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

Diagnosis: Obesity
Treatment: Wegovy 0.25 milligram (mg)/0.5 pen injector
The insurer denied coverage for Wegovy 0.25 milligram (mg)/0.5 pen injector.
The denial is overturned.
 

The patient has a diagnosis of obesity for which Wegovy is being prescribed for weight loss.

Insurance carrier denied coverage of Wegovy as insurance policy states "you must be at least 18 years old and your body mass index must be at least 30 or at least 27 with 1 or more serious disease (such as heart disease, cholesterol related disease, high blood pressure, diabetes, sleep apnea, female reproduction problems, arthritis, gallstones or stress incontinence) or at least 27 with 2 or more risk factors (such as elevated blood pressure, smoking, impaired fasting glucose, family history of early heart disease, age older than 45 for men and older than 55 for woman), you must not be taking Wegovy with any other weight loss medication, along with counseling and monitoring by your doctor's office you must be currently enrolled in a qualified complete weight management program for at least the past 3 months with prove of current and prior enrollment and at least monthly participation, you must not be taking a certain kind of diabetes medicine (for example Victoza, Byetta)."

According to supplied progress note, patient has a body mass index (BMI) of 32.89 and has a strong family history of morbid obesity, heart disease and type 2 diabetes. Patient has tried nonsurgical methods for weight loss without success. Patient has a history of high cholesterol. A Weight Watcher's receipt is also supplied.

It seems that based off of the criteria supplied by the insurance carrier, the patient fulfills the requisites for approval.

"WEGOVY is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in:

1) Adults with an initial body mass index (BMI) of [see Dosage and Administration (2.1)] 30 kilograms (kg)/ square meter (m2) or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g. [for example], hypertension, type 2 diabetes mellitus, or dyslipidemia) 2) Pediatric patients aged 12 years and older with an initial BMI at the 95th percentile or greater standardized for age and sex (obesity) [see Dosage and Administration (2.1)]." (Wegovy Package Insert)                                                         

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for Wegovy 0.25 milligram (mg)/0.5 pen injector is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Posterior neck pain 
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is overturned.

The patient is an adult male. He was noted to have started having sudden onset of posterior neck pain around 5 AM while he was at work. He was also noted to have trouble walking and needed to hold on the walls to maintain his balance. He had nausea, vomiting, leg weakness and transient left face droop as well. He went to the ED (emergency department) for his complaints, his BP (blood pressure) at admission was 180/110.
Acute stroke was suspected, and the patient was admitted for stroke/TIA (transient ischemic attack) work up with neurology consult.

The Inpatient Admission was medically necessary.

The patient presented with symptoms that were suggestive of an acute stroke, ischemic or hemorrhagic of the posterior fossa, especially as he was complain of neck pain. The transient left face droop strongly suggested that this is beyond vertigo. One does not expect to see focal neurological deficit with peripheral vertigo. High BP (blood pressure) can also be seen in the setting of acute stroke. High BP (blood pressure) by itself can mimic a stroke, but there is no way to tell without imaging, and in this case, stroke is most definitely first in the differential, and the patient should be and was treated as if he had a stroke or TIA (transient ischemic attack). Therefore, given all the above, this admission was medically necessary to complete stroke work up and to stabilize the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a female with a history of hypertension (HTN), who was sent to the emergency room (ER) from the doctor's office with a reported blood pressure (BP) of 200/128. It was 194/127 in the emergency room (ER). The patient had associated blurry vision and dizziness.
The patient was admitted for hypertensive urgency due to medication non-compliance. She was given intravenous (IV) labetalol in the emergency room (ER) followed by oral labetalol. She was given aspirin. She was given oral nifedipine. She had no chest pain, shortness of breath, slurred speech, or focal neurological findings on exam. The initial vital signs were blood pressure (BP) 194/127, 169/110,195/105, heart rate (HR) 84, respiratory rate (RR) 17, and oxygen saturation 98 percent (%) on room air, temperature 98.4 degrees Fahrenheit.
Lab results were significant for a negative troponin, brain (or B-type) natriuretic peptide (BNP) normal, normal creatinine. An electrocardiogram (EKG) showed normal sinus rhythm. An echocardiogram showed an ejection fraction (EF) of 60-65 percent (%). A chest x-ray was normal. A computed tomography (CT) scan of the head was normal. A computed tomography (CT) abdomen was negative for an adrenal mass.
At issue is whether the patient's hospitalization was medically necessary at an inpatient level of care.

The patient's hospitalization was not medically necessary at an inpatient level of care. The patient was admitted for hypertensive urgency due to medical non-compliance. She had no evidence of acute end organ damage, which is concerning for hypertensive emergency rather than urgency.
This patient did not have encephalopathy, an acute kidney injury (AKI), congestive heart failure (CHF), acute coronary syndrome. Imaging was unremarkable. The troponin and BNP were normal.
According to a review article on hypertensive crisis: "The majority of patients with asymptomatic hypertensive urgency can be safely managed in the outpatient setting without exposing them to the risks of aggressive blood pressure (BP) lowering. However, patients with hypertensive emergency (HTN-E) require hospitalization, prompt treatment and close monitoring."
This patient did not have hypertensive emergency. She did not require  continuous intravenous (IV) medication for blood pressure lowering or an invasive blood pressure monitoring system.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung Infection
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a teenage female with medical history significant for asthma that presented to the emergency department with four-day history of worsening chest tightness, shortness of breath, and cough. Her cough was initially non-productive but on the day of presentation became productive of yellow sputum. The patient was using her inhaler daily and her mother started giving her prednisone left over from a previous prescription. She was seen by her pediatrician the day prior to presentation, told she most likely had a viral infection, and was advised to continue prednisone. Vital signs included temperature 99.9, heart rate 113, respiratory rate 24 with 91% saturation in room air. Examination was significant for rales and wheezing. Chest x-ray revealed left upper lobe consolidation. Laboratory evaluation was significant for white blood cell (WBC) count of 7.5 thousand with 83% neutrophils, carbon dioxide (CO2) 21.8, and negative rapid viral screening. The patient was treated with albuterol/Atrovent, ceftriaxone, and dexamethasone prior to admission for ongoing treatment of asthma exacerbation secondary to community acquired pneumonia. 
Admission orders included albuterol every four hours, Atrovent every six hours for 24 hours, supplemental oxygen as needed to maintain saturation greater than 92%, ceftriaxone, and antipyretics. There were no acute overnight events. The patient was afebrile, tolerating breathing treatments, and on supplemental oxygen. She continued to have chest pressure with full breaths, but her distress was improving. Orders included continued ceftriaxone, continued antipyretics, albuterol every three hours weaning to every four hours, and weaning to room air as tolerated. She did well with weaning albuterol to every four hours, was deemed stable for discharge to complete a course of antibiotic treatment with cefdinir.

The acute inpatient admission was not medically necessary.

This female teen with history of asthma presented with worsening cough and respiratory distress. Laboratory evaluation was significant for mild metabolic acidosis. Chest x-ray revealed left upper lobe pneumonia. She was admitted for management of community acquired pneumonia and acute asthma exacerbation, treated with parenteral antibiotics and bronchodilators. While it was medically indicated for the patient to receive frequent bronchodilators and be monitored for improvement versus decline, she was overall hemodynamically stable with no persistent oxygen requirement and no significant dehydration. She did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Infliximab (Remicade) 
The insurer denied the Infliximab (Remicade).
The determination is overturned.

This is a female patient with Crohn's disease. She started on Remicade and the dose was escalated. She had abdominal pain and hematochezia starting at week 7 after infusions; she was changed from Remicade 12.5 milligrams per kilogram (mg/kg) every 8 weeks to 10 mg/kg every 6 weeks. She had abdominal pain, diarrhea, and hematochezia, and was changed to Remicade 10 mg/kg (500 milligrams (mg)) every 4 weeks. She was in remission on Remicade 10 mg/kg every 4 weeks but reported that her infusion was delayed for a few days, and she had severe Crohn's disease flare symptoms including nausea, vomiting, and unintentional weight loss. At issue is the medical necessity of Infliximab (Remicade).

Yes, the continued use of Remicade is medically necessary for this patient. At issue in this case is a change from Remicade to a biosimilar form of infliximab in this patient with Crohn's disease. Inflectra, Avsola, and Renflexis are Food and Drug Administration (FDA)-approved biosimilars to Remicade (infliximab) for the treatment of Crohn's disease and Ulcerative Colitis. Support for the safety and efficacy of biosimilar medications in inflammatory bowel disease is provided by studies which either extrapolated safety and efficacy from patients with other diseases (such as rheumatoid arthritis), or from studies in patients who had controlled inflammatory bowel disease; many of these trials are underpowered to assess for noninferiority in inflammatory bowel disease patients [1]. Although there is support for initiation of therapy with an infliximab biosimilar rather than Remicade, there is a lack of high-quality data or large studies to support the safety of a switch from one biosimilar to another in Crohn's disease in remission [7,8]. For these reasons, the request for continuation of Remicade is supported in this patient currently stabilized on Remicade.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Psoriasis vulgaris

Treatment: Tremfya

The insurer denied coverage for Tremfya

The denial is overturned
 

The patient is an adult with a diagnosis of psoriasis vulgaris.  The patient has severe disease with plaques on the trunk and extremities.  The patient has responded well to Tremfya every 8 weeks, but experiences flares between dosing.  The request is for dosing modification to Tremfya every 4 weeks.  

The patient has responded well to Tremfya without any reported adverse reactions.  The episodic flares between injections necessitates a more frequent dosing.  Rather than switch to a different biologic, the increased dosing of Tremfya at an every 4 weeks interval is preferred as it continues therapy with likelihood of resolution of symptoms.  The dosing change is not expected to cause the patient any adverse reaction.  Based on the patient's clinical history, the dosing schedule of every 8 weeks has been ineffective necessitating an altered dosing regimen of every 4 weeks.  One study of biologics in psoriasis found that 15% of patients on Tremfya were dose escalated and that dose escalation was common in such patients with other biologics as well. (Wu et al) 

The requested dosing of every 4 weeks would be expected to be more effective than the formulary dosing (every 8 weeks).  

The carrier's denial of a request for a Formulary Exception for Tremfya to treat psoriasis is overturned. Tremfya 100 mg (milligrams) injection is approved with a dosing frequency of every 4 weeks.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: GERD (gastroesophageal reflux disease) and hiatal hernia
Treatment: Formulary exception for Dexlansoprazole Delayed-Release
The insurer denied: Formulary exception for Dexlansoprazole Delayed-Release
The denial is upheld.

The patient is an adult female with GERD (gastroesophageal reflux disease) and hiatal hernia. She has failed Pepcid, famotidine, Tums and Omeprazole, and has done well on Dexilant (dexlansoprazole) for three years. Her provider is requesting continuation of Dexilant. Dexilant was denied coverage by the health plan, as the patient has not failed two other preferred formulary alternatives in addition to Omeprazole, out of esomeprazole, lansoprazole and pantoprazole. The 
denial is being appealed.

The health plan should not cover the Formulary exception for Dexlansoprazole Delayed-Release.

The patient has only failed one preferred formulary alternative, Omeprazole, and has not failed two others out of esomeprazole, lansoprazole and pantoprazole. Esomeprazole, lansoprazole and 
pantoprazole has not been effective. There is no medical literature to support that dexlansoprazole is more effective than esomeprazole, lansoprazole and pantoprazole for the treatment of GERD (gastroesophageal reflux disease). There is no medical literature to support that esomeprazole, lansoprazole and pantoprazole are more likely to have side effects than dexlansoprazole. Therefore, the health plan should not cover the formulary exception for dexlansoprazole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gout
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a female with a history of diabetes mellitus (DM), neuropathy, coronary artery disease (CAD), fibromyalgia, throat cancer, asthma, and depression. She presented with acute left foot pain for two days with an inability to ambulate. There was no history of recent trauma. Her vital signs showed that she was afebrile with a heart rate of 79, a blood pressure of 133/77, a respiratory rate of 20, and a room air pulse oximetry of 99 percent (%). Upon examination she was not in any acute distress. She had left toe swelling and tenderness to touch of her left foot.
The laboratory studies showed a glucose of 158, a creatinine of 0.60, a white blood cell count (WBC) of 8.65 and a hemoglobin of 14.2. Imaging did not show any signs of an acute fracture. She was admitted for further management. Podiatry was consulted and felt the patient may have acute gout so she was started on Colchicine and Prednisone.

The inpatient service was not medically necessary. The patient presented with acute left foot pain without a history or signs of trauma. She did not have signs of symptoms of sepsis or a complicated infection that required inpatient antibiotics. She did not have an open fracture that required inpatient surgical management. She was hemodynamically stable. She did not have severe electrolyte or metabolic abnormalities. She did not have severe or persistent pain that required inpatient pain management. She presented with a likely gout flare which was treated with Colchicine and Prednisone. She could have been managed at an alternate level of care.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypothyroidism
Treatment: Tirosint 72mcg Capsule
The insurer denied: Tirosint 72mcg Capsule
The denial is overturned.

The patient is an adult female with hypothyroidism. The request for Tirosint is under review. The prior request was denied coverage by the health plan, because "Coverage is provided in situations where the patient has tried the four preferred formulary alternatives: EUTHYROX, LEVOTHYROXINE SODIUM, LEVOXYL, UNITHROID." The denial is being appealed.
The patient is being treated with Armour Thyroid. Per an addendum on the submitted clinical note, the patient has tried and failed Levoxyl, Unithroid, levothyroxine, and Euthyrox. Per the prior authorization information, the patient has also tried Synthroid.

The requested Tirosint is medically necessary.

This request is for Tirosint for the treatment of hypothyroidism. The formulary alternatives are Euthyrox, levothyroxine, Levoxyl, and Unithroid. Although there is a lack of detail of the trials, the submitted clinical note date includes an addendum from 2 months ago indicating that the patient has tried and failed Euthyrox, levothyroxine, Levoxyl, and Unithroid. Therefore, these would be inappropriate alternatives in this clinical situation, as the note indicates that they have been trialed and failed. Without Tirosint, this patient will be at increased risk of the complications of untreated hypothyroidism, which can cause myxedema coma. Therefore, yes, the requested Tirosint is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dry Eye.
Treatment: Tyrvaya.

The insurer denied coverage for Tyrvaya.  The denial is overturned.
 
The patient has dry eye disease, has tried and failed artificial tears and Restasis, and has intolerance/contraindication to Xiidra.  Thus, Tyrvaya is one of the only remaining options to treat her condition.  Tyrvaya has been shown to be effective for treating dry eye disease and improved tear production in patients with dry eye disease.

The patient has dry eye disease, has tried and failed artificial tears and Restasis, and has intolerance/contraindication to Xiidra.  Thus, Tyrvaya is one of the only remaining options to treat her condition.

Tyrvaya is medically necessary for this patient because the patient has tried and failed and has intolerance/contraindication to the plan policy's formulary alternatives (artificial tears, Restasis, Xiidra).  Thus, Tyrvaya is medically necessary to treat the patient's condition.  Tyrvaya has been shown to be effective and well-tolerated for the treatment of dry eye disease.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Tyrvaya is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elective cardiac catheterization
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

This patient is an adult male for whom an inpatient hospitalization is under review. There was a history of hypertension and a cerebrovascular accident. There was shortness of breath that was worse when lifting heavy boxes. There was no chest pain. He was unable to attempt a treadmill test due to back pain. Echocardiography revealed an ejection fraction of 30-35%. A position emission tomography/computed tomography scan demonstrated an ejection fraction of 20% in a small area of mild inferior and inferior-lateral ischemia. The patient presented for an elective cardiac catheterization. Vital signs were essentially normal. The electrocardiogram was normal. Cardiomyopathy medical therapy was initiated. The patient underwent a successful percutaneous intervention of the circumflex. He remained stable and was discharged.

The proposed treatment is not medically necessary.

This patient presented electively for a heart catheterization in the setting of a cardiomyopathy. There was no congestive heart failure, respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, need for prolonged intravenous medications or oxygen support, introduction of high-risk medications requiring ongoing in-hospital monitoring, severe catheterization related complication (i.e., severe bleeding, cerebrovascular accident), need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal electrocardiogram. 
In the setting of this case, an acute inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care toward improved cardiac outcomes. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient admission. 
The insurer denied: Inpatient admission. 
The denial is upheld. 

The patient is an adult male. He was hospitalized for chest pain. He presented to the ED (emergency department) for evaluation of mid-sternal chest pain associated with nausea, which began at 5 AM. His past medical history included known subclinical multi-vessel coronary artery disease (CAD) incidentally detected on an abdominal CT (computed tomography) scan and negative nuclear stress test 2 years prior, hypertension, diabetes and hyperlipidemia. The patient's vitals were all stable. EKG (electrocardiogram) was initially concerning for possible STEMI (ST-elevation myocardial infarction), but STEMI (ST-elevation myocardial infarction) code was canceled by Cardiology. Echocardiogram was technically limited, but revealed LVEF (left 
ventricle ejection fraction) of 58%, no segmental wall motion abnormalities, but difficult to evaluate due to suboptimal image quality and mild dilation of the aortic root and ascending aorta. Serial troponin and BNP (brain natriuretic peptide) were normal.
The patient was treated medically, and he opted for outpatient cardiac catheterization. He did not wait for it to be done inpatient. 
The requested coverage for Inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed. 

The Inpatient admission was not medically necessary. 

Based on the peer-reviewed medical literature, including the MCG (Milliman Care Guidelines) guidelines for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization, cardiac arrhythmia of immediate concern or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care that the patient received, including rule out ACS (acute coronary syndrome) and other life-threatening causes of chest pain like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary.