Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: T1DM [type 1 diabetes mellitus]

Treatment: Basaglar

The insurer denied coverage for Basaglar.

The denial is upheld.

This patient was diagnosed with T1DM [type 1 diabetes mellitus] with hyperglycemia. This request is for Basaglar. As reported; she was taking Lantus for years to control her blood sugars then recently she had more severe low blood sugar. Lantus was discontinued due to severe low blood sugar, and she was started on Tresiba; but Tresiba has been contributing to multiple hypoglycemic episodes. Both previous long-acting insulins caused hypoglycemic episodes despite medication adjustments and adequate diet control. She was changed to Basaglar and she has not reported any low BG [blood glucose]. 

The formulary drugs Levemir and Toujeo are not any more likely to cause hypoglycemia or another reaction than the requested medication.

The patient has tried Lantus and Tresiba but has not tried Levemir or Toujeo.

Toujeo (glargine) Basaglar (glargine) Lantus (glargine)(5) and Levemir(6) are long acting basal insulins. Insulin degludec (tresiba) has been shown to be effective in the treatment of type 1 and 2 diabetes in the following clinical trials (1-3). The medication is FDA (Food and Drug Administration) approved for use in adult patients with diabetes mellitus (4). 

There are no studies demonstrating superiority of the requested medication over the formulary alternatives Toujeo and Levemir. The patient can try Toujeo or Levemir. The references provided are the most current/relevant to the case.

The requested drug is not likely to be more effective than the formulary drugs.

The insurer's denial of coverage for Formulary Exception for Basaglar is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with severe persistent asthma. He presented to emergency room with asthma exacerbation. The patient was treated with frequent nebulizer treatment as well as IV (intravenous) steroids without much improvement. The patient was admitted to acute inpatient level of care and continued to receive IV (intravenous) steroids, nebulization treatments and was seen by pulmonary specialist. The patient had difficult to treat symptoms of asthma and had prolonged hospitalization.

This entire admission was denied by the health plan due to lack of medical necessity. This denial is being appealed.

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient had severe asthma exacerbation, and had failed outpatient treatment as well as emergency room treatment. The patient was started on IV (intravenous) steroids but continued to have symptoms despite 24 hours of care, and the IV (intravenous) steroids were increased after pulmonary consultation. The patient continued to have SOB (shortness of breath) and wheezing on higher doses of IV (intravenous) steroids and needed prolonged hospitalization. The patient has history of severe persistent asthma with previous intubation and mechanical ventilation. Since patient had slow response to IV (intravenous) steroids, the prolonged hospitalization is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces.
The insurer denied Braces.
The determination is upheld.

The patient has a Class II occlusion with a 5 millimeter (mm) overjet and 5 mm overbite. The maxillary and mandibular arches have moderate crowding. He is treatment planned for orthodontics to correct his malocclusion. At issue is the medical necessity of braces.

There is no medical reason to correct the malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) However, this patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 5 mm overjet but this amount of overjet does not affect oral health related quality of life. (2) The treating orthodontist states the overjet is much greater than 5 mm but it does not appear so given the supplied cephalometric radiograph. If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. Therefore, orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic obstructive pulmonary disease (COPD).
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient was a female with a past medical history significant for chronic obstructive pulmonary disease (COPD), asthma, and hyperlipidemia who was brought to the emergency department with complaints of worsening shortness of breath and chest tightness. The patient said that her symptoms started six days before the presentation as cold and chest congestion.
She was seen by her primary care physician and received treatment with Augmentin. The patient reported worsening shortened breath and wheezing. She used a bronchodilator via nebulizers at home without significant improvement. The patient received an intramuscular injection of Decadron and Duoneb administered by Emergency Medical Services (EMS).

The inpatient hospital stay was not medically necessary. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care.
This patient was admitted to the hospital with respiratory symptoms that were attributed to acute respiratory failure due to COPD/asthma exacerbation.
However, the review of the medical records demonstrated no evidence of hemodynamic instability associated with respiratory distress. There was no mention that the patient had severe underlying COPD. There was no evidence that the patient had high-risk active acute comorbidities including congestive heart failure, pneumothorax, cardiac arrhythmias. There was no evidence that the patient had underlying pneumonia (chest x-ray was normal and the patient was afebrile). There were no reports that the patient had altered mental status.
Furthermore, the patient's respiratory symptoms improved within a short period of time. There was no evidence that the patient remained hypoxemic or hypercarbic beyond the observation period.
In fact, there was no evidence that the patient had arterial blood gas checked after initiation of treatment with BiPAP. Furthermore, I did not see that the patient had serial peak expiratory flow measurements to assess the progress of the treatment.
Taking into consideration all these facts, a lower level of care was most appropriate to ensure improvement in the patient's respiratory status after receiving treatment in the emergency department.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right arm weakness and numbness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient has a history of deep venous thromboembolism, prior stroke, and cocaine abuse who presented to the hospital for evaluation of 2-3 days of right arm weakness and numbness. The patient was admitted for evaluation of a stroke. A computed tomography (CT) scan of the head in the emergency room was negative for an acute ischemic process. The patient underwent a magnetic resonance imaging (MRI) scan of the brain that was also negative for stroke. The symptoms were not consistent with a transient ischemic attack as these symptoms can only last for 24 hours by definition. The patient was restarted on therapeutic Lovenox with a bridge to warfarin. She was discharged home with outpatient follow-up.
At issue is the medical necessity of an inpatient stay.

The inpatient stay  was not medically necessary for this patient.
The patient was admitted to the hospital after endorsing right arm numbness and weakness for three days. A CT scan in the emergency room was negative. If the patient had an ischemic stroke, it would often be visible on the CT scan of the head after 12 hours. The patient presented after 2-3 days. The patient was admitted for further imaging; however, an MRI of the brain did not show a stroke. The patient was diagnosed with a transient ischemic attack despite having symptoms for greater than (>) 24 hours. TIA is operationally defined based on symptom duration lasting less than 24 hours, with typical episodes lasting less than 1 hour.
The patient had a history of a deep venous thromboembolism but stopped taking warfarin due to insurance issues. She was restarted on warfarin with a Lovenox bridge.
Acute inpatient admission is not medically necessary as a transient ischemic attack does not require an acute inpatient admission for evaluation. It is standard of care to evaluate a TIA as part of a rapid outpatient clinic or by observation in the hospital. Obtaining imaging and developing a treatment (such as restarting warfarin) could be performed at lower level of care. The patient did not require complex nursing or rehabilitation and was discharged home with outpatient follow-up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe headache, weakness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was brought to the emergency room by ambulance after she developed a severe headache, left sided weakness, and slurred speech. The patient was evaluated as a stroke alert in the emergency room but her symptoms were improving on presentation. She underwent a computed tomography (CT) scan of the head and computed tomography angiography (CTA) of the head and neck that did not show any acute findings. She was treated with tissue plasminogen activator. She was admitted for further evaluation although the admission examination indicates a normal neurologic exam and mental status. The patient had a history of migraines and went to bed with a headache. She was further evaluated with a magnetic resonance imaging (MRI) scan of the brain which did not show any acute findings. During the hospitalization, the doctors learned that she had stopped her preventative medication topiramate. This drug was re-prescribed for migraine prevention with an outpatient referral for chronic migraine treatment.
At issue is the medical necessity of an inpatient stay.
An acute inpatient admission was not medically necessary.
The patient has a history of migraine and stopped migraine preventative and acute therapy. The patient developed a severe headache and later neurologic symptoms including difficultly speaking and left sided numbness and weakness. She was taken to the emergency room for evaluation. On arrival to the emergency room, the neurologic symptoms were improving. The patient was evaluated for an acute stroke with a CT scan of the head and vessel imaging. These did not reveal a large vessel occlusion. The patient was treated with tissue plasminogen activator.
She was admitted to the hospital for further evaluation. An MRI of the brain was performed. The patient did not have an acute stroke and the study did not have any other acute findings. The patient's presentation and symptoms were attributed to migraine rather than stroke. The staff learned that the patient had stopped taking migraine medications. Topiramate was re-prescribed. The patient was referred to outpatient neurology for migraine management.
The patient did not require acute inpatient care. Transient neurologic symptoms are evaluated at a lower level of care. The patient did not have any acute findings on imaging. There were no acute laboratory abnormalities. Neurologic symptoms were improving on presentation. All of the care provided is consistent with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation

Treatment: Inpatient hospital admission 

The insurer denied coverage for the inpatient hospital admission

The denial is upheld.

This is the case of a patient who presented to the hospital with symptoms of chest pain and shortness of breath for one week. Her past medical history was significant for hypertension, coronary artery disease, status post percutaneous coronary intervention, and hyperlipidemia. Previously she underwent a cardiac catheterization that revealed a patent stent in the left circumflex artery and a 50 percent blockage of the right coronary artery. Upon arrival to the hospital, her vital signs were stable (pulse 81 beats per minute, blood pressure 105/93). The physical examination was significant for an irregularly, irregular, rapid pulse. A 12-lead electrocardiogram (ECG) revealed atrial fibrillation with a ventricular rate of 147 beats per minute and prolongation of the QT (interval on ECG) interval . Serum troponin levels were not elevated. The patient was treated with intravenous diltiazem therapy and oral anticoagulant therapy (rivaroxaban) and her heart rate normalized. The patient was admitted to the telemetry ward for additional monitoring. Her heart rate remained controlled, and the patient was discharged the following day on appropriate medications. 

Bellew et. al. studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department. In this study of almost 600 patients, there was no difference in outcome. American Heart Association (AHA) guidelines note that admission to the hospital for management of atrial fibrillation in patients that achieve rate control do not require hospital admission.

This patient presented with symptomatic atrial fibrillation and was effectively treated with atrioventricular (AV) nodal blocking agents. This patient reverted to normal sinus rhythm several hours after presentation. Following evaluation and additional testing, the patient's heart rate was well-controlled, and she was released from the hospital. In conclusion, this patient could have been managed at a lower level of care. Inpatient hospital admission was not medically necessary.

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

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

Diagnosis: Ventricular Bigeminy

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This patient presented to the hospital complaining of palpitations and diaphoresis. Past medical history was significant for hypertension and bipolar depression. Several days prior to presentation, the patient underwent dental extraction and multiple teeth were removed. Upon arrival to the hospital, vital signs were stable; blood pressure (BP) 132/64, pulse rate 82 beats per minute. Physical exam was within normal limits. A 12-lead electrocardiogram (EKG) revealed sinus rhythm with ventricular bigeminy and a QTc (interval on EKG) of 427 msec (milliseconds). Serum blood testing demonstrated no abnormalities and no elevation of cardiac enzymes. Urine drug toxicology was positive for tetrahydrocannabinol (THC). The patient was admitted to the hospital for further evaluation. Regadenoson perfusion testing revealed no evidence of cardiac ischemia and a left ventricular ejection fraction (LVEF) of 78 percent. Echocardiogram demonstrated a normal LVEF (65 percent) without valvular abnormalities. The patient was discharged the day after presentation. 

The patient's symptoms were due to ventricular bigeminy. There were no significant abnormal findings on physical examination or EKG to warrant acute inpatient hospital admission. Echocardiogram revealed a normal LVEF. Evaluation of patients with ventricular ectopy is performed in the outpatient setting utilizing multiday ambulatory monitoring (1). Most patients with palpitations can be evaluated in the outpatient setting (2,3). In conclusion, inpatient hospital admission to assess palpitations due to premature ventricular contractions was not medically necessary for this patient without significant past cardiac history. 

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. Acute inpatient admission was not medically necessary

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
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 a past medical history significant for sickle cell trait, and anemia who presented to the emergency department with complaints of intermittent dull epigastric abdominal pain for 1 week. The pain became persistent and was associated with nausea and vomiting.
Upon initial evaluation in the emergency department, the patient was found to have anemia. She was admitted to the hospital for further evaluation. The review of systems was negative for anorexia, and chills. It was negative for nasal congestion, chest pain, cough, or dyspnea. The patient denied back pain.

The inpatient hospital admission was not medically necessary. The patient presented to the hospital with anemia, however, there was no evidence that the anemia was associated with hemodynamic instability, active bleeding, or hemolysis. The anemia was not associated with altered mental status, recurrent syncopal or near syncopal episodes. There was no evidence of high-risk low platelet count. The anemia was not associated with acute renal failure, heart failure, myocardial ischemia, acute peripheral ischemia, or any other signs of symptoms requiring intervention at the acute inpatient level of care.
The abdominal pain was unlikely the result of a pain crisis in the patient with sickle cell trait. The abdominal pain was not associated with hemodynamic instability, peritoneal signs. There was no evidence that it was severe enough to justify admission at the acute inpatient level of care. There was no evidence that the abdominal pain was the result of serious medical conditions such as aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, intestinal obstruction. There was no mention that the abdominal pain was associated with bacteremia or toxic megacolon. Therefore, the acute inpatient level of care is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain; leg pain
Treatment: Laminectomy (63047)
The insurer denied the Laminectomy (63047)
The denial is upheld.

The patient is a female with low back pain and leg pain. Her exam reveals no focal deficit. The patient takes NSAIDs (nonsteroidal anti-inflammatory drugs) for pain, and she has attempted chiropractic care. MRI (magnetic resonance imaging) shows L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) disc protrusion with moderate lateral recess and foraminal stenosis.

The patient was recommended L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) laminectomy.

No, the requested laminectomy is not medically necessary.
The patient's imaging does demonstrate stenosis, but the patient has not attempted an adequate trial of nonsurgical management. The patient has moderate foraminal stenosis that does correspond with the amount of pain, but because it is not documented that the patient has had adequate conservative therapy, the medical necessity of the recommended surgery is not supported. An adequate trial of multimodal therapy would include PT (physical therapy), injections, chiropractic care, amongst others for a minimum of 6 weeks, and up to 3 months, within the last 6 months.

Therefore, given the above, the requested laminectomy is not considered medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
As the requested laminectomy is not medically necessary, it is appropriate to deny surgery based upon lack of nonsurgical management.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: White Glass with Metal Crown, Tooth 18. 

The insurer denied White Glass with Metal Crown, Tooth 18. The health plan's determination is overturned. 

The patient is a male who presents for evaluation and treatment of tooth #18. Provided for review are previous letters of appeal and denial, full mouth radiographic images, one page of American Dental Association (ADA) claim forms and explanation of benefits. In question is the medical necessity of White Glass with Metal Crown, Tooth 18. 

The White Glass with Metal Crown, Tooth 18 is medically necessary for this patient.
From the radiographic images provided the tooth is missing a majority of the clinical crown including the cusps and internal structure which requires replacement with a full coverage restoration. The tooth in question does in fact have an opposing tooth and is important for mastication. Therefore, a White Glass with Metal Crown, Tooth 18 is medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Metastatic renal cell carcinoma
Treatment: Formulary exception for Oxycontin
The insurer denied the formulary exception for Oxycontin.
The denial is overturned.

The patient in this case is a man with metastatic renal cell carcinoma. He has extensive metastatic disease with multiple sites involved. An appeal letter states that this patient has been on Oxycontin for several years and most recently he has been taking Oxycontin 40mg (milligrams) three times daily along with Dilaudid as needed. He has been on these specific pain medications with good control of his pain. Most recently, his cancer has worsened. At issue in this case is continuation of Oxycontin as opposed to changing to a different pain medication regimen based on formulary requirements.

Yes, the health plan should cover the formulary exception for Oxycontin, based on the information provided.

This patient has been on Oxycontin for many years and he has been on a stable dose of this medication along with use of Dilaudid as needed with good control of his pain. Changing to a different regimen places him at risk of reduced efficacy as well as of having adverse effects and side effects. Changing between different narcotic agents is not an exact science, and there can definitely be variability in how patients respond to different doses. For example, a recently published study found that while overall pain control did not vary significantly between different agents, there was a proportion of patients who failed to respond to each drug, outlining the inherent variability in response to opioids between different patients. Based on this, it is also true that changing to a different agent would place this patient at risk for having increased difficulty with pain and possibly side effects. Therefore, in this reviewer's opinion, the health plan should cover the formulary exception.