressive therapy to prevent quick rejection of the new transplant.  Oral steroids cannot be used as they will cause severe hyperglycemia in this patient with diabetes.  Therefore, Acthar injections are recommended. A note documents the patient using ofloxacin, prednisolone and Muro 128. Vision was 20/400 in the right eye (OD) and 20/30-2 in the left eye (OS). Pseudophakic bullous keratopathy was characterized as stable in the right eye (OD) without epithelial defect. 

No, based upon a review of the peer reviewed medical literature, the proposed treatment is not established as medically necessary. 

According to the package insert, H.P. Acthar Gel may be used for the following disorders and diseases: rheumatic; collagen; dermatologic; allergic states; ophthalmic; respiratory; and edematous state. Ophthalmic diseases include severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa such as: keratitis; iritis, iridocyclitis, diffuse posterior uveitis and choroiditis, optic neuritis, chorioretinitis; anterior segment inflammation. As Corticotropin was approved prior to the 1962 Kefauver-Harris Amendment to the US Food, Drug, and Cosmetics Act, which added the requirement of evidence of efficacy to the Food and Drug administration (FDA) approval process, there is a lack of evidence supporting the use of corticotropin for most indications. 

In this case, Acthar is proposed for the prevention and treatment of corneal graft rejection/keratitis. While several case reports are identified in the peer reviewed medical literature which support the safety and efficacy of Acthar in the treatment of non-infectious uveitis, there is a lack of support for the safety and efficacy of such treatment for this patient's indication.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Post Traumatic Osteoarthritis
Treatment: Formulary exception for Pennsaid
The insurer denied the Formulary exception for Pennsaid.
The denial is overturned. 

The patient is a female with worsening bilateral knee osteoarthritis. She failed treatment with ibuprofen, naproxen and an unspecified topical agent. Per attached documentation, she has not tried or failed any of the other plan-preferred prescription oral NSAIDs (nonsteroidal anti-inflammatory drugs). The provider wishes to prescribe topical Pennsaid. The appeal is for Pennsaid for the treatment of knee osteoarthritis.

Yes, the health plan should cover the formulary exception for Pennsaid.

Topical Pennsaid is FDA (United States Food and Drug Administration)-approved for the treatment of knee osteoarthritis, as seen in this patient. This patient failed treatment with ibuprofen and naproxen. Subsequent documentation provided indicates that this patient also failed treatment with the prescription NSAIDs (nonsteroidal anti-inflammatory drugs) Celebrex, Voltaren gel, Voltaren ER (extended release) 100 mg (milligrams) and Mobic. Oral NSAIDs (nonsteroidal anti-inflammatory drugs) also cause gastrointestinal upset for this patient. Thus, various formulary prescription oral NSAIDs (nonsteroidal anti-inflammatory drugs) have been ineffective for this patient and led to gastrointestinal upset. The requested non-formulary topical Pennsaid may be more effective than additional oral formulary alternatives, and would not lead to gastrointestinal upset. Therefore, the health plan should cover the proposed formulary exception for Pennsaid, as various alternative formulary oral NSAIDs (nonsteroidal anti-inflammatory drugs) would not be appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Cholecystitis. 
Treatment: Full hospital admission. 

The insurer denied coverage for full hospital admission. 

The denial is overturned. 

The patient had a history of a sleeve gastrectomy and presented with abdominal pain and vomiting. She was afebrile and the vital signs were stable. There were no peritoneal signs. The white blood cell (WBC) count was 12.8. An ultrasound revealed sludge in the gallbladder with a thickened wall and a positive Murphy's sign. She was diagnosed with acute cholecystitis and given intravenous (IV) antibiotics. The pain resolved. She was then discharged on oral antibiotics with a plan to do a cholecystectomy. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone (M-555) include having acute cholecystitis as indicated by all of the following: pain, white blood count (WBC) over 10,000, and an interval cholecystectomy planned. The patient met all of these indications.

This patient had acute cholecystitis and met the Milliman Care Guideline (MCG) indications for an inpatient admission. 

The healthcare plan did not act reasonably with sound medical judgement and in the best interest of the patient. An inpatient admission was medically necessary.

The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This patient with a past medical history of asthma was brought to the Emergency Department (ED) by his mother for coughing, vomiting, and shortness of breath (SOB). In the ED, the patient improved with albuterol sessions, but he vomited after he drank water and spiked a fever in the ED of 100.7. The patient was admitted to Pediatrics for asthma exacerbation and oxygen saturation of 90% (percent) on room air. Further assessment revealed that the patient's asthma attack was triggered by rhinovirus. He was discharged home with outpatient primary care provider (PCP) follow-up.

The patient could have managed at a lower level. There was no need for Magnesium sulfate, no need for continuous nebs for prolonged time, no need for terbutaline drip or continuous steroids. The patient's lowest saturation was 90 percent. If one were to assess the asthma severity such as the pediatric asthma severity score or pediatric respiratory assessment measurement (PRAM), the score would indicate that patient needed only a lower level of care such as observational status or outpatient. Furthermore, the chest x-ray (CXR) was normal which is expected. Also, there was no underlying medical condition such as chronic lung disease or congenital heart disease. There was also no need for high flow nasal cannula oxygen or BiPAP [Bilevel Positive Airway Pressure]. The Hospital course was suggestive of rapidly improving clinical picture. Due to all the above reasons, the patient only required observational status care. 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: Upheld

Diagnosis: Sleep apnea.
Treatment: Sleep study (CPAP titration).
The insurer denied the sleepy study(CPAP titration).
The denial is upheld.

The patient is an adult female, who has a history of snoring, excessive daytime
sleepiness, an ESS (Epworth Sleepiness Scale) score of 7/24, and a Mallampati
Class IV airway. Her medical history was also notable for HTN (hypertension), IBS
(irritable bowel syndrome), CKD (chronic kidney disease), neuropathy, seasonal
allergies, "heart disease," Atrial fibrillation, RA (rheumatoid arthritis), elevated
cholesterol and RLS (restless leg syndrome).

The patient was seen regarding fatigue and was was referred for a HST
(home sleep test). The patient underwent a HST (home sleep test).
At that time, she was found to have an AHI (apnea-hypopnea index) of 32.3. She
has since been referred for an attended CPAP (continuous positive airway
pressure) titration sleep study.

No, the requested sleep study (CPAP titration) is not medically necessary.

There has been a gradual shift away from the performance of sleep testing and
treatment in the attended setting to the home/ambulatory setting/environment.
Studies have otherwise shown that the provision of therapy services (via autotitrating PAP [positive airway pressure]) can deliver equivalent results to patients in
place of them undergoing titration studies in a sleep center (see Rosen et al, Berry
et al). As was noted in recent practice guidelines from the AASM (American
Academy of Sleep Medicine): "The TF [Task Force] identified 10 RCTs [randomized
controlled trials] that compared initiation of PAP [positive airway pressure] using
home APAP [auto-titrating positive airway pressure] versus an in-laboratory PAP
[positive airway pressure] titration. Meta-analyses demonstrated no clinically
significant differences in adherence, sleepiness, or QOL [quality of life] between
APAP [auto-titrating positive airway pressure] at home and in-laboratory PAP
[positive airway pressure] titration. The overall quality of evidence for this
recommendation was high." (Patil et al). The authors also noted that their
conclusion applied to all patients who had been diagnosed with OSA (obstructive
sleep apnea), including those diagnosed with a "severe" AHI (apnea-hypopnea
index) on initial testing.

In their accompanying publication Patil and colleagues also stated that: "The
potential benefits of PAP [positive airway pressure] initiation using home APAP
[auto-titrating positive airway pressure] over in-laboratory titration are a reduced
time to initiation of therapy, particularly in areas with limited laboratory resources,
reduced time away from home, lower overall cost, and greater access to care."

Likewise, other publications have presented analyses showing that the provision of
care with the use of an AutoPAP (as opposed to having a patient undergo an
attended titration) otherwise is a more efficient manner in which care can be
provided (Hui et al, Bravata et al).

Therefore, given the above, the requested sleep study (CPAP titration) is not
medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's dementia.
Treatment: Increase Personal Care Worker (PCW) Services from 7 days per week,
5 hours per day to 7 days per week, 12 hours per day; a total of 84 hours per week.
The insurer denied the request for an increase in Personal Care Worker (PCW)
Services from 7 days per week, 5 hours per day to 7 days per week, 12 hours per
day; a total of 84 hours per week. 
The insurer approved PCW (personal care worker) 7 days per week, 6 hours per day, total of 42 hours per week.
The denial is upheld.

The patient is a senior female. Her conditions include Alzheimer's dementia. The
patient's UAS (Uniform Assessment System) evaluation performed shows moderately impaired cognition and functional status: total dependence with
managing finances; maximal assistance with meal preparation, housework,
managing medications, phone use, and shopping; extensive assistance with
bathing, dressing, walking, and locomotion, toileting; limited assistance with
personal hygiene, bed mobility, and eating. She has bowel and bladder
incontinence. Compared to UAS (Uniform Assessment System) evaluation
completed previously, there has been a decline in personal hygiene, upper
body dressing.

An appeal statement from the patient's husband states the patient requires
assistance with ADLs (activities of daily living), as already accounted for in the UAS (Uniform Assessment System) evaluation. The appeal statement notes that the patient has frequent day and night time incontinence for the past six weeks and
describes confusion with episodes of aggression.

A letter from the provider states the patient has progressive neurocognitive decline and decline in physical functioning. The letter states that the patient requires total assistance with ADLs (activities of daily living).

This patient has multiple chronic conditions including Alzheimer's dementia.
Compared to UAS (Uniform Assessment System) evaluation completed previously, there is no significant change in the patient's cognitive or physical
functioning. This patient has neurocognitive decline, but no significant decline in
physical functioning.

PCW (personal care worker) is not indicated for supervision or when no tasks are
being performed. The increase in PCW (personal care worker) 7 days per week, 6
hours per day, for a total 42 hours per week is sufficient to meet the patient's needs
for assistance with ADLs (activities of daily living) and IADLs (instrumental activities of daily living). The requested increase in PCW (personal care worker) to 84 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: upper gastrointestinal (GI) bleeding.
Treatment: inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission.
The denial is upheld. 

This male patient has a history of alcoholic cirrhosis with ascites, alcoholic hepatitis, substance-abuse disorder, hepatic hydrothorax, variceal bleeding requiring banding and spontaneous bacterial peritonitis.

Clinical indications for admission for upper gastrointestinal (GI) bleeding (M-180) include hemodynamic instability, ongoing active bleeding, high risk endoscopic features, bleeding from varices, a severe coagulopathy, peritoneal signs, or an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had vomited blood and was initially tachycardic. However, he responded to treatment given in the emergency department. It was determined that he was not actively bleeding and did not need an urgent endoscopy at that time. He could have been treated with a proton pump inhibitor (PPI) and had the hemoglobin level followed with an observation status. The patient was not having acute withdrawal from alcohol. He did not meet Milliman Care Guideline (MCG) criteria for admission for upper Gl bleeding.

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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain.
Treatment: inpatient emergency admission.
The insurer is denied coverage for inpatient emergency admission.
The denial is upheld. 

This male patient has a history of asthma, hypertension, morbid obesity and Covid(coronavirus disease) induced cardiomyopathy.

This patient presented with dyspnea and chest pain to the ED (emergency department). His medical record revealed multiple recent admissions with evaluation for similar symptoms. He had a known history of chronic systolic heart failure with reduced rejection fraction and was treated with guideline directed medical therapy. Serum blood testing revealed no evidence of an acute cardiac ischemic syndrome. Serum Brain natriuretic peptide(BNP) level was mildly elevated and no evidence of congestive heart failure on physical examination or on chest X-ray. He was appropriately treated with diuretics and neurohormonal blockade. (1) Masri et al compared patient outcomes following treatment of acute congestive heart failure in observation and inpatient settings and demonstrated no difference in mortality between the two groups. (2) The patient had no evidence of ventricular ectopy on electrocardiogram(EKG) or telemetry monitor. Primary prevention defibrillator implant was appropriate according to American Heart Association/ American College of Cardiology/ Heart Rhythm Society (AHA/ACC/HRS) guidelines, however implantation prior to discharge was not necessary. (3) This patient could have been treated in an observational setting and scheduled for Implantable Cardioverter Defibrillator(ICD) implant as an outpatient.

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

The carrier's denial of coverage for the inpatient emergency admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment inpatient hospitalization

The insurer denied coverage for inpatient hospitalization.

The denial is upheld.

This case involves a female who presented to the emergency department due to a 1-day history of nausea and vomiting.  The documentation indicated the patient has no past medical history.  The patient reported she had 3 episodes of vomiting and her mother stated she has not been eating.  Upon physical examination she was in mild distress.  She had a temperature of 98.9 with a pulse of 116 beats per minute (bpm).  Oxygen saturation was 100% (percent) on room air.  The patient did have tenderness to the right lower quadrant.  It was recommended she undergo laboratory studies.  The laboratory studies revealed a white blood cell count of 14.5.  It was recommended she undergo diagnostic studies for further evaluation.  A computed tomography (CT) scan of the abdomen and pelvis revealed a tubular fluid-filled structure within the pelvis which was suspicious for appendicitis although it could not be shown to definitely connect to the cecum.  She did undergo an ultrasound revealing a high suspicion of appendicitis.  The recommendation was to admit the patient to undergo a laparoscopic appendectomy.  The documentation indicated she did undergo surgical intervention without complication.  According to additional documentation there was no further significant adverse events, and she had a normal examination the following morning.  She was afebrile and was able to tolerate a regular diet.  Given the above she was discharged with instruction to follow-up.

This patient presented with symptoms suspicious for appendicitis. Physical exam, laboratory and radiologic work up revealed appendicitis for which she was taken to surgery. The patient was appropriately hydrated, antibiotics given, and surgery performed consistent with standard of care. However, this patient was found to have acute uncomplicated appendicitis for which laparoscopic appendectomy is a treatment option. Laparoscopic appendectomy was performed without any complication. It is certainly reasonable to have the patient admitted overnight for post op recovery with discharge the following day, as was the case. However, admission as inpatient is not necessary in this case. It would have been feasible, safe and practical to admit the patient as observation status and not inpatient following laparoscopic appendectomy for uncomplicated acute appendicitis in an otherwise stable patient.  

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 hospitalization is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Indirect Hyperbilirubinemia

Treatment inpatient stay at the acute medical surgical level of care

The insurer denied coverage for inpatient stay at the acute medical surgical level of care.

The denial is overturned.

The patient is male born to a Gravida 3 Para 2 mother by Cesarean - section with a birth weight of 3970 grams that was referred to the Emergency Department for assessment and management of indirect hyperbilirubinemia. The baby was blood type O Rh [protein]+[ positive]/ Coomb's negative. He was breast feed with some formula supplementation. His total bilirubin followed in the outpatient setting trended from 12.2 (at hospital discharge) to 18 the day of presentation. His vitals were notable for Temperature (T) 97.6, Heart Rate (HR) 122, Respiratory Rate (RR) 32, Blood Pressure (BP) 84/60 and oxygen saturation of 100% [percent] on room air. His physical exam was notable for jaundice but was otherwise unremarkable. His admitting weight was 3660 grams. Admitting laboratories were notable for sodium 138 potassium 6.3, bicarbonate 21, blood urea nitrogen (BUN) 4, creatinine 0.42, white blood count 10.5 (neutrophils 18%, band 3%), hemoglobin 20.3, platelets 133, retic count 1.1 and total bilirubin 18/direct bilirubin 0.3. He was admitted to the inpatient setting for phototherapy and oral hydration.  Phototherapy was discontinued and the patient was discharged home the same day for outpatient follow-up. His weight at discharge was 3760 grams.
 
This full-term neonate had escalating indirect hyperbilirubinemia in the setting of breast feeding and no hemolysis making him standard, not medium risk for morbidity as stated in the appeal.
 
According to a review of the management of indirect hyperbilirubinemia in term or late pre-term infants from UptoDate the authors conclude the following: "Overview - Phototherapy, using light of specific wavelengths and doses, is considered a safe and effective intervention to reduce total serum or plasma bilirubin (TB) levels based upon its extensive use in millions of infants over six decades. Although sunlight includes the effective blue-green light wavelength range (425 to 475 nm [nanometer]) that reduces TB, it also contains the harmful ultraviolet (UV) range (<400 nm), which increases the risk of sunburn and potential for skin malignancies. Therefore, unfiltered sunlight should not be used for phototherapy.
 
Risk stratification Factors that increase the risk of unconjugated hyperbilirubinemia include is immune hemolytic disease (eg, glucose-6-phosphate dehydrogenase deficiency [G6PD]), asphyxia, lethargy, temperature instability, sepsis, acidosis, hypoalbuminemia (albumin <3 g/dL [grams per deciliter]), East Asian ethnicity, and inadequate fluid intake with excessive weight loss.
 
Overturned denial of coverage for acute inpatient hospital admission. The health plan did not act reasonably with sound medical judgment.

The insurer's denial of coverage for the inpatient stay at the acute medical surgical level of care is overturned. Medical Necessity is substantiated.