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

Diagnosis: Immunologic Disorders/Alopecia areata, unspecified
Treatment: Pharmacy/Prescription Drugs/ Olumiant 25MR OR Tabs
The health plan denied the requested medication, Olumiant 25MR OR Tabs as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with alopecia areata.  The patient was noted to have a 1-1.5 centimeter (cm) oval area with loss of hair, which was diagnosed as alopecia areata. The clinic note for that date reported improvement with topical augmented Betamethasone Dipropionate lotion. 
Health plan coverage of Olumiant is under review for medical necessity.

The health plan denial of Olumiant coverage is recommended to be upheld.

No. Olumiant is only Food and Drug Administration (FDA) approved for moderate to severe alopecia areata in adults. This patient has very limited alopecia areata, and which appears to be improving, or at least is controlled, on topical steroids. The risks of use of this systemic treatment (Olumiant) by far outweigh any potential benefits--if any significant benefits are likely to be achieved that time and current treatment alone would otherwise perform. 
The health plan only covers medications that are FDA-approved and evidence-proven for a given condition. Olumiant is FDA-approved for moderate to severe alopecia areata in adult patients (18 years of age or older). This patient has at best mild alopecia areata, which appears to be improving or controlled on topical steroids, and is by far too young to prove any safe indications for being treated with a medication with potential side effects and lab monitoring as exists with the Janus Kinase inhibitor Olumiant. The proper dosing for this patient is not known, and any benefits or favorable outcomes of Olumiant for this particular clinical scenario are also unknown. Olumiant is therefore not only not medically necessary, but is arguably entirely medically inappropriate with respect to safety issues in the treatment of this patient's mild alopecia areata.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain.
Treatment: Thermal Destruction of the Intraosseous Basiverterbral Nerve.
The insurer denied: Thermal Destruction of the Intraosseous Basiverterbral Nerve.
The denial is upheld.

The patient is an adult male with low back pain. The patient has previously undergone a bilateral L (lumbar) 4-S (sacral) 1 MBB (medial branch block) with greater than 75% relief. He had bilateral L5-S1 TFESI (Transforaminal Epidural Steroid Injection) 2 times nine months apart with significant and 90% relief, respectively.

At his follow-up, the patient's pain is a 3-4/10 and improves with medications and injection therapy. Pain medications include: gabapentin, Celebrex and methocarbamol.

The patient's MRI (magnetic resonance imaging) of the lumbar spine is significant for a L1 superior fracture, DDD (degenerative disc disease), and L4-5 moderate canal stenosis.

The request for L5-S1 Intracept procedure was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the Thermal Destruction of the Intraosseous Basivertebral Nerve.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure. As such the health plan should not cover the requested health service.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain.
Treatment: Thermal Destruction of the Intraosseous Basivertebral Nerve.
The insurer denied: Thermal Destruction of the Intraosseous Basivertebral Nerve.
The denial is overturned.

The patient is an adult male with chronic low back pain not responsive to conservative management. The patient has undergone greater than six weeks of physical therapy, chiropractic care, medication management with NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, gabapentinoids, and opioids, and interventional injections including lumbar epidural steroid injections. His treating provider diagnosed him with vertebrogenic low back pain confirmed by MRI (magnetic resonance imaging) findings of Modic changes at the L (lumbar) 5 and S (sacral) 1 vertebral bodies. The treating physician recommended the Intracept procedure, but the procedure was denied coverage by the health plan due to it being considered experimental/investigational. The denial is being appealed.

The health plan should cover the Thermal Destruction of the Intraosseous Basivertebral Nerve.

The Intracept procedure is FDA (United States Food and Drug Administration)-approved, and there is enough data in the medical literature to show it is safe and effective in the treatment of vertebrogenic low back pain. A prospective, randomized, multi-center study by Khalil et al in 2019 and another prospective, randomized, multi-center study done by Fischgrund also in 2019 both presented high-quality evidence of efficacy and safety of the procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain.
Treatment: Thermal Destruction of the Intraosseous Basivertebral Nerve.
The insurer denied: Thermal Destruction of the Intraosseous Basivertebral Nerve.
The denial is upheld.

The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, home exercises. The patient has failed multiple medications including opiate medications, NSAIDs (nonsteroidal anti-inflammatory drugs) and muscle relaxants. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. The patient is positive for facet loading maneuvers signs.

The health plan should not cover the Thermal Destruction of the Intraosseous Basivertebral Nerve.

The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, home exercises. The patient has failed multiple medications including opiate medications, NSAIDs (nonsteroidal anti-inflammatory drugs) and muscle relaxants. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. The patient is positive for facet loading maneuvers signs.

The procedure is an FDA (United States Food and Drug Administration)-approved procedure for axial low back pain. It has been shown effective in RCT (randomized controlled trials) with five-year results. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA)-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted.

However, in this particular case, the patient has not failed or attempted sacroiliac joint injections, which are common causes of axial low back pain. The Intracept procedure should be employed after all conventional and evidence-proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives, sacroiliac injections do show favorable outcomes in the literature and have lower risk and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute appendicitis.
Treatment is an inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is overturned.

The patient had a history of melanoma and presented with right lower quadrant (RLQ) abdominal pain and fever of 101. She had RLQ abdominal tenderness but no peritoneal signs. The white blood count (WBC) was 15.88. The computed axial tomography (CAT) scan was read as acute appendicitis. She was kept NPO [no oral intake] and given intravenous (IV) antibiotics. It was decided that an interval laparoscopic appendectomy should be done in about 2 months. 

Milliman Care Guidelines (MCG) MG-GAS reviews clinical indications for admission for Gastroenterology. Acute appendicitis with planned nonoperative management or interval appendectomy to be done at a later date is an indication for admission. A requirement for inpatient care is that appendectomy is not the preferred treatment for uncomplicated appendicitis during this hospitalization. 

This patient had RLQ pain, fever, leukocytosis, and a CAT scan that was read as acute appendicitis. It was decided to treat her with NPO and IV antibiotics and to plan on an interval appendectomy. This non-operative management met MCG criteria for admission under Gastroenterology. The health care plan did not act reasonably or with sound medical judgment. An inpatient admission was medically necessary. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: pulmonary embolism/deep vein thrombosis.
Treatment: Pradaxa.

The insurer denied Pradaxa.
The denial is overturned.

The patient is a male with dermatomyositis on chronic prednisone, with history of prior pulmonary embolism and deep vein thrombosis (DVT), gastroesophageal reflux disease (GERD), prostatitis, hyperlipidemia, and allergic rhinitis who was switched from Pradaxa to Xarelto due to a change in formulary. He had tolerated Pradaxa well but then developed hematuria on Xarelto. 

The health plan's determination is overturned.

In this case the Pradaxa is the better drug choice for this patient. While the patient's preference for Pradaxa given the availability of a specific reversal agent is noted, it is not a sufficient cause to request coverage. However, the patient did have an intolerable side effect, hematuria, on Xarelto, which is a problem he did not have while on Pradaxa. Studies do suggest that bleeding is a more common complication on Xarelto as compared to Pradaxa, so it is not unreasonable that a patient could experience bleeding issues on one direct oral anticoagulant (DOAC) (e.g., Xarelto) but not another (e.g., Pradaxa). As such, the formulary alternative of Xarelto would and does have adverse effects for this patient and is not a valid option.
In terms of warfarin, this is also an inferior option for this patient. Numerous studies have found DOAC drugs to have similar efficacy to warfarin with a lower bleeding risk. As such, this is not a valid alternative for this patient when other DOACs exist that could be tried when the one DOAC on formulary caused side effects.
Therefore, the non-formulary drug Pradaxa is the most appropriate choice for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible pneumonia
Treatment: Inpatient emergency admission
The insurer denied the inpatient emergency admission.
The denial is upheld.

The patient is an adult male with ethanol (ETOH) abuse, Cirrhosis, Atrial Fibrillation, intracerebral brain hemorrhage (ICH), chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidemia and coronary artery disease (CAD). He presented to the emergency department (ED) with shortness of breath for 2 days. A prior echocardiogram (ECHO) revealed ejection fraction (EF) 20% (percent). The patient had taken inhalers and nebulized medications but without relief.

Vital signs at presentation were Temperature 97.7 degrees Fahrenheit, Heart Rate 79, Respiratory Rate 16, Blood Pressure 159/82 and oxygen saturation 95% on room air. Lungs had decreased breath sounds. The patient was in no distress.  
There was positive pedal edema. White Blood Cell (WBC) count was 5.2, Hemoglobin 11.5 and brain natriuretic peptide (BNP) was elevated at 1981. Chest X-ray (CXR) revealed bilateral patchy infiltrates, congestive changes and right pleural effusion.

The patient was admitted for congestive heart failure (CHF) and possible pneumonia. He was treated for decompensated Heart Failure with Lasix, continued betablockers, angiotensin-converting enzyme (ACE) inhibitors, Aldactone and statins. Intravenous (IV) Rocephin and Azithromycin were administered. There was consistent improvement with decreased cough, less lower extremity edema, clear lungs and afebrile status. 

The patient was afebrile and hemodynamically stable, with normal WBC, mild congestive heart failure (CHF), and normal oxygen saturation. The patient was discharged home on oral medications.

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

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

Diagnosis: Supraventricular tachycardia (SVT)

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient with a history of hypertension, asthma, supraventricular tachycardia (SVT), arthritis, and tobacco abuse, presented to the emergency room (ER) from urgent care with complaints of dyspnea, nausea, lightheadedness, and chest pressure. An electrocardiogram (EKG) revealed narrow complex tachycardia. Three rounds of adenosine were given in the ER. He converted spontaneously to sinus rhythm. Electrophysiology (EP) recommended 25 milligrams (mg) of metoprolol twice a day (BID).  Troponin in ED (emergency department) was elevated at 0.89 with repeat of 0.82. The patient was admitted.

He was started on aspirin and a statin. A transthoracic echocardiogram (TTE) revealed normal biventricular size and function. Cardiology noted patient had known SVT and was not compliant with beta blockers. They recommended SVT ablation.  EP atrioventricular nodal reentrant tachycardia (AVNRT) slow pathway modification/ablation was performed. The patient tolerated the procedure well. 

The patient was scheduled to undergo coronary CT (computed tomography) angiography to rule out significant CAD (coronary artery disease) but due to scheduling issues that was not possible. As such, the patient was discharged. 

The patient had a tachycardia associated with elevated troponin, indicating myocardial injury. It was judicious to admit the patient to the hospital for monitoring to assure that patient did not have spontaneous myocardial infarction (MI) as contrasted with a "demand" myocardial ischemia from the tachycardia. In view of the marked symptomatic status from the arrhythmia continued hospitalization for ablation is reasonable. The inpatient hospitalization is medically necessary.

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

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

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


The patient has a past medical history (PMH) of diabetes mellitus type 2 (DM2), hypertension (HTN), coronary artery disease (CAD) status/post (s/p) coronary artery bypass graft (CABG), and ischemic cardiomyopathy who was admitted with complaints of (c/o) cough associated with rhinorrhea. Vital signs were significant for peripheral capillary oxygen saturation (SpO2) of 97% on room air (RA). The physical exam was notable for no apparent distress (NAD), and mild bilateral wheezing. Lab work was notable for positive influenza. A chest x-ray (CXR) was negative for pneumonia. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with viral pneumonia and treated with Tamiflu, Duonebs, and clinical monitoring. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) a cough associated with rhinorrhea. The patient was found to have viral pneumonia and was treated with antivirals and pulmonary treatments. The patient was hemodynamically stable, did not require intubation or non-invasive positive pressure intubation, did not have any severe respiratory distress, tachypnea, use of accessory muscles in the neck, severe intercostal retractions, cyanosis, new altered mental status (AMS), hypoxia, and the CURB-65 [confusion, urea, respiratory rate, blood pressure, age greater than or equal to 65] score was 1, indicating a low-risk patient. The pneumonia severity index was risk class III, indicating that outpatient therapy was reasonable. The patient was diagnosed with non-severe pneumonia and treated with pulmonary treatments and antivirals all of which could have been safely provided at a lower level of care. The patient did not have impending or actual respiratory arrest, severe airflow abnormalities, severe respiratory findings, a chronic lung disease with severe deterioration, empyema, abscess, lung collapse, high-risk pulmonary infection, tracheostomy complication, severe pulmonary arterial hypertension (HTN), cystic fibrosis (CF), serious arrhythmias, severe AMS, acute peripheral ischemia, hemodynamic instability, or need for pulmonary catheter monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia, Asthma
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with asthma and a prior Aspergillus infection causing right lung collapse who presented with a progressively worsening productive cough and dyspnea that did not respond to outpatient antibiotics and prednisone.
 She was not in distress, heart was regular but tachycardic, she was breathing comfortably but wheezy and congested, and was alert and oriented. The white blood cell count (WBC) was 11.5, sodium (Na) 136, creatinine (Cr) 0.98. A chest x-ray (CXR) showed a patchy, ill-defined right middle lobe (RML) opacity, small right and trace left pleural effusions. She was given steroids and nebulized bronchodilators, felt better, and the wheezing resolved. She was admitted, diagnosed with pneumonia and asthma exacerbation, and started on antibiotics (levofloxacin), intravenous (IV) steroids, and nebulized bronchodilators. The next day she felt much better, was breathing comfortably, and she was discharged on a course of prednisone and levofloxacin. At issue is the medical necessity of an inpatient stay.

An inpatient stay was not medically necessary. While the patient did not respond to her initial treatment as an outpatient, when she presented, she was not severely ill; she had no encephalopathy, hemodynamic instability, respiratory failure (she had mild hypoxemia but was the oxygen saturation was over 88% (percent) on room air (RA) and improved during emergency department (ED) and observation stay). She did not have an acute kidney injury or marked electrolyte abnormality. Scoring systems (SMART COP [Systolic blood pressure, Multilobar infiltrates, Albumin, Respiratory rate, Tachycardia, Confusion, Oxygen and potential hydrogen (pH)], Pneumonia Severity Index (PSI), American Thoracic Society (ATS) / Infectious Diseases Society of America (IDSA) minor criteria, CURB65 [Confusion, urea, respiratory rate, blood pressure, age greater than or equal to 65] would suggest that her risk of worsening and needing intensive care unit (ICU) care was low. She improved over an observation care time frame. There were no alternative diagnoses. She did not have any typical red flags for a severe asthma flare.
Given her lower severity of illness at presentation and low risk of worsening, she did not need inpatient-only testing, monitoring, or treatment. As she improved rapidly, she did not require an inpatient stay for prolonged care. Care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia, Asthma. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a patient with asthma and a prior Aspergillus infection causing right lung collapse who presented with a progressively worsening productive cough and dyspnea that did not respond to outpatient antibiotics and prednisone. 
 She was not in distress, heart was regular but tachycardic, she was breathing comfortably but wheezy and rhonchorous, and was alert and oriented. The white blood cell count (WBC) was 11.5, sodium (Na) 136, creatinine (Cr) 0.98. A chest x-ray (CXR) showed a patchy, ill-defined right middle lobe (RML) opacity, small right and trace left pleural effusions. She was given steroids and nebulized bronchodilators, felt better, and the wheezing resolved. She was admitted, diagnosed with pneumonia and asthma exacerbation, and started on antibiotics (levofloxacin), intravenous (IV) steroids, and nebulized bronchodilators. The next day she felt much better, was breathing comfortably, and she was discharged on a course of prednisone and levofloxacin. At issue is the medical necessity of an inpatient stay. 

An inpatient stay was not medically necessary. While the patient did not respond to her initial treatment as an outpatient, when she presented, she was not severely ill; she had no encephalopathy, hemodynamic instability, respiratory failure (she had mild hypoxemia but was the oxygen saturation was over 88% (percent) on room air (RA) and improved during emergency department (ED) and observation stay). She did not have an acute kidney injury or marked electrolyte abnormality. Scoring systems (SMART COP [Systolic blood pressure, Multilobar infiltrates, Albumin, Respiratory rate, Tachycardia, Confusion, Oxygen and potential hydrogen (pH)], Pneumonia Severity Index (PSI), American Thoracic Society (ATS) / Infectious Diseases Society of America (IDSA) minor criteria, CURB65 [Confusion, urea, respiratory rate, blood pressure, age greater than or equal to 65] would suggest that her risk of worsening and needing intensive care unit (ICU) care was low. She improved over an observation care time frame. There were no alternative diagnoses. She did not have any typical red flags for a severe asthma flare.
Given her lower severity of illness at presentation and low risk of worsening, she did not need inpatient-only testing, monitoring, or treatment. As she improved rapidly, she did not require an inpatient stay for prolonged care. Care could have been provided at a lower level.