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

Diagnosis: Respiratory System/Other/COVID (Coronavirus Disease) 
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld, in whole.

The patient is a male with a past medical history (PMH) of pulmonary embolism (PE), congestive heart failure (CHF), and ST-Elevation Myocardial Infarction (STEMI) status post a left anterior descending (LAD) stent who was admitted with complaints of nausea and vomiting associated with mid-epigastric pain. Vital signs were unremarkable. A physical exam was significant for no apparent distress (NAD), and a non-tender abdomen. Lab work was notable for a creatinine of 2.02, a blood urea nitrogen (BUN) of 51, and a mildly elevated troponin (trending down). Imaging studies included a chest x-ray (CXR) which showed no acute disease. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with COVID-19 and acute kidney injury (AKI) and was treated with intravenous (IV) fluids and clinical monitoring. The patient was discharged in stable condition.
What is at issue is the medical necessity of the inpatient level of care.

I uphold, in whole, the health plan's determination of medical necessity.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints nausea and vomiting associated with mid-epigastric pain. The patient was found to have acute kidney injury, for which intravenous fluids (IVF) were administered and the patient's creatinine responded. This patient did not have hypertension (HTN) requiring continuous vasoactive medication and there was no urgent indication for dialysis, marked electrolyte abnormalities, volume overload, severe hyponatremia, hyperkalemia, or acute respiratory distress. The patient was diagnosed with COVID-19 during his stay, but the patient did not have any hemodynamic instability, there was no hypoxia, respiratory failure or distress, apnea, intentional overdose/exposure, fever, significant trauma, or unstable vital signs. This patient without distress was admitted for acute kidney injury and COVID-19, received IVF, and was discharged home in stable condition, and this could have been provided safely at an observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital. 

The insurer denied coverage for inpatient hospital. 

The denial is upheld. 

This case of a gentleman that presented to the hospital complaining of palpitations and chest pain while walking in the street.  Past medical history is significant for hypertension.  Upon arrival to the hospital, vital signs were stable, BP (blood pressure) 169/82 mmHg (millimeters of mercury) and pulse 109 beats per minute. No abnormal findings were reported on physical examination.  A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm, left ventricular hypertrophy with strain.  Serum blood testing revealed no significant elevation in high sensitivity troponin level (20ng/L [nanogram per liter]).  The patient was admitted to the hospital for observation and treatment.  Echocardiogram revealed a preserved left ventricular ejection fraction of 65-70% (percent) and left ventricular hypertrophy. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with chest pain and palpitations.  He had a past medical history of hypertension. His pretest probability of coronary artery disease was low (Reference 1).  Utilizing the HEART (history, EKG, age, risk factors, troponin) score, he was considered low risk (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST (interval on EKG) changes on EKG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care. 

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

Diagnosis: Gastritis.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented with abdominal pain. The pain was epigastric, and she had a history of gastritis. An endoscopy one month earlier showed gastritis. There was no abdominal rebound or guarding. There was no leukocytosis. An abdominal CAT (computed axial tomography) scan showed a possible enteritis. She was treated with Protonix and Carafate. She was placed on a regular diet. The enteritis was felt to be related to having a virus. She rapidly improved and was able to tolerate a diet.

Clinical indications for admission for Gastritis (MCG (millman care guidelines) M-560) include hemodynamic instability, gastric outlet obstruction, perforation, peritoneal signs, severe vomiting, severe pain, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

Clinical indications for admission for Gastroenteritis (MCG M-170) include having a suspected severe infection, severe abdominal pain, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, or an inability to maintain oral hydration after observation care.
The patient did not have these conditions.

This patient had gastritis and a possible viral enteritis. Intravenous (IV) hydration, PPI (proton pump inhibitor) therapy, and Carafate could have been given with observation status. She did not have intestinal obstruction or require any surgical interventions. She did not meet MCG criteria for admission for either Gastritis or Gastroenteritis. An inpatient admission was not medically necessary,

The denial is upheld.

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

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

Diagnosis: Chronic Atrial Fibrillation. 
Treatment: Formulary exception for Eliquis. 

The insurer denied the Formulary exception for Eliquis. 
The denial is overturned. 

The patient is a male with chronic atrial fibrillation who has been stable on Eliquis anticoagulation for several years. The patient's provider have requested approval for continued Eliquis treatment. 

The health plan denied coverage for Eliquis, since the patient has not tried and had an inadequate treatment response or intolerance to the formulary anticoagulant alternatives (warfarin, Xarelto), or have a documented clinical reason such as expected adverse reaction or contraindication that prevents the patient from trying the formulary alternatives. 

Yes, the health plan should cover the Formulary exception for Eliquis. 

The formulary anticoagulant drug options under the health plan included warfarin and Xarelto. Warfarin has been well-demonstrated to be inferior to Xarelto and Eliquis for stroke prevention in atrial fibrillation. 

Ray et. al published evidence in JAMA (Journal of the American Medical Association) journal revealed that treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events. 

Fralick et. al published evidence that showed that adults with atrial fibrillation prescribed apixaban had a lower rate of both ischemic stroke or systemic embolism and bleeding compared with those prescribed rivaroxaban. 

Switch from Eliquis to the health plan's formulary alternatives could jeopardize the patient's clinical stability. It is standard of care in clinical practice to continue use of Eliquis in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Varicose Veins. 
Treatment: Surgical Services. 

The health plan denied the requested surgical procedure. 
The health plan's determination is overturned. 

The patient is a woman who was evaluated for bilateral lower extremity tenderness, restless legs, tiredness/fatigued legs, heavy sensation in legs and ankle swelling of one year. Her symptoms have worsened over the last 6 months and over the last 3 months she has experienced increased restless legs, increased swellings, and increased pain. The patient has used compression stockings. She was noted to have extensive/bulging varicose veins on the right leg. She had bilateral ankle swelling, subdermal reticular veins and telangectasias. 

A lower extremity venous duplex exam performed demonstrated reflux of the bilateral small saphenous veins and perforating vein reflux at the left medial calf. A right lower extremity venous duplex exam performed demonstrated reflux of the right great saphenous vein. 

The patient was offered endovenous ablation of the left small saphenous vein, endovenous ablation of the right great saphenous vein, phlebectomy of left lower extremity varicose veins, and macrofoam ablation of the distal remnant right great saphenous vein. 

The patient had an endovenous ablation of the left small saphenous vein, and endovenous ablation of the right great saphenous vein. 
The patient underwent phlebectomy of the left lower extremity varicose veins and microfoam ablation of the distal remnant right great saphenous vein.
The issue at hand is whether or not the microfoam ablation of the distal remnant right great saphenous vein was medically necessary. 

I overturn in whole, the health plan's determination of medical necessity. 

Yes. The patient has symptomatic bilateral lower extremity varicose veins and venous insufficiency. 

The proposed treatment including endovenous ablation of the left small saphenous vein, endovenous ablation of the right great saphenous vein, phlebectomy of left lower extremity varicose veins and macrofoam ablation of the distal remnant right great saphenous vein was medically necessary. 

The proposed treatment was medically necessary and is the standard of care for the treatment of symptomatic varicose veins and venous insufficiency. The patient will benefit from the treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Respiratory Failure. 
Treatment: Backup Ventilator. 

The insurer denied a Backup Ventilator. 
The determination is overturned. 

The patient has a medical history significant for nemaline rod myopathy, with chronic respiratory failure, hypoxemia, ventilator dependence status post tracheostomy tube placement, severe scoliosis with associated restrictive lung disease, gastroesophageal reflux disease, asthma, and gastrostomy dependence. She requires round-the-clock full ventilator support. In her current housing situation, there are three levels. In order to facilitate mobility, she requires a second ventilator unit. In addition, it would provide back-up should the primary unit fail. She is monitored via end-tidal carbon dioxide (CO2) monitoring to assess for hypoventilation and hyperventilation. She was recently started on Diamox for headaches associated with nausea and began noticing drying out of secretions and increase in mucous plugging. Her mother reports some resistance to tracheostomy (trach) changes. At issue is the medical necessity of a backup ventilator.
The requested transport ventilator is medically necessary and appropriate for this young woman who is completely dependent upon mechanical ventilation. 
This young patient is significantly disabled as a result of and in addition to her neuromuscular disease with associated end-stage chronic respiratory failure. She is fully ventilator dependent and cannot be off the ventilator without the potential for significant and severe morbidity and potential mortality. She practices aggressive airway clearance with Xopenex, Pulmozyme, Vest therapy, and CoughAssist. She is unable to use hypertonic saline as a mucolytic. Her current use of Diamox for headaches and nausea has resulted in drying of airway secretions and increase in mucous plugging, placing her at risk for airway compromise from mucous plugging. She is monitored with end-tidal carbon dioxide (CO2) monitoring to assess for hypo- and hyperventilation. 
 She cannot be without mechanical ventilation at any time without the potential for a significant life-threatening event. The requested second ventilator will allow her increased mobility inside of her living situation and will also provide necessary back-up should the primary ventilator fail. She is not in a position where there are other immediately-available life-saving resources should there be mechanical ventilatory failure. Based on the current standard of care and her clinical history, a second back-up ventilator is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 

The insurer denied Image-guided radiation therapy (IGRT), Proton Beam. 
The denial is overturned. 

This patient is a male with a history of a high grade mucoepidermoid carcinoma of his left lower lobe status/post (s/p) lobectomy and mediastinal lymph node dissection showing pT4N0M0 disease. He has been recommended for postoperative proton beam radiation therapy. 

At issue is the medical necessity of Image-guided radiation therapy (IGRT), Proton Beam. 

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

The requested health service/treatment of Image-guided radiation therapy (IGRT); Proton Beam is medically necessary for this patient. 

Proton beam radiotherapy is medically necessary for this patient. The patient has an uncommon malignancy which portends a better prognosis than non- small cell or small cell lung cancer. Given that the patient has a reasonable likelihood of long-term survival, it is critical to minimize his risk for long term radiation-induced morbidity. The treating provider has supplied a proton/photon plan comparison. Due to the intimate location of the target volume directly adjacent to the patient's heart, the photon-based plan resulted in significantly higher cardiac exposure. If delivered, this would translate into a clinically significant increased risk for cardiac morbidity/mortality. The proton radiation plan is able to significantly reduce the heart exposure, thereby minimizing this risk for serious toxicity. Proton radiation therapy in the member's setting is supported by the American Society for Radiation Oncology (ASTRO) Model policy and is widely utilized throughout the oncology community for situations where photon-based radiotherapy would lead to a higher risk for radiation induced mortality. There are numerous high quality prospective clinical outcomes reported in the medical literature that support the use of proton radiation therapy for thoracic malignancies in a patient with good chances for long term survival. 

Therefore, the requested health service/treatment of Image-guided radiation therapy (IGRT); Proton Beam is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma Injuries-Brain Injury/Concussion
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This is the case of a patient who presented to the emergency room on after a mechanical fall with loss of consciousness. Her initial Glasgow Coma Scale (GCS) was 14 and subsequently 15. She was found to have a 2-centimeter (cm) scalp laceration and a scalp hematoma. She had no intracranial injuries. She was admitted to the trauma service and discharged the next day. 

No. The anticipated length of observation after such a head injury is 24 hours. The patient had no significant injuries. With a GCS of 15, no evidence of intracranial injury on imaging, and a normal neurologic exam, it would be appropriate to treat this patient at a lower level of care. This is supported by an article on the subject in UpToDate. "Outpatient observation may be permitted for the patient whose neurologic condition is very unlikely to deteriorate. There is substantial evidence that patients with a GCS = 15, normal examination and head computed tomography (CT) scan, and no predisposition to bleeding are unlikely to suffer subsequent neurologic deterioration." [4] Multiple guidelines for concussion state that patients with a GCS of 15 and no injuries may be treated at a lower level of care. The hospital stated that the patient was hypotensive, however, this was not mentioned in the notes and the lowest MAP (Mean arterial pressure) was always greater than 60. Thus, there was not any major concern for ongoing hypotension and there was no documentation of treatment for hypotension during the inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Universalis.
Treatment Xeljanz 10 mg (milligrams) tablets dispensed at a quantity of 60 tablets every 30 days.
The insurer denied coverage for Xeljanz 10 mg tablets dispensed at a quantity of 60 tablets every 30 days.
The denial is overturned.

The patient is an adult female who has a diagnosis of alopecia universalis. She has failed therapy with platelet-rich plasma (PRP) and intralesional Kenalog. The patient's disease severity is significant and involves nearly her whole scalp as well as the hair on her eyelashes, eyebrows, and body. The requested medication is Xeljanz.

The use of light therapy and topical therapy would not be appropriate given the extent of involvement as well as involvement of sensitive areas, such as eyelashes. No FDA (Food and Drug) approved systemic therapies are available for treating alopecia universalis. In this clinical situation, Xeljanz is an appropriate treatment option for treatment of alopecia universalis. The patient has extensive disease involvement of alopecia which necessitates systemic therapy. The use of Xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment. 

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 Xeljanz 10 mg tablets dispensed at a quantity of 60 tablets every 30 days is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Pharmacy/Prescription Drugs. The insurer denied Vyepti (eptinezumab-jjmr). The denial is upheld. 

The patient is a female, who has been under the care of a neurologist for a history of migraine headaches. She is said to have previously been started on Vyepti (infusions) for her migraines. Notes indicated that her preventative regimen at that time was a combination of nerve blocks every 6 weeks, zonisamide, gabapentin, magnesium and Vyepti. She was also taking duloxetine, Levothyroxine, Nexplanon, spironolactone and hydroxyzine as needed (PRN). Prior preventative therapies were said to have also included amitriptyline (no benefit), propranolol and atenolol (dropped blood pressure), Aimovig (greater than [>]3 months without benefit) and Emgality (4 months without benefit).
At issue is the medical necessity of Vyepti (eptinezumab-jjmr).

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

The requested health service/treatment of Vyepti (eptinezumab-jjmr) is not medically necessary for this patient.
There have not yet been any direct comparison studies completed to date between the self-administered calcitonin gene-related peptide (CGRP) drugs. As such it cannot be concluded that Vyepti would be expected to result in superior outcomes to a trial of Ajovy. There remains a need for direct comparison studies to be concluded to permit such a determination. While the patient self-reports an aversion to needle/injections, it is not otherwise clear why another lay individual or a clinical provider would not otherwise be able to assist with administration of the plan's preferred agent (on a monthly or quarterly basis). The mode of administration is not otherwise a contraindication to a trial of this therapy. The plan offered an alternative service, which is well supported by current literature and has otherwise been shown to be beneficial in the patient's condition. Given these factors, it cannot be concluded that the requested drug is otherwise medically necessary at this time.
Therefore, the requested service/treatment of Vyepti (eptinezumab-jjmr) is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal Pap Smears. 
Treatment: Current Procedural Terminology (CPT) code 57460 colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix. 

The insurer denied coverage for CPT code 57460 colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix. 

The denial is upheld. 

The patient is a female with a history of abnormal pap smears. Her latest pap smear was reported as atypical squamous cells of undetermined significance with high-risk HPV (human papillomavirus infection). A colposcopy was performed. Cervical biopsy consistent with Low grade SIL (squamous intraepithelial lesion). 

The provider wants to proceed with a LEEP (loop electrosurgical excision procedure) procedure. The LEEP is being done at a surgical center because the patient does not want to be awake nor have local anesthesia in the office. 

Review of the submitted records do not provide any rationale that the LEEP procedure would require a surgery center. The literature clearly supports this being done in an office center. The doctor does not indicate that his office does not have the requisite facility to safely perform the procedure. Lastly, ACOG (American College of Obstetricians and Gynecologists) states "In most cases, LEEP is done in the office of an ob-gyn. The procedure takes a few minutes." 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the cervical procedure to be done at an ambulatory surgical center instead of in the office is upheld. Medical Necessity is not substantiated.