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

Diagnosis: Fever, Infection
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who was hospitalized secondary to the presence of a fever and chills. He initially went to a different hospital and left against medical advice prior to presenting to the admitting hospital. His medical history includes Hodgkin's lymphoma (status/post (s/p) prior chemotherapy and in remission), prior Port catheter placement, human immunodeficiency virus (HIV) infection (controlled on antiretroviral therapy), adjustment disorder with depression, and history of diverticulitis. At the time of his presentation, he was noted to be tachycardic.  A chest x-ray demonstrated bibasilar airspace consolidation. Blood cultures were obtained and grew methicillin-susceptible staphylococcus aureus (MSSA). Initial treatment included intravenous antibiotic therapy with vancomycin and cefepime. Infectious disease was consulted and modified antibiotic regimen to intravenous cefazolin alone. A computed tomography (CT) scan of the chest demonstrated new bilateral cavitary nodules consistent with septic emboli. An echocardiogram was performed and did not demonstrate valvular vegetation. At issue is the medical necessity of an inpatient stay.

Based on the information provided, the requested health service/treatment of inpatient medical services was medically necessary for this patient.
This patient had a complicated, systemic staphylococcal infection. His blood cultures grew methicillin-susceptible Staphylococcus aureus (MSSA). The port catheter was the source of infection as evidence by the catheter tip culture also growing MSSA. Computed tomography (CT) chest imaging demonstrated findings consistent with septic emboli. On admission, this patient had an elevated heart rate indicative of systemic infection and was periodically febrile during the hospital stay. This patient should be considered immunosuppressed based on prior cancer diagnosis requiring chemotherapy and current HIV infection. Based on the severity of his infection (MSSA bacteremia with septic pulmonary emboli) and his immunosuppressed state, he was at risk for worsening sepsis and end organ disease manifestations. Urgent removal of the port catheter was medically necessary. Parenteral antibiotic therapy was also medically necessary in this setting. Based on the available information, the medical care provided was medically necessary and could not have safely and effectively been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic medical problems including avascular necrosis

Treatment: Continued Inpatient Rehabilitation

The insurer denied coverage for Continued Inpatient Rehabilitation

The denial is upheld 


This is an adult male with chronic medical problems including avascular necrosis, neuropathy and depression.  He was transferred from the skilled nursing facility to the acute hospital, for scheduled left hip replacement surgery.  He was re-admitted rehabilitation center for post-surgical rehabilitation.  

The patient's clinical condition and functional ability were not at a level as to require continued inpatient rehabilitation for the time period under review.  The patient made excellent functional progress after the hip surgery.  According to the physical therapy notes, the patient was at the supervision and stand by assist level for transfers and ambulating with a rolling walker, respectively.  More recent therapy notes were not submitted for review. There were no acute medical or complicated nursing issues that prevented his discharge from Rockaway Care Center.  The clinical records do not document a level of care that required continued inpatient rehabilitation for the time period under review.  The patient could have been discharged home and continued with outpatient therapy if needed.   

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Continued Inpatient Rehabilitation services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: nausea/vomiting
Treatment: Compounded Aprepitant 
The insurer denied Compounded Aprepitant. 
the health plan's determination is overturned. 

This patient is a young male with a history of feeding intolerance, gastroparesis, nausea and vomiting. He has tried and failed numerous therapies.

Compounded Aprepitant is medically necessary for this patient. The current literature supports the use of aprepitant in treating chronic nausea and vomiting in children.
According to Patel, Bhumik, et al.: "Our results demonstrate the effectiveness of aprepitant in helping to restore emetic control in those children with progressive disease, whose nausea and vomiting had remained refractory to multiple lines of prior antiemetic therapy. All children started on aprepitant were reported by the children themselves or by a parent to have had immediate resolution of nausea and vomiting."
According to Kovacic, Katja et al.: "Prokinetics may improve symptoms of nausea if there is evidence of delayed gastric emptying. Dopamine-2 receptor antagonists such as metoclopramide and domperidone were mainstay treatments for gastroparesis in the past. Their use has, however, been limited more recently because of the potential for serious adverse effects. Domperidone is currently available only in the United States through Food and Drug Administration exemption. Erythromycin is a motilin receptor agonist with potent prokinetic activity. Long-term use may be limited because of the common development of tachyphylaxis. Furthermore, erythromycin may induce pain as it increases gastric tone. Case reports of refractory nausea because of gastroparesis suggest that agents such as mirtazapine (antiserotonergic, antihistamine properties) and the neurokinin-1 receptor antagonist aprepitant have potential efficacy for nausea."
This patient has already tried and failed the available alternatives. Therefore, continuation of compounded aprepitant is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and Vomiting
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult male patient with a history of perforated viscus, laparoscopic cholecystectomy, and pyloric stent who presented with nausea and vomiting. The patient was seen in the emergency department (ED) the day prior with a potassium of 2.9 and hiccups all day. The patient had presented to the hospital before with nausea / vomiting and was found to have gastric outlet obstruction. The pylorus was dilated with a balloon at that time. The pylorus was re-dilated up to 20 millimeters. The patient had similar symptoms a few months later and was referred to gastrointestinal for management of partial gastric outlet obstruction. He had esophagogastroduodenoscopy (EGD) done and the prior placed AXIOS stent was displaced into the stomach. The stent was then reinserted into the pyloric channel. After that, the patient was tolerating food well and was scheduled for another esophagogastroduodenoscopy for possible stent replacement with a 15 millimeter by10 millimeter Lumen apposing stent. During the admission, the patient was treated with intravenous fluids, intravenous Zofran, intravenous proton pump inhibitor (PPI), replacement of electrolytes, and diet as tolerated. Computed tomography (CT) of the abdomen / pelvis showed a slightly distended stomach but was otherwise normal. The patient was discharged on day #3.

The requested health service was not medically necessary.

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding; or evaluation requiring the patient to not eat or drink for extended period (e.g., more than 24 hours). The patient did not have inability to maintain oral hydration (e.g., needs intravenous fluid support) that persisted after observation care; and did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure that could not have been performed on an ambulatory basis. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Heart Failure.
Treatment:  Increase in personal care hours to 7 days per week, 10 hours (hrs) per day.

The insurer denied increase in personal care hours to 7 days per week, 10 hours (hrs) per day.  The determination is overturned.

This is a female patient with a medical history notable for heart failure. The patient is approved for 6 hours per day, 7 days per week (42 hours per week) of personal care hours. The patient and her care team requested an increase to 10 hours per day, 7 days per week (70 hours per week), and the request was denied by the health plan. This denial is the subject under review.
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient has been declining from a cognitive and functional standpoint. She is unable to ambulate independently with a walker and requires human support. She is essentially homebound. She cannot independently perform any activities of daily living. The provider recommends an increase in personal care hours to tend to the patient's needs.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via video teleconference. The patient lives alone in her apartment. She was alert and oriented but very forgetful; recall was 0 out of 3 (0/3) at five minutes. Procedural memory was intact and she is able to make her needs known. For her Instrumental activities of daily living (IADLs), the patient requires total dependence for housework and stairs. She requires maximal assistance for shopping and meal preparation. She requires extensive assistance for all others. For her activities of daily living (ADLs), the patient requires maximal assistance for bathing. She requires extensive assistance for dressing, walking, locomotion, toilet transfer, and toilet use. She was observed requiring weight-bearing human assistance for transfers. She is frequently incontinent of urine and infrequently incontinent of stool. She uses pull ups for incontinence care. The patient had three falls in the month prior to the assessment. There was no pressure ulcer present. Compared to a prior assessment, the patient showed a modest decline in functional status. At issue is the medical necessity of increase in personal care hours to 7 days per week, 10 hours (hrs) per day.
The requested health of increase in personal care hours to 7 days per week, 10 hrs per day service is medically necessary for this patient.
The patient requires personal care assistance to complete nearly all activities of daily living including toileting, transfers, and ambulation. She also has incontinence and requires assistance with changing pull ups. Her recent falls are evidence of unmet personal care needs. Furthermore, her needs can be reasonably expected to be continuous and unscheduled throughout the day. Therefore, the requested increase in personal care hours is medically necessary and reasonable for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Reactive airway disease
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female child with a medical history significant for reactive airway disease and possible intubation (language barrier) that was taken to the emergency department (ED) with a two-day history of a tactile fever, runny nose, cough, and wheezing.  The examination was significant for mild respiratory distress, non-toxic appearance, rhinorrhea, moist mucous membranes, regular heart rate and rhythm, tachypnea, prolonged expiration, retractions, decreased air movement, wheezing, benign abdomen, and non-focal neurologic exam.
Rapid viral testing was positive for respiratory syncytial virus (RSV). She was given two nebulized treatments with improved aeration but persistent tachypnea. She was given a third nebulized treatment and a dose of dexamethasone, with ongoing tachypnea and wheezing. She was started on treatments every two hours, given a DuoNeb treatment, and admitted for further management.
Admission orders included albuterol every two hours weaning as tolerated, regular diet for age, Environmental Health consultation, Asthma Social Work consultation. She was able to wean quickly to treatments every four hours, was given a second dose of dexamethasone, and started on Flovent with metered dose inhaler (MDI) spacer. She tolerated her diet and remained stable in room air. The family received asthma teaching via interpreter. The patient was diagnosed with mild persistent asthma, and was deemed stable for discharge. Prior to discharge, immigration screening labs were obtained, and she was given a one-time dose of albendazole as treatment for possible intestinal worms. At issue is the medical necessity of an inpatient stay.

Inpatient hospital admission was not medically necessary for this patient.
About half of all children experience an episode of wheezing in the first six years of life, often linked with a viral respiratory infection (eg respiratory syncytial virus, rhinovirus. Human metapneumovirus, influenza). Children may even experience recurrent episodes of wheezing as triggered by viral infection.
The young female child with history of multiple viral-associated episodes of wheezing presented with tactile fever, runny nose, cough, and wheeze. Testing revealed infection with respiratory syncytial virus (RSV). She was treated aggressively in the ED with bronchodilators and steroids with some improvement, but ongoing tachypnea and wheeze. While it was reasonable to monitor this child in the hospital for improvement, she was overall hemodynamically stable with no supplemental oxygen requirement, tolerating regular diet. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld


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

The patient is a female with past medical history (PMH) of daily marijuana smoking who was admitted with complaints of abdominal pain associated with nausea, vomiting, and fatigue after eating Chinese food. Vital signs were unremarkable. Physical exam was notable for no apparent distress (NAD), abdomen NT/ND (nontender/nondistention). Lab work was unremarkable. Imaging studies showed no acute abdominal or pelvic pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) without acute ischemia. The patient was diagnosed with nausea/vomiting and treated with intravenous fluids (IVF), anti-emetics, proton pump inhibitor (PPI), and pain control, with symptomatic improvement. 

The inpatient hospital admission was not medically necessary. This patient presented to the ED (emergency department) with complaints of abdominal pain associated with nausea and vomiting. The patient did not have associated high-risk features, such as severe acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, appendicitis, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with nausea/vomiting, was treated and responded to intravenous fluids, anti-emetics, and proton pump inhibitor (PPI), and pain control, with symptomatic improvement, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine

Treatment: Qulipta

The insurer denied coverage for Qulipta

The denial is upheld 

This is an adult who tried and failed nortriptyline, topiramate, and Nurtec. The patient was seen by their provider and was treated at the hospital for paresthesias, issues with aphasia, and a right facial tic. There was a concern for a cerebrovascular event and possible focal seizures versus other differential diagnoses. A head computed tomography (CT) revealed no acute intracranial abnormalities. Brain magnetic resonance imaging (MRI) ruled out acute ischemia. The patient presented with moderate-intensity headaches with an aura consistent with complex migraine and was given a migraine cocktail with relief. 

The patient noted that they had been overall stable since the last appointment. Migraines have been persistent, and the patient started nortriptyline 25 milligrams (mg) at bedtime and utilized Emgality monthly and Qulipta 60 mg daily. Tremors had persisted but had not improved since starting Zoloft since the last appointment. The patient remained out of work and plans to restart in the next couple months. Examination revealed normal general, head, eye, ear, nose, throat, neck, chest, heart, abdomen, back, extremity, and skin examinations with motor and vocal tics and stuttering speech. The patient underwent treatment with Ajovy on that date, and at that time, they were provided with Qulipta samples and provided with an injection of Emgality. The patient was also provided with Nurtec and Ubrelvy samples. The patient was being seen by a movement disorder specialist elsewhere for the motor and vocal tic disorder and had improved since starting Abilify and Zoloft. There was no significant decline or fatigue. The treating provider has requested treatment with Qulipta 60 milligrams (mg) by mouth (PO) daily, which is under review.

All formulary drugs are not any more likely than Qulipta to cause an adverse reaction. While all medications have possible adverse reactions, there is no evidence that Qulipta has a superior adverse reaction rate compared with all formulary migraine medications.      

Not all formulary drugs have been ineffective. Prior formulary drugs use were topiramate and Nurtec. Nortriptyline is not formulary. The patient is also currently receiving Emgality. There is no evidence that Emgality has been ineffective. There is no evidence that candesartan, propranolol, topiramate, venlafaxine, divalproex/valproic acid, levetiracetam or zonisamide have been ineffective.     

There is no evidence that the requested drug is more effective than all formulary drugs. There is no evidence in the peer-reviewed literature that Qulipta is superior in efficacy to Aimovig, Ajovy, Emgality, Nurtec, Candesartan, levetiracetam, propranolol, topiramate, venlafaxine, divalproex, valproic acid and zonisamide.

Therefore, the request for Qulipta 60 milligrams (m) by mouth (PO) daily is not medically necessary and is denied.

The carrier's denial of a request for a Formulary Exception for Qulipta is upheld.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a medical history of diabetes mellitus type 2, gastroparesis, asthma, and hypertension. He presented to the emergency department with the inability to tolerate liquid or solid oral intake, dark emesis without frank blood, and constipation. He had recently been discharged after undergoing an endoscopy with finding of esophagitis and gastritis.
He had persistent vomiting. Lab results showed a low hemoglobin of 11.0 g/dL (grams per deciliter) and hematocrit of 34.4% (percent), and unremarkable basic metabolic panel. A gastroenterology consultation noted intractable nausea and vomiting with gastroparesis, recent endoscopy with finding of esophagitis and gastritis, and slow transit constipation; the recommendation was to continue the proton pump inhibitor and Carafate, small frequent meals, optimize blood glucose, and standing Reglan. Endocrinology noted diabetes mellitus type 2, uncontrolled hyperglycemia, and dyslipidemia; the recommendation was to continue fingersticks, check lipids in the morning, continue atorvastatin, and blood pressure control. He was discharged on lactulose, Miralax, pantoprazole, and sucralfate, with a plan for Cardiology follow-up. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care is not medically necessary in this case. Although the patient presented with nausea and vomiting, he did not have persistent hypotension, organ failure, or other stigmata of severe volume depletion. The presenting gastrointestinal symptoms of nausea and vomiting were consistent with his known gastroparesis or other etiologies such as esophagitis, gastritis, or peptic ulcer disease; he had recently undergone esophagogastroduodenoscopy with finding of esophageal and gastric inflammation, and repeat endoscopy was not deemed necessary during his stay [1-7]. He was appropriately treated with proton pump inhibitor therapy and metoclopramide [1-6]. However, the patient did not have evidence of bowel obstruction, peritonitis, abscess, fistula, sepsis, gastrointestinal bleeding, or other complications warranting inpatient level of care. All of the measures that were undertaken, including observation, monitoring, labs, intravenous fluids with gradual advancement of diet, and gastroenterology and endocrinology consultations, could have been performed in sequence after presentation and without the inpatient level of care. [1-9].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back injury.
Treatment:  Inpatient stay.

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

The patient is a male with a recent seizure, who presented to the emergency department complaining of mid-back pain radiating bilaterally for several weeks. Point tenderness in the midline of his lower thoracic region developed shortly after the seizure occurred.

At the same time, he denied fever, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, headache, or dizziness. A computed tomography (CT) of the abdomen and pelvis during the emergency room (ER) visit revealed a subacute T (thoracic)12 compression fracture.

Upon admission, the review of systems was positive for back pain only. 

The inpatient hospital admission was not medically necessary for this patient.
The patient presented to the hospital after he sustained a fall, which was most likely related to seizures. The fall resulted in multiple vertebral compression fractures, however, these fractures were not associated with instability or neurologic compromise. Furthermore, there was no evidence that the patient required longer-term treatment with parenteral pain medications beyond the reasonable timeframe for observation.
The acute inpatient level of care was not indicated for seizures since there was no evidence of hemodynamic instability or status epilepticus. The imaging studies did not reveal the presence of brain disorders such as tumors, edema, trauma, or hydrocephalus. There was no mention that the patient's seizures were associated with an infectious process such as encephalitis or meningitis. There was no evidence that the seizures were the result of drug toxicity or withdrawal. There was no mention that the patient had any cardiac arrhythmias of immediate concern associated with seizures. The physical exam did not reveal new focal neurologic deficits.
Laboratory evaluation was not consistent with metabolic abnormalities except for hypokalemia, which was corrected. Furthermore, there was no mention that the patient had increased intracranial pressure or cerebral edema. Once the patient received treatment with antiseizure medications in the hospital, he had no recurrent seizures.
Taking into consideration these facts, a lower level of care was appropriate.