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

Diagnosis: Gender identity disorder
Treatment: 19303 - Gender affirmation surgery / double mastectomy / transgender top surgery
The insurer denied the 19303 - Gender affirmation surgery / double mastectomy / transgender top surgery
The denial is overturned.

This patient is a non-binary patient who requests top surgery. They use they/them as their preferred pronouns. They were diagnosed with gender dysphoria. They are not planning on starting hormone therapy. For the past one year, they have lived as a non-binary individual.

The patient's breast cup size is a 36D. They currently do binding, and prior to that, they were using multiple compression bras. They like the appearance of their chest more when they are binding. They do have a history of depression. This is being treated. They have not been hospitalized or had a diagnosis of suicidal ideation for over a year.

The patient has significant dysphoria associated with the appearance of the chest. The patient has excellent support from friends.

Yes, the 19303 - Gender affirmation surgery / double mastectomy / transgender top surgery is medically necessary.
Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines:

Criteria for Breast/Chest Surgery (One Referral)
Criteria for mastectomy and creation of a male chest in FtM patients:

1. Persistent, well-documented gender dysphoria;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country (if younger, follow the SOC [standard of care] for children and adolescents);
4. If significant medical or mental health concerns are present, they must be reasonably well controlled.

Hormone therapy is not a prerequisite. Of note, these guidelines do not have a two-year requirement for diagnosis.

The WPATH (World Professional Association for Transgender Health) guidelines are recognized as the definitive standard of care for transgender surgery. The patient meets these guidelines. They have well documented gender dysphoria and have the capacity to make an informed decision.  They are the age of majority.  They do not have significant mental health concerns.  A mental health professional has recommended the mastectomies.

The patient meets the WPATH (World Professional Association for Transgender Health) guidelines, which are widely accepted by physicians and insurers as the standard of care for the management of gender dysphoria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient is a female with a benign past medical history who presented to the Emergency Department (ED) with complaints of fever, body aches, and shortness of breath. Vitals on presentation included: Temperature-99.6 Fahrenheit, Blood Pressures-123/76, Pulse-115, Respiratory Rate-42, and Oxygen (O2) saturation-93 percent (%) on Room Air. Laboratory values were notable for the following: White blood cell (WBC) count-2.5, hemoglobin (Hgb)-11.2, hematocrit (Hct)-33.4, creatinine-1.05, glucose-94, d-dimer 1.54, C-reactive protein-2.5, and ferritin-350.9. 

The patient was admitted to the hospital for coronavirus (COVD-19) pneumonitis. Chest computed tomography (CT) scan showed extensive right lung consolidation compatible with pneumonia. She was treated with dexamethasone, intravenous (IV) Remdesivir, and azithromycin. She required supplemental O2 support. The patient improved clinically, remained afebrile and hemodynamically stable. She was discharged to continue outpatient management. 

According to medical records, the patient returned to the ED after progression of respiratory symptoms secondary to COVID-19. The patient had tachycardia (heart rate-115), tachypnea (respiratory rate-42), and borderline O2 saturation on room air. Laboratory results showed leukopenia, and elevated inflammatory markers. CT scan of chest showed extensive right sided lung consolidation consistent with pneumonia. Based on above findings with documented failure of outpatient intervention, hospital admission was medically necessary.  

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

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

Diagnosis: Cardiac/Circulatory Problems-Other-Pseudoaneurysm
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 a  patient who sustained a Le Fort 2 facture in a fall and underwent closed reduction. He has a history of seizure activity and left temporal lesion resection. Due to epistaxis, he was admitted through the Emergency room with persistent epistaxis on exam with blood pooling in his mouth. The left nasal vault was packed, and he underwent embolization of a pseudoaneurysm of the left posterior superior alveolar artery. The procedure was uneventful, and he tolerated it well. There was no documented seizure activity. He was observed in the Neurosurgical Intensive Care Unit. No postoperative bleeding was documented. Placed on a liquid diet, the head of the bed was elevated, he received intravenous antibiotics which were changed to oral antibiotics on the day of discharge

The requested health service/treatment of Inpatient Stay was not medically necessary for this patient. Clinically the patient underwent an uneventful embolization with no further bleeding. His was stable from a cardiovascular standpoint, with stable blood pressure, He was afebrile, taking liquids orally, and with no respiratory distress or seizure activity. He was cleared for discharge from an otolaryngology standpoint on the day after surgery. Therefore, having met Milliman Care Guidelines (MCG) criteria for discharge, an inpatient stay was not medically necessary.
The patient underwent an uneventful embolization procedure, was stable and with no additional bleeding and could be followed up on at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Erectile Dysfunction.
Treatment: Formulary exception for Viagra (sildenafil).
The insurer denied the Formulary exception for Viagra (sildenafil).
The denial is upheld.

The patient is a male. He has requested coverage for Viagra for continued use.   Coverage was denied because he has not tried sildenafil and tadalafil.

No, the health plan should not cover the formulary exception for Viagra.
The formulary alternatives, sildenafil and tadalafil, are generic versions of brand name Viagra and Cialis.  The formulary alternatives have equivalent safety and efficacy compared to the brand name versions. There is no documentation that the patient has tried and failed the health plan's preferred alternatives. Switching to the health plan's preferred alternatives would not reasonably be expected to pose a health risk to the patient.

Therefore, given the above, the health plan should not cover the formulary exception for Viagra.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID.
Treatment: Long Term Acute Care (LTAC) admission.

The insurer denied the Long Term Acute Care (LTAC) admission.  The denial is overturned.

The patient is a female. She was admitted with COVID pneumonia.  She was intubated and managed with ECMO (extracorporeal membrane oxygenation). She was sedated and proned.  She developed septic shock and was placed on pressers.  She developed ARDS (acute respiratory distress syndrome).  Trach and PEG (percutaneous endoscopic gastrostomy) were placed.

Current progress reports show the patient's vital signs are stable.  Her mental status has improved.  Her septic shock has resolved. She has finished Remdesivir and tocilizumab.  She is status post ECMO (extracorporeal membrane oxygenation).  She is status post antibiotics.  There is no concern for mastoiditis. She has IV (intravenous) Synthroid and PEG (percutaneous endoscopic gastrostomy) feeds.  She has wound care for ECMO (extracorporeal membrane oxygenation) groin wound.

Yes, the long term acute care admission is medically necessary.

LTAC (long term acute care) is indicated for individuals with complex medical conditions who require long-term, highly skilled nursing and rehabilitation services.  In LTAC (long term acute care), the patient requires services of on-site specialty services, skilled nursing services and daily intervention of a medical practitioner.

The patient in this case has respiratory failure as a complication to COVID pneumonia. She has been ventilator-dependent, and she has a trach.  She has PEG (percutaneous endoscopic gastrostomy).  She is receiving wound care to the groin.  This patient has a complex need of vent weaning.  An LTAC (long term acute care) level of care is in accordance with generally accepted medical standards and medically necessary to manage this patient's vent weaning and rehab.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic migraines without aura, intractable.  
Treatment: Formulary Exception for Ubrelvy (ubrogepant).  

The insurer denied coverage for Formulary Exception for Ubrelvy (ubrogepant).  

The denial is overturned.  

The patient has a past medical history of chronic migraine headaches.  An office visit indicated the patient was being seen by telehealth for a diagnosis of chronic migraines without aura, intractable.  The patient stated that she felt Ajovy was helping.  The patient was having headaches once every 2 weeks.  Her headaches were stable.  The patient had tried both sumatriptan and naratriptan in the past without benefit.  The provider recommended Ubrelvy.  

The provider appeal letter noted the patient had a history of migraine headaches since she was a teenager.  The patient was currently utilizing Ajovy for migraine prevention but continued to suffer from an average of 3-5 breakthrough migraines monthly.  These consisted of severe debilitating pain that lasted all day and interfered with all aspects of daily living during that time.  

There is no documentation provided of adverse reactions to trialed medications. However, the patient has documented failure of Rizatriptan, Sumatriptan, and Naratriptan which are first line medications.  

Ubrelvy is a new class of drug and should theoretically be as effective or more effective than previously trialed alternatives.  It is an oral calcitonin gene-related peptide receptor antagonist approved for the acute treatment of migraine.  

The patient had tried rizatriptan, sumatriptan, and naratriptan for greater than 30 days without success.  Therefore, the provider requested Ubrelvy as the next step. The requested drug is likely to produce a more clinically beneficial outcome. This decision is consistent with the Headache Society guidance on use of calcitonin gene - related peptide receptor antagonists.  

The insurer's denial of Request for Formulary Exception for Ubrelvy (ubrogepant) is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine headache disorder.
Treatment: Formulary exception for Ubrelvy (ubrogepant),  Pre-service.

The insurer denied the Formulary exception for Ubrelvy (ubrogepant),  Pre-service.  The denial is upheld.

The patient is a female with migraine headache disorder. She has tried and failed sumatriptan and rizatriptan for abortive therapy. The provider is requesting Ubrelvy. The requested medication was denied coverage, as the patient has only tried and failed two preferred agents.

No, the health plan should not cover the formulary exception for Ubrelvy.

There is no documented reason as to why the patient cannot be treated with the preferred formulary agents. All of the preferred agents are FDA (United States Food and Drug Administration)-approved for acute treatment of migraine headaches and are considered first-line, standard-of-care, abortive agents (Thorlund et al.). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Ubrelvy relative to the preferred agents. There is no evidence that the preferred agents are more likely to result in an adverse event.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea, and emesis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient was a female who was noted to be underweight. The patient presented to the hospital's emergency department with a history of recurrent Clostridium (C) difficile colitis. The patient noted abdominal pain, nausea, and emesis despite an outpatient regimen of oral vancomycin. 

The patient was hyperglycemic and had elevated lactic acid, leukocytosis, elevated inflammatory markers, and a long segment of bowel wall thickening on abdominal computed tomography (CT) scan. The patient was admitted to an acute level of service and underwent an unremarkable colonoscopy. The patient received six doses of intravenous (IV) morphine as an observation level care patient and six more once admitted. She received IV fluids and supportive care and was discharged on the same oral vancomycin after 48 hours.

No, the proposed treatment was not medically necessary.

The treatment as rendered was medically appropriate but not medically necessary at the level at which it was provided.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had recurrent Clostridium (C) difficile and abdominal pain, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, persistent signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias, or any other indication for an acute admission. The colonoscopy could have been performed at a lower level of care. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sigmoid diverticulitis.

Treatment: Inpatient stay.

The insurer denied coverage for the inpatient stay.

The denial is upheld. 

This is a female patient with a medical history of hypothyroidism and constipation who presented to the emergency department (ED) for abdominal pain. The patient presented with constipation.  She was afebrile and her vital signs were stable.  Mild abdominal tenderness was present without rebound or guarding.  A computed axial tomography (CAT) scan revealed sigmoid diverticulitis.  There was no fluid collection or obstruction.  Intravenous (IV) fluids and antibiotics were given.  Her symptoms improved.

Based on Milliman Care Guidelines (MCG), clinical indications for admission for acute diverticulitis include hemodynamic instability, peritoneal signs, persistent gross bleeding, or a significant imaging abnormality.  This can be a fistula, obstruction, perforation, or abscess.  The patient did not have these conditions.  She also did not have severe pain, severe vomiting, severe dehydration, or an inability to maintain oral hydration after observation care.

This patient had a diverticulitis that was not complicated by a fluid collection or obstruction.  She could have been treated with observation status and discharged on a course of oral antibiotics.  She did not meet MCG Criteria for Acute Care for Acute Diverticulitis.  The healthcare plan acted reasonably and with sound medical judgment.  An inpatient stay was not medically necessary.  

The insurer's denial of the inpatient stay is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility.

Treatment: Human leukocyte antigen (HLA) typing. 

The insurer denied coverage for HLA typing.

The denial is upheld. 

This is a female patient with a history of infertility, recurrent pregnancy loss, a unicornuate uterus, a pelvic kidney, and uterine adhesions. She had multiple intrauterine inseminations (IUI) and in vitro fertilizations (IVF) without success. She had human leukocyte antigen (HLA) testing done as part of an infertility workup.

Much controversy exists regarding the role of parental human leukocyte antibodies and infertility and miscarriages. A search of the available evidence does not lead to valid, consistent conclusions regarding testing, efficacy of treatment or improved pregnancy outcomes. Several methods of inducing immunity have been investigated and include antibodies derived from blood [e.g., intravenous immunoglobulin (IVIG)]. Evidence in the published, peer-reviewed scientific literature and professional society recommendations suggests that these treatments do not provide significant beneficial effects over placebo in preventing miscarriages or implantation failures and therefore remain unproven therapies. Additionally, the authors of a Cochrane review of 20 randomized trials indicated there was no improvement in live births when either paternal cell immunization, intravenous immune globulin, or other immunotherapy regimens were utilized. The authors concluded, "Immunotherapy does not lower the risk of future miscarriage in women who repeatedly miscarry." A large Canadian randomized controlled trial found no benefit to the use of immunosuppressant therefore supporting the fact that testing for HLA antibodies is not medically necessary.

A thorough search of PubMed did not lead to any randomized controlled study that showed any benefit or improvement in a patient's ability to conceive when HLA was tested and treated. Note that neither the American Society for Reproductive Medicine (ASRM) nor the American College of Obstetricians and Gynecologists (ACOG) recommend testing for HLA antibodies nor treating HLA antibodies with immunologic medication like IVIG.

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

The insurer's denial of coverage for HLA typing is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a history of diabetes, hypertension, coronary artery disease (CAD) and homelessness who was admitted to the hospital. He presented with a chief complaint of increased thirst and urinary frequency in the setting of hyperglycemia. He had been recently admitted for treatment of uncontrolled hyperglycemia in the setting of medication non-adherence and community acquired pneumonia. He reported again that he was not taking his insulin as prescribed and he stated it was difficult to adhere to his medications because of homelessness. He complained of lightheadedness but denied chest pain, shortness of breath, nausea and vomiting. Vital signs showed blood pressure 142/78, heart rate 94, respiratory rate 18, and temperature 98.1 Fahrenheit. On physical exam, heart was regular, breath sounds were normal, and the abdomen was soft and nontender. Labs showed white blood cell (WBC) 6.5, hemoglobin 12.7, platelets 228, sodium 128, potassium 5.0, creatinine 1.42, and Glucose 675. The patient was admitted with uncontrolled diabetes likely due to medication adherence. 

The patient hospital admission was not medically necessary. The patient had hyperglycemia with no evidence of diabetic ketoacidosis or other complications triggering hyperglycemia. He did receive additional care for an elevated creatinine along with diabetes teaching and smoking cessation counseling, but isolated hyperglycemia without other complications that are significant does not require inpatient level of care. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Elevated BMI
Treatment: Saxenda 18mg (milligram)/3ml (milliliter) prefilled pens
The insurer denied the Saxenda 18mg/3ml prefilled pens
The denial is overturned.

The patient is a female diagnosed with PCOS (polycystic ovarian syndrome); elevated BMI (body mass index). This request is for Saxenda.

As reported, the patient has been taking metformin to control her BG (blood glucose) for over a year. However, her other comorbidities place her great risk for developing diabetes. She has seen a nutritionist to assist her developing a weight-loss plan. Since meeting with nutritionist, she has lost 5 pounds. She has history of depression and anxiety. She is on Bupropion XL (extended release), which is one of the ingredients found in Contrave.

The patient's BMI (body mass index) was 30.29; weight was 82.6 kg (kilograms).

Two months prior, the patient's BMI (body mass index) was 31.78; weight was 86.6 kg (kilograms).

One month prior, the patient's weight was 84.8 kg (kilograms).

Yes, the treatment with Saxenda is medically necessary.
Saxenda is a GLP1 (glucagon-like peptide-1) agonist that is used in the treatment of obesity [1-4]. The standard of care is to use the medication most compatible with the patient's condition and other medications. The requested medication is clinically superior and more appropriate for this patient, who is at high risk of developing diabetes, than the formulary alternatives. The request is consistent with generally accepted standards of medical practice.