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

Diagnosis: Autism

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned. 

This female patient with a history of asthma, autism spectrum disorder and speech delay who has been on previous treatments with albuterol. The patient developed a cough, wheezing and increased work of breathing 2 days prior to admission. The patient's mother had administered albuterol 3 times to the patient at home, but patient had no clinical improvement in her symptoms. The mother brought the patient to the Emergency Room (ER) for further treatment. In the ER, the patient was noted to have respiratory distress with retractions, prolonged expiration and evidence of increased work of breathing. There was nasal flaring and wheezing noted on physical examination. The patient was given 3 doses of albuterol and Atrovent followed by intravenous (IV) Decadron twice and IV fluids. The patient's chest X-ray demonstrated a mild infiltrate at the right base. The patient's blood gas was performed and showed a low carbon dioxide (pCO2) of 24 and her bicarbonate level was low at 19. The patient improved following treatment in the ER but she had persistent evidence of nasal flaring which was consistent with increased work of breathing. In view of the blood gas finding and the nasal flaring, the decision was made to admit the patient with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 3 hours.  

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. The patient was treated appropriately in the Emergency Room (ER) for a cough, wheezing and respiratory distress. The patient had a history of asthma and evidence of persistent increased work of breathing following treatment in the ER. The patient's blood gas demonstrated a low carbon dioxide pCO2 of 24 which was consistent with increased respiratory rate and work of breathing. The presence of nasal flaring following 3 nebulized treatments with Duoneb, intravenous (IV) fluids and Decadron, indicated ongoing need for albuterol treatments. When there was ongoing respiratory distress with increased work of breathing, it was appropriate and consistent with the standard of care to admit the patient to the hospital for ongoing treatment with albuterol every 3 hours. The patient had failed outpatient management of her asthma and she was not stable enough to be sent home.  

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The insurer's denial of coverage for the inpatient hospital admission is substantiated. The denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission.

The denial is overturned. 

This female patient has a history of keratoconus and migraines.  She presented to the hospital with complaints of abdominal pain.  She was at 24 weeks and 3 days of gestation.  She was recently diagnosed with cholecystitis. Vital signs were within normal limits (WNL) and the patient was afebrile. There was a positive Murphy's sign.  White blood cell (WBC) count was elevated. Liver function tests (LFT) were WNL.  The urinalysis (UA) was negative for infection. Intravenous (IV) fluids, Famotidine, and Zofran were started.  She was admitted  for symptomatic cholelithiasis.  The patient was started on IV Cefoxitin.  General surgery consulted over the case. They recommended continuing antibiotics and performing a cholecystectomy on an outpatient basis postpartum.  Her diet was advanced to a regular diet.  The patient was transitioned to oral (PO) Cefpodoxime.  She remained afebrile and pain improved after antibiotics were given.  She was discharged after a period of medical stability.

Cholecystitis should be considered in the evaluation of any pregnant woman with abdominal complaints. Acute cholecystitis can mimic many other intra-abdominal problems, both obstetric and nonobstetric. Most patients respond to conservative management, with minimal increase in maternal or fetal morbidity and mortality. A few will not respond to therapy or will have severe complications requiring more aggressive management, including surgery.

The initial management of pregnant patients with gallstone disease is supportive and includes pain control, intravenous fluid therapy, and, for patients with acute cholecystitis, antibiotic therapy. Additional imaging and repeat laboratory studies are indicated to assess for potential complications if symptoms worsen.

If acute cholecystitis occurs during the third trimester, every effort should be made to avoid surgery. Cholecystectomy during the trimester is not only technically difficult but also has been associated with worse outcomes (eg, increased premature delivery). Once the woman has delivered her baby, a cholecystectomy is performed after 6 weeks to allow her to recover from the delivery, bond with the infant, and regain her strength.
This patient was pregnant and was diagnosed with acute cholecystitis. Admission for intravenous antibiotics and close monitoring for worsening condition that could put the patient and the fetus at risk was medically necessary. Once the patient's condition stabilized and improved as shown by decreased pain and ability to tolerate oral intake, she was discharged home.

The health plan did not 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 overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Aimovig. 
The denial is upheld in whole.

The patient is a female diagnosed with chronic migraine. The patient has previously tried and failed the preventative agent topiramate. A letter of medical necessity also states that the patient has tried and failed nortriptyline and propranolol. Aimovig is requested.
The subject under review is the medical necessity for Aimovig in this case.

Aimovig is not medically necessary. Aimovig is requested for treatment of chronic migraine. Office notes are provided showing that the patent has tried and failed topiramate. However, office notes are not provided showing that the patient has had an adequate trial or failure of any other medications for prevention of migraine. There are numerous first line agents for prevention of migraine including antidepressants, anticonvulsants, and beta-blockers. The plan has numerous agents such as Propranolol, Metoprolol, Timolol, Nadolol, Atenolol, Divalproex-delayed release or extended release tablet, amitriptyline, venlafaxine and venlafaxine ER. Although the physician argues that a beta-blocker is not appropriate as the patient is on another blood pressure medication, the patient does not have a reasonable contraindication to the use of Divalproex, amitriptyline, or venlafaxine. These medications all provide similar decrease in headache frequency and Aimovig has not been shown to be superior.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hemicrania continua.
Treatment: inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is upheld. 

This female patient has a history of migraines, hypertension, diabetes who presented to the Emergency Department for a headache that was progressively worsening. She had been seen at another facility and given medications, but had no relief. She was given pain medication, magnesium, and anti-emetics. She was admitted and received intravenous (IV) fluids. A neurology consult was called. It was determined she had hemicrania continua. She was started on IV Valproate and improved. She was then cleared for discharge for outpatient follow up.

According to current literature a patient may be admitted to inpatient services when there is evidence that the patient has an altered mental status that is severe or persistent, vomiting that is severe persistent, dehydration that cannot be corrected in a lower level or when there is documentation of severe new neurologic findings requiring inpatient services.  The documentation does detail this patient presented with complaints of 3 months of left-sided headaches radiating with associated symptoms.  The examination revealed the patient was alert and oriented.  There were no vision changes and no difficulty with walking or talking.  She underwent imaging revealing no acute findings and was given medication without improvement.  The patient was admitted and was treated with further IV fluids and medications.  While it is noted this patient initially presented with ongoing complaints of a headache, the documentation does not detail this patient was appropriate for admission to inpatient services.  There was no evidence of significant hemodynamic instability, dehydration that was severe or persistent, vomiting that was severe or persistent or altered mental status that was severe or persistent.  The documentation indicated the patient was given IV Toradol and Reglan.  It does not appear she exhausted all outpatient management options for her appropriate care in a lower level prior to admission into inpatient services.  Therefore, given the patient could be treated at a lower level, the requested inpatient was not medically necessary and the prior determination remains upheld.

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: Overturned

Diagnosis: Bipolar disorder, Schizophrenia.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is overturned. 

This male patient has a history of hypertension (HTN), morbid obesity, pre-diabetes, active bipolar disorder, schizophrenia disorder status post multiple psychiatric hospitalizations, polysubstance abuse (cocaine, cannabis), alcohol abuse, and active smoker who presented to the Emergency Department (ED) after a fall the night prior to presentation.  The patient reported he felt dizzy and fell down on his knees in the street and passed out for 30 seconds.  He described chest pain as constant chest soreness for 2 weeks, 8/10 in intensity not related to positional changes, taking a deep breath, food intake or physical activity.  It was noted the patient was non-compliant with his psych meds, anti-HTN meds(Antihypertensive Medications) Amlodipine 10mg for the past year and stated he had been hearing voices and was increasingly depressed since his mother passed away a week prior to presentation.  The patient was admitted for chest pain which was attributed to fall and likely musculoskeletal in origin. He was placed on continuous telemetry monitoring with no significant events recorded.  Echo cardiogram was negative.  The patient was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicidal plan are in need of inpatient hospital treatment as they are considered a danger to self. It also states that patients with psychotic symptoms are also at increased risk for suicide.

The health plan did not 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 overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Humira. 
The denial is upheld.

The patient is a female with severe rheumatoid arthritis (RA). Past medical history (PMH) also includes diabetes mellitus type 2 (DM2), breast and uterine cancer (CA) and ischemic visual loss of the right (R) eye. The issue in this case is Humira is being denied by the health plan. The reason cited is plan maximal doses of formulary alternatives must be considered first, including methotrexate (MTX), leflunomide, hydroxychloroquine (Plaquenil) and sulfasalazine (SSZ). However, per chart review, the patient has tried and failed MTX, SSZ, prednisone, Tylenol and Motrin. Her provider wrote a note stating she has already tried and failed SSZ at maximally tolerated doses and she is currently taking MTX 10 milligrams (mg) weekly, but is at risk of hepatotoxicity due to pre-existing liver disease, which is why it has not been further titrated up. Of note, liver function tests (LFTs) are within normal limits.

The subject under review is the medical necessity for Humira.

The health plan's determination is upheld in whole. 

The requested treatment with adalimumab (Humira) is not medically necessary for this patient. There is no medical reason the patient cannot try the other formulary alternatives, such as hydroxychloroquine. She is currently on MTX 10 mg weekly and per chart review, she has hepatic steatosis, which is why she is not on maximal doses of MTX. Likewise, Arava (leflunomide) is not recommended for patients with pre-existing liver disease. However, there is no medical reason why she cannot try hydroxychloroquine.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Skilled Nursing Facility

Diagnosis: respiratory failure.
Treatment: Sub-Acute rehab Inpatient Admission.
The insurer denied the continued Sub-Acute rehab Inpatient Admission. 
The health plan's determination is upheld.

The patient is a female with a significant history of underlying history of Alexander disease with chronic dysphagia/dystonia with chronic hypoxemic respiratory failure requiring a feeding tube and tracheostomy. She was admitted from the hospital to the Skilled Nursing Facility (SNF) with a primary diagnosis of acute on chronic hypoxic respiratory failure secondary to septic shock due to a urinary tract infection with pyelonephritis and pneumonia. Her hospital course was complicated by recurrent septic shock, complicated urinary tract infections, gastrocutaneous fistula with left lower diverting colostomy and unstageable decubitus ulcer with a wound vac (vacuum assisted control). Under review is the medical necessity of Continued Sub-Acute rehab Inpatient Admission.

Continued Sub-Acute rehab Inpatient Admission is not medically necessary for this patient.

This patient was admitted to the skilled nursing facility (SNF) from the hospital with a primary diagnosis of acute on chronic hypoxic respiratory failure secondary to septic shock due to a urinary tract infection with pyelonephritis and pneumonia. The patient has an underlying history of Alexander disease with chronic dysphagia/dystonia with chronic hypoxemic respiratory failure requiring a feeding tube and tracheostomy. Her hospital course was complicated by recurrent septic shock, complicated urinary tract infections, gastrocutaneous fistula with left lower diverting colostomy and unstageable decubitus ulcer with a wound vac. Per the most recent notes, she is hemodynamically stable, is on the ventilator with oxygen saturations > (greater than) 90% and is tolerating tube feeds. Although she was working with physical & occupational therapy, sessions were ended as it was felt her progress was slow and she would benefit from wound healing prior to continuing. Also, since admission she has been unable to wean from the ventilator for any extended period of time and there is no documentation that she will be able to liberate from the ventilator. Per the clinical information provided, although the patient has decubitus ulcers, she did not require intravenous antibiotic therapy for treatment, there was no documentation of wound care requiring skilled nursing. In addition, there is no documentation she requires nursing >= (greater than or equal to) 4 hours per day, she does not currently have rehabilitation potential with an expectation for clinical or functional improvement. Therefore, the requested Continued Sub-Acute rehab Inpatient Admission  is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-coronary artery disease.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Repatha for medical necessity. 
The denial was overturned. 

This patient is a male with a history of coronary artery disease involving the left anterior descending (LAD), familial hyperlipidemia who had been treated with phytosulfokine (PSK) 9 inhibitor, Repatha. The review of the patient records indicate that the patient has been intolerant to multiple statin medications causing abnormal liver function tests and myalgias. His baseline low density lipoprotein (LDL) was found to be severely elevated at 233 milligrams (mg)/deciliter (dl) prior to starting Repatha. The patient was prescribed Repatha for treatment of severe hyperlipidemia, LDL reduction, and cardiovascular risk reduction. Since starting Repatha, the patient's LDL has improved to 197 mg/dl. The patient has tolerated Repatha well.
At issue is the medical necessity of Repatha.

The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Repatha is medically necessary for this patient.
Treatment with Repatha has been shown to significantly lower LDL and reduce future cardiovascular death, myocardial infarction (MI), stroke, hospitalization for unstable angina, or coronary revascularization in patients with known atherosclerotic disease and high LDL. [1] Given the established benefits of Repatha, continued treatment of this patient with Repatha is medically appropriate and necessary for his treatment of hyperlipidemia.
This patient has been diagnosed with severe hyperlipidemia and coronary artery disease (CAD) at risk for future adverse cardiovascular events. He is known to be intolerant to multiple statin medications. For these reasons, the patient's provider has appropriately prescribed Repatha for LDL and cardiovascular risk reduction. Based on results of the Fourier clinical trial which randomized 27,564 patients with atherosclerotic cardiovascular disease and high LDL to evolocumab (Repatha) or placebo, Repatha treatment was shown to significantly lower LDL and reduce the primary outcome of cardiovascular death, MI, stroke, hospitalization for unstable angina, or coronary revascularization. [1] Given the established benefits of Repatha, continued treatment of this patient with Repatha is both medically appropriate and necessary for treatment of hyperlipidemia.
Therefore, the requested treatment of Repatha is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure disorder, congestive heart failure, cardiac pacemaker, atrial fibrillation, hypertension and gait ataxia
Treatment: Increase Personal Care Worker (PCW) to 7 Days per Week, 12 Hours per Day
The insurer denied the Increase Personal Care Worker (PCW) to 7 Days per Week, 12 Hours per Day.
The denial is overturned. 

The patient is a female with a history of seizure disorder, congestive heart failure, cardiac pacemaker, atrial fibrillation, hypertension and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours per week Personal Care Worker service to offer increased ADL support.

Yes, the proposed treatment of 84 hours per week Personal Care Worker service is deemed medically necessary.

Recent correspondence received from the patient's medical provider indicates that due to progressively worsening functional decline related to the combination of her medical conditions, she was admitted to the inpatient hospital service with symptoms of chest pain and shortness of breath. Her gait disturbance and fall risk is increased, and given her current therapeutic anticoagulation regimen of Coumadin, she is at high risk for internal bleed with any major falls.

For these reasons, the currently approved plan of 56 hours per week Personal Care Worker service is not sufficient to meet the patient's current needs. Hence, the proposed treatment of 84 hours per week Personal Care Worker service is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary Arterial Hypertension.
Treatment: Sildenafil.

The insurer denied coverage for Sildenafil.  The denial is overturned.


The patient is male with a history of Tetralogy Fallot repair as a child and recent pulmonic and tricuspid valve surgery.  This patient suffers from pulmonary arterial hypertension (PAH)r that is present following corrective surgery for congenital heart disease (Tetralogy of Fallot). As per Simonneau et al. (2009), the patient's condition is classified as World Health Organization (WHO) Group 1, type D- pulmonary arterial hypertension (PAH) involving congenital systemic to pulmonary shunts.  Following this patient's corrective surgery for pulmonic and tricuspid valve regurgitation, the patient developed shortness of breath and lower extremity edema. The patient's echocardiogram revealed severe right ventricular dilatation with severe tricuspid regurgitation (TR) and paravalvular pulmonic valve regurgitation. The patient's estimated pulmonary artery pressure was 60mmHg (millimeter of mercury) plus right atrial pressure on echocardiogram.  On physical exam, the patient demonstrated findings consistent with severe right-sided volume overload.  The patient was prescribed with diuretics and sildenafil. The patient's prior right heart catheterization revealed severe pulmonary artery hypertension with mean pulmonary artery pressures of 30mmHg. These clinical findings support a diagnosis of WHO Group I and WHO functional class III PAH.  

As per Galie et al. (2016), current guidelines support a class I indication for treatment of such patients with phosphodiesterase type 5 inhibitors such as sildenafil. Multiple randomized controlled trials have demonstrated that these agents are beneficial. (3-5)

Based on the review of the medical record and literature, sildenafil is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for sildenafil to treat PAH should be reversed. The medical necessity is substantiated.