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

Diagnosis: Syncope. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is a young adult male. He was hospitalized from for syncope. He has a past medical history remarkable for vasovagal syncope. Prior to this admission, he had smoked marijuana and had a few beers. He became anxious, and while walking, he passed out for approximately 30 seconds. This repeated several times. He had associated nausea and weakness. By the time he reached the emergency department, he nearly passed out again right after his bloodwork was taken. 

The patient's vitals were stable, and there were no apparent significant injuries from the falls. Echocardiogram revealed decreased the LVEF (left ventricle ejection fraction) 46-50% with global hypokinesis. EKG (electrocardiogram) was concerning for possible Brugada with a QTc (corrected QT interval) of 420. EP (electrophysiology) consultation offered procainamide challenge, but the patient refused and left AMA (against medical advice). The request for coverage for inpatient hospitalization was denied coverage by the health plan a not medically necessary. The decision is being appealed. 

The Inpatient Hospital Admission was not medically necessary. 

Based on the provided MCG (Milliman Care Guidelines) guideline, the requested service, inpatient stay is not medically necessary. There was not a medical need for the acute inpatient hospital stay, because the criteria for inpatient stay are not met. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the guideline, there was no suspicion of imminently dangerous cause, such as pericardial tamponade, pulmonary embolism, syncope causing injury requiring hospitalization, inpatient admission required rather than observation care because of a significant finding or clinical condition judged too severe or too persistent to be within scope of observation care, such as hemodynamic instability that is severe or persistent, cardiac arrhythmias of immediate concern, acute coronary syndrome or myocardial Infarction, structural cardiac disorder like severe aortic stenosis or suspected as cause that requires immediate correction, respiratory distress, stroke, seizures, altered mental status, severe electrolyte abnormalities requiring inpatient care or other significant finding or clinical condition judged not to be within scope of observation 
care. In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care he received for uncomplicated vasovagal syncope with typical triggers identified such as in this case, is routinely provided safely and effectively at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Multiple Sclerosis.
Treatment: Pharmacy/Prescription Drugs- Mavenclad.
The insurer denied the Pharmacy/Prescription Drugs- Mavenclad.
The determination is upheld.

The patient has a medical history of relapsing remitting multiple sclerosis who is prescribed Mavenclad. The drug was denied because the member has not tried the available formulary alternatives. At issue is the non-formulary medication (Mavenclad).

There is no documentation that the member has tried and failed any of the available formulary alternatives such as Aubagio, Betaseron, Copaxone, Gilenya, glatiramer, Glatopa, Rebif and dimethyl fumarate.

There is no head to head comparison of Mavenclad to the available formulary alternatives. Comparative analyses performed in the peer-reviewed literature have showed cladribine tablets have comparable relative efficacy to fingolimod in all subpopulations studied (1). Cladribine also demonstrated comparable effectiveness on relapse activity to fingolimod in patients with highly active relapsing multiple sclerosis (2). In addition, cladribine tablets showed lower annualized relapse rate compared with matched patients who started interferon, glatiramer acetate, or dimethyl fumarate; was similar to fingolimod; and was higher than natalizumab (3).

As such, there is no data to suggest that Mavenclad is superior to Gilenya. Low-level data suggests that Mavenclad is superior to interferons, glatiramer acetate, and dimethyl fumarate. There is no comparative data to Aubagio. Lastly, it is noted that Mavenclad is requested as a first-line medication for this patient with multiple sclerosis; however, the Food and Drug Administration (FDA) prescribing information cautions against the use of this drug as a first-line agent.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Transplant.
Treatment: Envarsus XR.
The insurer denied Envarsus XR.
The determination is upheld.

This is a male patient with end stage renal disease (ESRD) presumed secondary to diabetes mellitus (DM) / hypertension (HTN) who underwent a deceased donor renal transplant which was complicated by acute anemia requiring blood products, acute tubular necrosis and hypotension. The patient was discharged home on Envarsus extended release (XR) (tacrolimus) 9 milligrams (mg) daily, and Myfortic for his anti-rejection therapy. The most recent creatinine was 4.51 and the most recent tacrolimus level was 8.5. At issue is the medical necessity of the Envarsus XR.

The requested health service/treatment of Envarsus XR is not medically necessary for this patient based on the documentation provided. The health plan has other preferred calcineurin inhibitor therapy such as cyclosporine (either Gengraf or Sandimmune), tacrolimus (Prograf) or sirolimus. The patient was prescribed Envarsus XR which is an extended release formulation of tacrolimus. The records do not document any severe adverse reaction or intolerance to twice daily tacrolimus. Envarsus XR has been shown to be non-inferior to twice daily tacrolimus with similar efficacy and safely profile. However, there is a lack of data to suggest that Envarus XR is superior to twice daily tacrolimus which is a preferred medicine for the health plan. Nor was there any documentation that the patient had tried and failed the other preferred medications.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus (with diabetic neuropathy). 
Treatment: Formulary exception for Rybelsus 14MG (milligram) Tablet. 
The insurer denied: Formulary exception for Rybelsus 14MG (milligram) Tablet. 
The denial is upheld. 

The patient is an adult female diagnosed with Type 2 Diabetes Mellitus (with diabetic neuropathy). This request is for Rybelsus. She is using Rybelsus and Jardiance, since she has heart disease. She is stable on Rybelsus. 

The health plan denied coverage of the request with the following rationale: "Coverage for this medication is denied for the following reasons. We reviewed the information we received about your condition and circumstances. We used the plan approved policy when making this decision. The policy states that this medication may be approved when there is a clinical reason the member is unable to take an alternative dosage form of the requested drug on the formulary due to your condition. Based on the policy and the information we have your request is denied. We did not receive any documentation that there is a clinical reason you are unable to take an alternative dosage form that is available on the formulary. Formulary alternatives are Ozempic, Trulicity, Victoza. 
Requirement: 3 in a class with 3 or more alternatives, 2 in a class with 2 alternatives, or 1 in a class with only 1 alternative. Please refer to your plan documents for a complete list of alternatives. Note: Formulary alternatives may require a prior authorization. Your prescriber will be responsible for determining what alternative is appropriate for you." This denial is being appealed. 

The health plan should not cover the Formulary exception for Rybelsus. 

RYBELSUS is a GLP1R (glucagon-like peptide 1 receptor) agonist [1, 2] that is FDA (United States Food and Drug Administration) approved in the treatment of adults with type II diabetes [2-5]. There are no studies showing superiority of the requested medication over the formulary alternatives. The patient has not tried the formulary alternatives Ozempic, Trulicity, Victoza. They are not expected to be less effective than the requested medication. Studies in patients with heart disease 
show that GLP1 (glucagon-like peptide 1) agonists are beneficial for patients with heart disease, but there are no studies showing that Rybelsus is superior to the formulary alternative GLP1 (glucagon-like peptide 1) agonists. They are not expected to have more adverse effects than the requested medication. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary. 

Therefore, given the above, the health plan should not cover the formulary exception for Rybelsus.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Worsening Shortness of Breath, Cough and Wheezing (Chronic Obstructive Pulmonary Disease [COPD]). 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male with history of polysubstance abuse, bipolar disorder and schizophrenia who presented to the emergency room with shortness of breath. In the emergency room, the patient received intravenous steroids, intravenous antibiotics and duonebs. The patient had elevated venous partial pressure of carbon dioxide (pCO2) and was placed on bi-level positive airway pressure (BIPAP). The patient was admitted to acute in hospital level of care for the management of chronic obstructive pulmonary disease (COPD) exacerbation. The patient was continued on intravenous steroids and duonebs during the hospitalization. The patient was discharged home the next day. The admission was denied due to lack of medical necessity. This denial is being appealed. 

The proposed treatment was not medically necessary. 

This patient's chronic obstructive pulmonary disease exacerbation improved with emergency room treatment. At the time of admission, the patient was hemodynamically stable. The patient was not in any distress. The patient was ambulating and tolerating diet. The acute in hospital level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a school aged female. She had abdominal pain and was hospitalized. The health plan denied coverage of this hospital stay with the contention that it was not medically necessary. 

Brief summary of hospital stay: 
On the day of admission, the patient was seen in the ED (emergency department) for acute left-sided abdominal pain. Her x-ray and upper GI (gastrointestinal) study showed dilated gastric bubble and contrast in stomach. She had an enema and had a large bowel movement. She failed an oral challenge and was admitted. The plans were for IV (intravenous) fluids and close monitoring for possible volvulus.
The next day, no acute events were noted; repeat abdominal x-ray was normal. The patient tolerated diet. The patient was discharged home. 

The Inpatient Hospital Admission was not medically necessary. 

As documented in ED (emergency department) note, admission H&P (history and physical) and discharge summary, this patient had acute abdominal pain. The patient did not have other symptoms such as fever, vomiting or diarrhea. Labs were unremarkable. Abdominal x-ray showed dilated gastric bubble and upper GI (gastrointestinal) study showed contrast in stomach. Surgery was consulted and requested to admit the patient for monitoring of symptoms and serial abdominal exam. After admission, the patient did not have much pain and was able to tolerate regular diet. Repeat x-ray showed passage of contrast. The patient was in the hospital for observation and close monitoring. There was no documentation of any hemodynamic instability, peritoneal signs, suspected toxic colon, intestinal perforation, inability to maintain hydration, or electrolyte abnormalities. 

Thus, given the above, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is an adult patient with a past medical history significant for diabetes mellitus who presented to the emergency department with complaints of a worsening abdominal wound. On presentation, the patient's vitals were temperature 98.9 degrees Fahrenheit, blood pressure 114/74, pulse 76, respiratory rate 18, and oxygen saturation 96% (percent) on room air. Laboratory values were notable for a white blood cell count of 9.5, hemoglobin 14.3, hematocrit 42.3, creatinine 0.9, and a glucose of 109.

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and cefepime) for abdominal cellulitis. Surgery performed a bedside incision and had drainage of 10 cubic centimeters (cc) of purulent yellowish fluid. A computed tomography (CT) scan of the abdomen and pelvis was negative. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue antibiotics as an outpatient. Based on these findings, the patient met criteria for observation level of care. The patient did not meet criteria for acute hospital admission.

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

Diagnosis: Cellulitis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is an adult patient with a past medical history significant for diabetes mellitus and hypertension who presented to the emergency department with complaints of fever and pimple/rash to bilateral buttocks. The patient was treated with steroid creams as an outpatient.

Vitals on presentation included: Temperature 98.3 degrees Fahrenheit, blood pressure 124/82, pulse 89, respiratory rate 18, oxygen (O2) saturation 98% on room air. Laboratory values were notable for the following: white blood cell count (WBC) 11.2, hemoglobin 13.8, hematocrit 38.2, creatinine 0.98, and glucose 276.

The patient was empirically started on intravenous antibiotics (vancomycin and Zosyn) for a right buttock wound. A Computed tomography (CT) scan of the pelvis showed skin thickening and subcutaneous reticulation of bilateral gluteal regions. General Surgery was consulted and deemed no surgical intervention was required. Infectious Disease recommended antibiotics for folliculitis. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics as an outpatient.

According to documentation, the patient presented with rash/cellulitis to the buttocks. Otherwise, the patient remained afebrile and hemodynamically stable. Laboratory results were unremarkable including normal WBC (white blood cell count). The patient had no evidence of a disseminated infection, and no surgical intervention was deemed necessary. Based on these findings, the patient did meet criteria for observation level of management. The patient did not fulfill criteria for acute hospital admission.

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: D8080 Braces, D8670 Monthly Visit. 

The insurer denied: D8080 Braces, D8670 Monthly Visit. 
The denial is overturned. 

The patient is a teenage male with skeletal class I occlusion. He has Class II canine malocclusion with moderate upper spacing and moderate lower crowding. He has a deep impinging overbite with soft tissue damage to palate. The request is for braces and monthly visits. The health plan's prior denial of coverage of the request was due to the patient's handicapping index score of 18. The denial is being appealed. 

The requested braces and visits are medically necessary. 

The patient has a deep, impinging overbite with soft tissue damage to his palatal tissue. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem. Therefore, the request is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastritis. 
Treatment: Inpatient hospital admission. 
The insurer denied coverage for inpatient hospital admission. 
The denial is upheld. 

The patient presented with abdominal pain, nausea, and vomiting. The patient had a low-grade fever, but the vital signs were stable. There was no abdominal rebound or guarding, the liver enzymes were elevated. An abdominal ultrasound showed cholelithiasis but not acute cholecystitis. The surgeon recommended against any surgical interventions at this time. A computed tomography (CT) scan showed inflammation of the second portion of the duodenum. Proton-pump inhibitor (PPI) therapy was given. A hepatobiliary iminodiacetic acid (HlDA) scan was negative. An endoscopy revealed gastritis and duodenitis. 

Clinical indications for admission for Gastritis and Duodenitis Milliman Care Guidelines (MCG) M-560 includes hemodynamic instability, gastric outlet obstruction, perforation, peritoneal signs, severe vomiting, severe dehydration, severe pain, severe electrolyte disorders, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Gallbladder or bile Duct Stone or Inflammation (MCG M-555) include having acute cholecystitis or acute cholangitis if certain criteria are met. The patient did not have acute cholecystitis or acute cholangitis. Gallstones are an indication for admission if there is hemodynamic instability, common bile duct (CBD) obstruction, severe vomiting, severe pain, or bacteremia. The patient did not have these conditions. 

This patient had abdominal pain and was diagnosed with gallstones, gastritis, and duodenitis. The patient required a workup including an endoscopy and treatment with a PPI. This could have been done on an ambulatory setting. The gallbladder workup was also amenable to being done as an outpatient. The patient did not have acute cholecystitis. If antibiotics were felt to be necessary, the patient could have been treated with a course of oral antibiotics as an outpatient. The patient did not meet MCG criteria for admission for either Gastritis and Duodenitis or Gallbladder or Bile Duct Inflammation or Stone. 

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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is: Upheld.

The patient is a female with a history of hypertension, hyperlipidemia, obesity, who presented to the emergency department (ED) complaining of acute onset chest pain described as burning located in her left upper chest radiating to her left arm. In the ED, the patient was severely hypertensive with blood pressure (BP) of 199/120. Electrocardiogram (ECG) showed sinus bradycardia with nonspecific T wave abnormality. The patient was admitted to telemetry service under inpatient level of care for evaluation and treatment of uncontrolled hypertension and rule out acute coronary syndrome (ACS). Echocardiogram showed normal left ventricular ejection fraction (LVEF) and stress test was negative for infarct and ischemia. The patient was discharged home the following day. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

Inpatient hospital admission was not medically necessary. ACS was unlikely. The patient presented with atypical chest pain with an overall normal ECG without ischemic changes and negative cardiac troponins. The patient's calculated Heart score was 3, which is low risk for short-term major adverse cardiac events (MACE) events. The patient would be appropriate for treatment at a lower level of care status. According to the well-validated Heart pathway and expert consensus guidelines on acute chest pain management, a lower level of care status was medically appropriate and safe in this case (1-4).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Otezla 30 mg (milligram) tablet
The health plan denied the Otezla 30 mg tablet as not medically necessary.
The health plan's determination is upheld.

The patient is a male with plaque psoriasis. The total body surface area affected is 50%. He has failed triamcinolone and clobetasol. He has been prescribed Otezla 30 milligrams (mg) tablets by his provider. At issue is the medical necessity of the requested health service/treatment of Otezla 30 mg tablet.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Otezla 30 mg tablet is not medically necessary for this patient. According to the "National Physician Specialty Society Recommendations" for psoriasis, the American Academy of Dermatology Psoriasis Guidelines, and dermatology literature, systemic therapies such as methotrexate are effective treatments for the management of psoriasis[1, 2]. The request for Otezla is not medically necessary because the submitted records do not indicate that the patient has failed, has a contraindication, or has had an inadequate response to conventional systemic therapy.

Within the peer-reviewed literature, West et al. 2016 conducted a review of 11 comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint. Thus, methotrexate is an effective first-line treatment for the management of psoriasis [3].
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not medically necessary. It is noted that the patient has failed numerous topical steroids. However, there is no documentation provided that the patient has tried and/or failed methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Otezla medically more appropriate than the other options.

Therefore, the administration of Otezla is not strongly supported for this patient, and Otezla is not medically necessary for this patient based on the current evidence-based medical literature.