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

Diagnosis: Asthma Attack.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is a young male child with a medical history significant for mild intermittent asthma. He presented to the emergency department with a dry cough and runny nose. The mother started treatment with nebulized albuterol, administering five doses without improvement.
The patient's vital signs included a temperature of 37.1, heart rate of 76, respiratory rate of 26, and blood pressure of 101/66. The patient's examination was significant for tachypnea, increased work of breathing with nasal flaring, retractions, inspiratory wheezing, and use of accessory muscles. The patient was hypoxic to 90%, improved with supplemental oxygen and DuoNeb treatment. Work-up included blood work, respiratory viral panel, and chest x-ray. The viral panel was significant for positive rhinovirus/enterovirus. Chest x-ray revealed patchy consolidation in the perihilar region consistent with pneumonia. He was admitted for further management.
Admission orders included nebulized albuterol every three hours, daily prednisone, supplemental oxygen to maintain saturations greater than 95%, ceftriaxone daily for pneumonia, a regular halal diet, and Tylenol as needed. The patient was weaned to room air and remained stable on room air for the duration of his hospital stay. He continued to receive albuterol treatments, weaning to every four hours. He tolerated his regular diet and was voiding adequately. He was deemed stable for discharge to follow up with his primary care practitioner the following day.

The inpatient hospital admission was not medically necessary in this case.
Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough.

This school-aged male child presented with signs and symptoms consistent with viral-mediated acute asthma exacerbation. While it was reasonable to monitor him in the hospital for resolution versus deterioration, he was overall hemodynamically stable with no evidence of impending respiratory failure or persistent oxygen requirement. He did not require acute inpatient admission and could have been safely managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Vomiting.
Treatment: Inpatient Hospital Admission.
The insurer denied the Inpatient Hospital Admission.
The denial is upheld.

This is an adult female patient with a history of diverticulitis, ovarian cyst, alcohol (EtOH) use disorder complicated by alcohol (EtOH) withdrawal, and hypothyroidism who presented to the emergency room with abdominal pain and nausea.  She had right upper quadrant (RUQ) pain, eight out of ten (8/10), radiating to the back, and dull.  Her lipase was 211, aspartate aminotransferase (AST) was 104, and alanine aminotransferase (ALT) was 70. Computed tomography (CT) of the abdomen/pelvis showed hazy fat stranding around the pancreatic head suggesting acute pancreatitis.  Abdominal ultrasound showed no gallstones.  
The patient was treated with normal saline (NS) one liter (L) intravenous, Zofran four milligrams intravenous, and morphine four milligrams intravenous in the emergency room. The patient was admitted to medicine and treated with nothing by mouth (NPO), Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol, start multivitamin (MVI), thiamine, and folic acid, and morphine four milligrams intravenous every four hours as needed (PRN) and intravenous (IV) hydration with normal saline (NS) at 250 cubic centimeters per hour (cc/hour).
There were no acute events overnight. The patient was tolerating oral (PO) intake. The pain had improved. The patient still had right costovertebral angle (CVA) tenderness. The patient was continued on intravenous fluids, Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol, pain regimen, and bowel regimen.
Per progress note, "No acute events overnight. Pt is tolerating PO intake. Pain has improved, still have R CA tenderness. Today, pt states she has not improved much in regards to her pain and is agreeable to staying another day. Endorses some pain with deep inspiration, and endorses no BM since Saturday." Intravenous fluids were discontinued. Magnesium was replaced. 

The proposed treatment was not medically necessary.
There were no acute events overnight. The patient was tolerating oral (PO) intake. The patient still had right costovertebral angle (CVA) tenderness, but the pain had improved. The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. The patient did not require any procedural or surgical intervention, did not require further treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have liver failure, and did not have any complications such as an intra-abdominal abscess or a surgical abdomen.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara 130MG (milligrams)/26ML (milliliters) IV (intravenous) Solution. 

The insurer denied: Stelara 130MG (milligrams)/26ML (milliliters) IV (intravenous) Solution. 

The denial is overturned. 

The patient is an adult male with moderate to severe Crohn's. He has failed  Mercaptopurine (6-MP). The attending physician is requesting treatment with Stelara. 

The health plan denied the request for Stelara stating: 
"* The request is not approvable at this time as there are other medications on the preferred drug list (formulary), per the health plan Ustekinumab (Stelara) Clinical Criteria, that may work equally well for your condition. 
*The health plan is required to approve this medication if your doctor explains why (i) Humira (ii) Renflexis, Inflectra or Avsola and (iii) Entyvio (please submit a prior authorization request) would not be appropriate for the treatment of your condition. Please note these recommendations are consistent with the United States Food and Drug Administration (FDA) product labeling or Official Compendia's approved labeling for your condition. 
* The information your doctor submitted did not indicate a contraindication (a specific situation in which a drug should not be used) to the preferred alternatives as defined by the United States Food and Drug Administration (FDA) product labeling." 

The proposed treatment with Stelara is medically necessary. 

The patient has moderate to severe Crohn's and has failed conventional therapy. Stelara is Food and Drug Administration approved, safe and effective for the treatment of moderate to severe Crohn's. While Entyvo is effective in moderate to severe Crohn's, recent literature at the Digestive Disease Week (DDW) in 06/2021 showed Stelara to be more effective. In addition, Stelara is as effective as and safer than anti-tumor necrosis factors (TNFs), Humira and the three biosimilars, Renflexis, Inflectra and Avsola, for the treatment of Crohn's. The requested Stelara is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis.
Treatment: Corticotropin (H.P Acthar Gel 80Unit/ML (milliliter) IJ [injection]).

The insurer denied the Corticotropin (H.P Acthar Gel 80Unit/ML (milliliter) IJ [injection]).  The denial is overturned.

The patient is a male with multiple sclerosis. He is currently having an exacerbation. He has tried methylprednisolone, which was not effective. His provider wishes to start corticotropin. The request was previously denied coverage by the health plan, as the plan did not think that the patient had already tried methylprednisolone.

Yes, the requested Corticotropin is medically necessary.

It is medically necessary, as the patient has tried and failed first-line treatment with methylprednisolone. Furthermore, a clinical trial done showed that corticotropin is safe and effective for those who had tried and failed methylprednisolone.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient has an exacerbation of MS (multiple sclerosis), and failure to put him on corticotropin when he has failed methylprednisolone could lead to increased disability.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Nausea
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female who had the complaints of nausea and abdominal pain. The patient underwent an acute inpatient hospital admission. The patient has rheumatoid arthritis and had recently started treatment with methotrexate. The patient presented with acute right upper quadrant abdominal pain, epigastric pain and nausea.
In the emergency department, the patient had mild tachycardia with leukocytosis of 12.5. Her aspartate aminotransferase (AST) was 561 and her alanine aminotransferase (ALT) was 1,736. The patient's vital signs and lab values were otherwise within normal limits. A computed tomography (CT) scan had no acute findings. The patient was admitted for supportive care.
The patient received pain medication and she was allowed a clear liquid diet. Two days after admission, the patient's liver function tests had dropped to 322 and 1,384. A magnetic resonance cholangiopancreatography (MRCP) was unremarkable. The methotrexate was held for concern of drug induced liver injury.
The patient was discharged when deemed stable.

The proposed inpatient hospital admission was not medically necessary.
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 elevation of liver enzymes; yet she did not evidence a change in mental status, high fevers, neurologic changes,
hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, or need for nothing by mouth (NPO) status. She did not evidence need for invasive surgery, evidence of jaundice, evidence of ascites, evidence of coagulopathy, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope. 
Treatment: Inpatient Hospital. 

The insurer denied the inpatient hospital stay. The health plan's determination is overturned. 

This man, with a history of hypertension, diabetes and polysubstance use, presented to the emergency department (ED) via Emergency Medical Services (EMS) for complaints of 2-3 days of "dizziness", loss of balance and diaphoresis. Per EMS, his blood pressure was 88/60 with a heart rate of 48. He was treated with intravenous fluid and transported to the ED where his blood pressure was 96/58 with a heart rate of 44. An electrocardiogram showed sinus bradycardia. His serum troponin level was normal. A Chest X-ray showed a small left pleural effusion. His serum creatinine level was 1.93. His brain (or B-type) natriuretic peptide (BNP) level was 160. Urine toxicology was positive for cocaine, methadone and opiates. His blood ethanol level was 0.41. The patient was treated with intravenous fluid and heparin. Patches for external cardiac pacing were placed in the event that it became necessary. He was admitted to the hospital with symptomatic bradycardia and to rule out acute coronary syndrome. 

An inpatient level of care was medically necessary. 

This patient presented to the hospital with symptomatic bradycardia that was associated with acute kidney injury (AKI). He was not taking any negative chronotropic medications and there was some concern that his bradycardia might have been due to myocardial ischemia. The patient's blood pressure, symptoms and AKI indicated that the bradycardia was hemodynamically significant and associated with tissue/organ hypoperfusion. He required careful and continuous monitoring in a setting that would allow for emergent intervention, including external or transvenous cardiac pacing, if needed. This warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: vasovagal syncope

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

The patient is an adult female. Healthfirst issued a final adverse determination notice stating that the inpatient admission is not considered medically necessary. 

The ED (emergency department) note states that the patient was confused and uncomfortable and had weakness. She has been diagnosed with vasovagal syncope, with five (5) prior syncopal episodes over the past eight (8) years. She complained of weakness in the right side. The exam showed normal strength, sensation was intact, but the patient reported numbness. The assessment was syncope of unknown cause. The patient's physical exam was unremarkable for stroke symptoms. She was COVID positive and had mild symptoms. 

The discharge summary states that the patient had a negative work up with computed tomography (CT) of the head, a benign neurological exam, an extensive work up including viral serology, which was negative, an electrocardiogram (EKG) and negative troponins.

"Typically, vasovagal syncope is treated conservatively. When known and avoidable, patients are instructed to avoid triggers. Patients are also instructed to drink more fluids to improve their volume status (and therefore their preload) and to change positions slowly. Patients are educated as to the "warning signs" of a vasovagal event and instructed to place themselves in a supine position should they feel an event coming. This often prevents actual syncope and reduces traumatic risk from falling. In refractory or disabling cases and cases of prolonged asystole, cardiac pacing is a therapeutic option.[9][10][11][12]" (Jeanmonod, R., et al. 2022). 

An electroencephalography (EEG) is indicated if seizures are suspected.
Treatment of underlying cause is the focus of treatment in syncope. During acute an acute episode, patients should be made to sit or lay down quickly and raising the legs helps recovery in patients with reflex postural hypotension event. Place patients in a horizontal position after the acute event and prevent rising too soon. Treatment of any injuries sustained during a sudden fall from syncope warrants immediate attention. Follow-up: Patients with unknown etiology and without underlying heart disease have a good outcome. Patients with syncope and underlying heart disease needs regular follow-up with a primary care physician and cardiologist" (Grossman, S. A., & Badireddy, M., 2022).

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

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

Diagnosis: Crohn's disease
Treatment: Entyvio 
The insurer denied the Entyvio.
The determination is overturned.


The patient has Crohn's disease diagnosed. She failed prednisone, mesalamine, 6-mercaptopurine, Remicade, Humira, Cimzia, and Stelara. She started Entyvio 300 milligrams (mg) every 4 weeks, with subsequent stability and maintenance of endoscopic remission. She has had a positive response to increase in Entyvio dose to 300 mg every 4 weeks. She presented with significant abdominal pain and diarrhea 5-6 times per day. At issue is the medical necessity for Entyvio 300 mg every 4 weeks for the treatment of Crohn's disease.

The requested Entyvio 300 mg every 4 weeks is medically necessary for the treatment of Crohn's disease in this case. In the randomized placebo-controlled GEMINI I and II trials, which supported Food and Drug Administration (FDA) approval, it was part of the study protocol for patients who had not achieved remission by week 6 to continue Entyvio every 4 weeks rather than every 8 weeks [1,2]. In Crohn's disease, Entyvio every 4 weeks resulted in remission in over 36 percent (%) of patients after one year [2]. The GEMINI LTS [long term safety] study of 57 Crohn's disease patients who failed Entyvio every 8 weeks has reported increased remission rates with treatment every 4 weeks as well [3]. Studies have shown that insufficient Entyvio dosing can result in uncontrolled disease [4-6]. Additionally, American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should...ave their medication dose adjusted in order to attempt to optimize therapy" [4]. These data apply to this case, in which continuation of dose intensification is requested for Entyvio infusion every 4 weeks. Given that the patient has failed all other recommended biologic therapy classes for the treatment of Crohn's disease, alternatives to Entyvio are limited [4]. Additionally, the patient has had some ongoing symptoms (abdominal pain and diarrhea) while on Entyvio 300 mg every 4 weeks. Therefore, if the Entyvio dose is decreased to 300 mg every 8 weeks, or if Entyvio is discontinued and an alternative is attempted, she is at risk for uncontrolled Crohn's disease, flare, hospitalization, need for surgery, fistula, and stricture. Therefore, the request for Entyvio 300 mg every 4 weeks is supported as medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the emergency department (ED) with blurry vision, dizziness, palpitations, and chest pain for one week. His chest pain was described as dull and left sided. He also had mild headache, nausea, and diaphoresis.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with symptomatic hyperglycemia and atrial fibrillation with rapid ventricular rate. He had known atrial fibrillation. He required one intravenous (IV) injection of Metoprolol. Then, he was treated with oral metoprolol and his rate was well controlled. The patient's blood pressure and O2 (oxygen) saturation was normal. He did not have acute myocardial ischemia or heart failure. The level of care for this patient with atrial fibrillation should be observation. His troponin was negative.
The patient also presented with very high blood sugar (BS), which probably was giving him blurred vision. Despite the very high blood sugar, he was not in diabetic ketoacidosis. His anion gap was normal. He did not require IV insulin drip to control his BS. And his BS came down fast. Based on above, the patient did not meet criteria for inpatient admission. A lower level of care would be more appropriate.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Taltz. 
The insurer denied: Taltz. 
The denial is upheld. 

The patient is an adult male with severe psoriasis since childhood affecting 50% body surface area. He also has severe itching. He has tried and failed betamethasone, calcipotriene, triamcinolone, Duobrii, Vtama, prednisone, and clobetasol. His comorbidities are hyperlipidemia, hypertension, a bicuspid aortic valve with aortic regurgitation, GERD (gastroesophageal reflux disease), and BPH (benign prostatic hyperplasia). He enjoys regular alcohol consumption. The appeals letter states that TNF (tumor necrosis factor) alpha inhibitors and methotrexate are contraindicated for the patient due to his comorbidities. 

The requested Taltz is not medically necessary. 

The patient has severe psoriasis for which systemic therapy is indicated. In the era of biologic therapies for psoriasis, use of methotrexate is not the most appropriate first-line treatment, because its long-term safety and efficacy is inferior to biologic therapies. 

Biologics show superior results to conventional systemic therapies (70% improvement versus 40% improvement) for the treatment of patients with moderate to severe psoriasis, as measured by decrease in simple-measure for assessing psoriasis activity (S-MAPA) (physician global assessment [PGA] multiplied by body surface area) at week 24. These results were observed despite the fact that patients on biologics had a greater baseline severity and had a greater number of previous treatments. 

The patient's healthcare provider states that TNF (tumor necrosis factor) alpha inhibitors are not appropriate due to the patient's comorbidities. However, the plan also offers Cosentyx, Skyrizi, and Stelara, which share the plaque psoriasis indication with Taltz and have similar efficacy and safety profiles. It also offers Otezla. 

Therefore, based on the above data, Taltz is not medically necessary for this patient.