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

Diagnosis:  Abdominal Pain.
Treatment:  Inpatient admission.
The insurer is denied coverage for inpatient admission.  The denial is upheld. 

This is a female patient with a history of morbid obesity, fatty liver and lap band surgery.  The patient presented to the Emergency Department (ED) with complaints right upper quadrant (RUQ) pain and vomiting after eating.  Upon arrival to the ED, the patient was afebrile, heart rate (HR) 117, respiratory rate (RR) 22 and blood pressure (BP) 170/109 with a pulse oximetry of 100% on room air (RA).  The patient recently started gaining weight, and the patient was evaluated on an outpatient basis with manipulation of saline in the port.  An ultrasound was done and revealed an enlarged liver with steatosis and no gallstones.  The patient's labs were essentially unremarkable except for elevated glucose.  The patient was admitted to the hospital and made nothing by mouth (NPO).  Intravenous (IV) fluids were given. An abdominal x-ray, upper gastrointestinal (UGI) series were performed; the UGI series was negative and the abdominal X-ray showed non-specific bowel pattern.  The Hospitalist service was consulted.

The patient requested that the lap band be removed during this admission as the lap band was most likely the etiology of her presenting symptoms.  A Hospitalist note indicated that the patient's abdomen was soft, non-tender with normal bowel sounds.  The patient's UGI report indicated gastric band in stable position without obstruction with no abnormal narrowing of the lumen at the level of the band.  The recommendation was to control hyperglycemia.  Cardiology saw the patient and cleared the patient for surgery.  Pulmonary saw the patient and also cleared the patient for surgery.  A progress note indicated that the patient was sitting comfortably in bed.  The patient denied chest pain or shortness of breath (SOB); denied abdominal pain, nausea or vomiting.  The patient was taken to the Operating Room (OR) and underwent an uneventful diagnostic laparoscopy, lysis of adhesion, removal of lap band and esophagogastroduodenoscopy (EGD).  The patient's findings included esophagitis and no iatrogenic perforation to the stomach and no gastric outlet obstruction.  A progress note indicated that the patient was doing well, tolerating diet and was to be discharged home with instruction to maintain a liquid diet for two days and then transition to a soft diet.

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

The carrier's denial of coverage for the acute inpatient admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Renal cysts and Diabetes Syndrome.
Treatment:  Genetic testing.
The insurer denied the genetic testing.  The denial is overturned. 

Yes, the genetic testing is medically necessary. 

The patient is a male child that has developmental delay and end-stage renal disease due to congenital anomalies of the kidney and urinary tract (CAKUT).  His other medical problems include undescended left testis, hypokalemia, hypocalcemia, anemia, feeding difficulties, developmental delay, peritoneal dialysis, previous peritonitis, and birth at 36 weeks of gestation.  Chromosomal Microarray was normal.  Previous whole exome sequencing revealed a paternally inherited variant of uncertain significance in the HFN1B gene, potentially consistent with a well-characterized the highly variable genetic syndrome, termed Renal Cysts and Diabetes Syndrome/congenital anomalies of the kidney and urinary tract (CAKUT).  His attending physician (AP) geneticist has requested specific sequencing and copy number variants testing of this single gene to determine whether or not the variant of unknown significance in this gene is the cause for his multiple medical problems related to CAKUT.

There is a reasonable expectation, based on previous testing that this patient's anatomic malformations, end-stage renal disease, and other findings, that he has a specific genetically inherited condition, CAKUT, potentially due to as yet unidentified mutations in the HFNB1 gene not able to be detected by previous whole exome sequencing.  Determining whether or not this patient has a pathogenic variant/mutation in this gene is important for his future health maintenance and surveillance, since pathogenic variants in this gene are also associated with development of diabetes, gout, and abnormalities in liver function and exocrine pancreatic function.  Therefore, it is important to determine whether or not he has a genetic syndrome due to pathogenic variants/mutations in this gene. 

Determining whether or not this patient has a pathogenic variant in HFNB1 gene is medically necessary and clinically appropriate; performing this testing is based on his symptomatology and anatomic abnormalities; pathogenic genetic variants in this gene are well known to be associated with this genetic syndrome and the test is analytically and clinically valid.  The results of the test will have clinical utility as discussed above and will influence future decisions and surveillance for other manifestations of this syndrome due to mutations in the HFNB1 gene in this child.  The results of this test will also provide reproductive risk information to his parents for future pregnancies.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a female with a history of cerebrovascular accident (CVA) and transient ischemic attack (TIA), which has left her with left-sided peripheral vision deficit, who presented to the emergency department with headache dizziness and blurriness of the vision in the left eye.  The patient is chronically anticoagulated with Pradaxa.  The headache started during the evening hours before admission, and 4 hours later, the patient woke up, went to the bathroom, and noted some weakness in the left lower extremity. 

The inpatient hospital admission is not medically necessary for this patient.  The patient can be managed at a lower level of care.  There is no evidence of neurologic trauma, causing the patient's symptoms.  The patient presented to the hospital with paresthesia to the left lower extremity.  Extensive and advanced imaging failed to demonstrate an acute stroke, bleed, tumor, intracranial and extracranial stenosis of the arteries.  As a result, there is no evidence of a neurologic emergency that would require inpatient hospitalization.  This presentation could have been managed at a lower level of care, with appropriate imaging as was done, with subsequent transition to home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

Yes, the inpatient admission was medically necessary.

The patient is a female whose inpatient admission is under review. The patient has a history of sickle cell disease, anemia, and asthma.  She presented with three days of suprapubic pain and dysuria. No vaginal bleeding/discharge was noted.

In the ER: 
Temperature (T) - 99.0  
Respiratory rate (RR) - 18 
Pulse - 78  
Blood pressure (BP) - 134/77
General - well-developed/well-nourished
Chest - normal
Cardiovascular system (CVS) - normal
Abdomen - normoactive bowel sounds (NABS), no mass, positive to tenderness, no guarding, positive suprapubic tenderness without rebound

White blood cell (WBC) - 12.1(high)
Hemoglobin (Hg) - 6.3 (low)
Hematocrit (Hct) - 21.8 (low)
Platelets (Plt) - 399
Sodium (Na) - 135
Potassium (K) - 5.1
Chloride (Cl) - 102
Carbon dioxide (CO2) - 20 (low)
Blood urea nitrogen (BUN) - 8
Creatinine (Cr) - 0.83

In the ER, the patient was thought to have severe anemia, as well as abdominal pain of unknown origin. She was admitted, initially treated with Linezolid and Zosyn. She received a blood transfusion, but with no correction, she received a second unit. Abdominal computed tomography (CT) did not reveal an abscess, but Chlamydia infection and possible pelvic inflammatory disease (PID) diagnosed (antibiotics changed to doxycycline and cefoxitin). In the hospital she was also evaluated by surgical and gynecology (GYN) teams. The patient improved and was discharged home.

The patient had severe anemia that did not correct with a transfusion. Standard of care in these cases would be to clinically follow and rule out active bleeding with serial blood draws, as was done in this case. In addition, the patient had severe abdominal pain. Work-up did not reveal an etiology except for possible PID, which she was treated for. Failure to admit such a patient can result in severe hypotension, circulator shock, sepsis and death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces
The insurer denied the braces.
The denial is overturned. 

Yes, the Braces are medically necessary. 

The patient is a female.  The request is for orthodontic benefits.

The patient has a deep, impinging overbite with severe soft tissue damage on her palate. This is an automatic qualifying condition according to the handicapping index scale. Orthodontic treatment is needed to correct this problem.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital

This is the case of a  female with past medical history of hypertension, ankle fracture, gastroesophageal reflux disease, and recent EGD (Esophagogastroduodenoscopy) showing gastritis who presented to the emergency department with burning chest pain that was non-radiating and associated with shortness of breath, palpitations, and tingling of her face. She also noted she felt food getting stuck in her throat, unintentional weight loss of 22 pounds in 5 months, orthopnea, dyspnea on exertion, and paroxysmal nocturnal dyspnea.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This is a patient who presented with reports of weeks of ongoing difficulties with swallowing, weight loss, and chest pain associated with shortness of breath, palpitations, and tingling of her face. She had new T wave inversions on EKG but otherwise serial cardiac enzymes that were negative and a history that was atypical for cardiac ischemia. She furthermore had just had an EGD that showed mild gastritis only. Given her presentation with new T wave inversions, she was reasonable to bring into the hospital for serial cardiac enzymes, telemetry, and stress testing. In the absence of stress test suggestive of cardiac ischemia, hemodynamic instability, esophageal dysmotility or obstruction completely precluding oral intake, and with otherwise unremarkable labs, it is unclear why inpatient care was medically necessary. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory
Treatment: Inpatient Hospital

This is a patient with hypertension (HTN), hyperlipidemia, diabetes mellitus (DM), hypothyroidism and coronary artery disease (CAD), with a previous percutaneous coronary intervention (PCI). He reported increasing chest pain and exertional dyspnea over a few months prior to admission. He was admitted for a cardiac catheterization. The patient was found to have stenosis of the proximal left anterior descending coronary artery, and a stent was placed to this vessel. He was started on Brilinta. The procedure was uncomplicated. He was discharged home on Aspirin, Brilinta, Lipitor, Toprol and Imdur, in addition to medication for diabetes. 

At issue is the medical necessity of the inpatient stay. 

The health plan's determination is upheld. Inpatient hospitalization was not medically necessary for this patient. He was hemodynamically stable on admission and presented electively for a cardiac catheterization. The procedure, including diagnostic coronary angiography and coronary stenting, was uncomplicated. Per Milliman Guidelines, the usual length of stay for this procedure is ambulatory. Inpatient stay may be needed in certain situations, such as acute myocardial infarction, need for urgent coronary artery bypass graft (CABG) surgery, procedure-related complications, such as peri-procedural myocardial infarction (MI), cerebrovascular accident (CVA), retroperitoneal bleed, or vascular entry site complications causing ischemia. None of these conditions were present in this case.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history significant for asthma, and thyroid disease.  He is a former smoker.  The patient presented to the emergency department (ED) with a cough, shortness of breath (SOB), wheezing, and dyspnea on exertion for 2 days.  He was using his Combivent inhaler but without improvement.  He denied having a fever or chills.  He had a recent admission a month prior for an asthma exacerbation.  He had had no prior intubations.
In the ED his blood pressure (BP) was 107/75, pulse 107, respiratory rate (RR) 16, oxygen saturation 95%, and he was afebrile.  His peak flow was 210.  On exam, he was in no acute distress.  He was breathing comfortably without the use of accessory muscles.  His lungs had bilateral wheezes throughout.  There was no lower extremity edema.
Abnormal blood work included a white blood cell count (WBC) count of 12.4 and a partial pressure of oxygen (pO2) of 63 on a venous blood gas.  A chest x-ray showed no acute infiltrate or edema but did show obstructive lung disease.
The patient was admitted to the hospital for an asthma exacerbation.  He was started on nebulizers and oral steroids.  He had a computed tomography (CT) scan of his chest which showed a dilated esophagus with an air fluid level.  It was felt that he may have an aspiration pneumonia and was started on a proton pump inhibitor (PPI) and Augmentin.  The patient remained in stable condition.  He was not hypoxic.  He did not have any oxygen saturations (O2 sats) documented less than (<) 90%.  His breathing improved and he was discharged home two days later.
The health plan's determination is overturned.
This patient continued to have breathing difficulties despite outpatient treatment.  He met Millman Care Guidelines for Asthma given a peak flow between 40-60% of predicted and a hospitalization for asthma in the past year.  Based on the patient's age, his normal peak flow should be between 400 and 600, the variation based on weight.  His peak flow was only 210, which at the low end of the range would put him at 40-60%.
Given asthma with diffuse wheezing, a low PO2, and low peak flow, inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: congestive heart failure, coronary artery disease, end stage renal disease on hemodialysis and cognitive impairment
Treatment: PCA Level II - Live in 24 hours per day (split shift) 
The insurer denied the PCA Level II - Live in 24 hours per day (split shift).
The denial is overturned.

The patient is an male with a history of multiple medical issues, including congestive heart failure, coronary artery disease, end stage renal disease on hemodialysis and cognitive impairment. Due to impairments related to these conditions, he requires assistance for the completion of the majority of his activities of daily living (ADLs). 

An appeal review was requested for potential approval of an increase in Personal Assistance Services to PCA Level II - Live in 24 hours per day (split shift) to offer increased ADL support.

Yes, the proposed treatment of an increase in Personal Assistance Services to 24 hours/day live in (split shift) is deemed medically necessary. 

Recent documentation from the patient's Primary Care Physician indicates that due to the patient's worsening functionality and cognitive impairment, he now requires 24 hour/around the clock supervision to maintain his health and prevent further decline. Hence, the currently approved plan of 42 hours/week is insufficient to meet the patient's current needs.  For these reasons, the proposed treatment of an increase in Personal Assistance Services 24 hours/day live in (split shift) is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central nervous system /neuromuscular disorders/other.
Treatment:Home health care.
The insurer denied  Personal care services - 24 hours per day, 7 days per week (split shift) total 168 hours per week, Level 2.
The denial is upheld in whole.

The patient is with a past medical history of osteoarthritis, hypertension, coronary artery disease, osteoporosis and hearing loss who had been assigned Personal Care Aid (PCA) services .
No, PCA services, 24 hours/day, 7 days/week (split shift) total 168 hours/week, level 2, is not medically necessary for this patient.
The patient was approved for 24 hour/day, live-in, 7 days/week to total 168 hours/week. The patient does not have PCA care needs in the overnight hours such as turning, repositioning, wound care or medication administration that would necessitate 24 hour/day split -shift PCA services. The patient does not have the need for supervision of tasks overnight outside of the time frame of a live-in PCA. Split-shift PCA services (12 hours each) is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: IBS-C (irritable bowel syndrome with constipation)
Treatment: Zelnorm
The insurer denied the Zelnorm.
The denial is upheld. 

The patient is a female with IBS-C (irritable bowel syndrome with constipation). She has failed Benefiber and Levsin, and she is doing well on Zelnorm. Her MD is requesting treatment with Zelnorm.

No, the treatment with Zelnorm is not medically necessary.

The patient has IBS-C and has failed conventional therapy. According to the provided medical policy, in order for criteria for Zelnorm to be met, the patient must have tried and failed Linzess. As the patient has not tried and failed Linzess, criteria for Zelnorm is not met. As there is no medical literature to support that Zelnorm is more effective than Linzess for the treatment of IBS-C, the proposed Zelnorm is not medically necessary, and the health plan acted reasonably, with sound medical judgment and in the best interest of the patient in denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine /metabolic /nutritional/Diabetes
Treatment: Home health care  
The insurer denied Personal care services - 12 hours per day, 7 days per week. total of 84 hours per week Level 2
The denial is overturned in whole 

The patient  with past medical history of cognitive decline, hypertension, depression, diabetes mellitus type 2 and arthritis. The patient had been assigned Personal Care Aid (PCA) services 45 hours/week
Yes, the requested services of Personal care services 12 hours per day, 7 days per week, total of 84 hours per week level 2 is medically necessary.
The patient lived with spouse  who died and provided some help with ADL, IADL's. The patient doesn't have an informal caregiver. The patient's PCA service hours are not solely for supervision and safety but for prompting and supervision of ADL's and IADL's. The patient had COVID 19 and was recovering from this illness but even without having recuperation from COVID 19, the patient required increased assistance with ADL's and IADL's. There is documentation in the assessment tool from  that patient had significant change in assistance needs from the prior assessment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal Reflux disease
Treatment Dexilant 60 mg
The insurer denied Dexilant 60 mg.
The determination is overturned.

This is a patient with gastroesophageal reflux disease (GERD). Per the provider letter, he has failed omeprazole, esomeprazole, lansoprazole, rabeprazole, and Zegerid (omeprazole/sodium bicarbonate); he has had relief only from Dexilant 60 milligrams (mg) daily, which he has taken for the past 10 years. He has recently been on pantoprazole and sucralfate. Per the provider note, he failed Prevacid. The coverage is requested for Dexilant 60 mg daily for the treatment of gastroesophageal reflux disease (GERD). The formulary alternatives are rabeprazole and Zegerid over-the-counter (OTC). At issue is the medical necessity of the Dexilant 60 mg.

The Dexilant 60 mg is medically necessary for this patient. Proton pump inhibitor (PPI) therapy is recommended by American College of Gastroenterology guidelines for gastroesophageal reflux disease [1]. The patient is reported to have failed several proton pump inhibitors, and has had good control of symptoms with Dexilant for many years. Comparison of multiple proton pumps inhibitors (PPIs), including those attempted (omeprazole, esomeprazole, pantoprazole, lansoprazole, rabeprazole) has found no difference in control and healing of GERD between them, and superiority of Dexilant to esomeprazole [2,3,4,6]. Dexilant, unlike all other proton pump inhibitors, is released in an extended fashion; this delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric potential of hydrogen (pH) than other proton pump inhibitors [5]. A significant majority of patients (88%) on other PPIs twice daily were able to control symptoms on Dexilant once daily [6]. Dexilant is also more effective to treat heartburn than alternatives such as esomeprazole [7-9].
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Asthma.
Treatment:  Formulary exception for Alvesco 80mcg INH.
 
The insurer denied the Formulary exception for Alvesco 80mcg INH.  The denial is overturned. 

The patient is a male with a history of mild persistent asthma and allergic rhinitis.  The request is for approval for Alvesco.

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

The CVS non-formulary exception criteria require that for Alvesco to be covered, three of the formulary alternatives have been tried and outcome documented, or that contraindications to these formulary alternatives be shown.  According to the provider's letter of appeal, the patient has a documented adverse reaction with dry powder-based inhalers such as Advair, Breo, Symbicort and Arnuity.  He has shown contraindication to these formulary alternatives.  Since Alvesco is the only non-dry powder inhaled corticosteroids, the health plan should cover the Formulary exception for Alvesco.