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

Diagnosis: Pneumonia
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is a patient with history of diabetes Mellitus (DM) and obesity. He presented to the hospital with complaint of (C/O) cough and congestion for 4 days. The patient also had complaints of some white and yellow sputum. The patient had some subjective shortness of breath (SOB).  Vital signs (V/S) at presentation Temperature 98.2 Fahrenheit, Respiratory Rate 18, Blood Pressure 127/73 mm Hg (millimeters of mercury), Heart Rate 113 Oxygen (O2) saturations 94 % (percent) on Room Air. The patient was in no acute distress (NAD). Lung exam revealed some rhonchi. The patient was awake and alert with a non- focal neuro exam. Labs revealed White blood cell count (WBC) 13.2, Hb (hemoglobin) 10.3, Electrolytes were within normal limits (WNL), blood urea nitrogen BUN 12, and Creatinine 0.7. Atrial blood gas: potential of hydrogen (pH)7.40, pressure of carbon dioxide (pCO2) 41, pressure of oxygen (pO2) 122, and bicarbonate (HCO3) 25. The patient was Influenza A positive.

Chest x-rays revealed (CXR) bilateral (B/L) patchy opacities. The patient was started on Rocephin and Azithromycin in emergency department (ED). Also, the patient was given intravenous (IV) Ketorolac.  Repeat V/S as per H&P (history and physical) T (temperature) 98.1 Fahrenheit, heart rate (HR) 100, respiration rate (RR) 22, blood pressure (BP) 153/95 mm Hg (millimeters of mercury), oxygen saturation (O2 sats) 98 % on room air (RA). The 
patient remained stable after admission and was switched to oral (PO) antibiotics (Abx) and subsequently discharged home.

This patient did not need inpatient hospitalization. The patient could have been placed in Observation status while diagnostic testing and treatment were initiated.
This patient was afebrile and hemodynamically (HD) stable. The patient was not hypoxic and was tolerating oral.  He was stable and remained stable during his hospital stay and subsequently discharged on PO medication.  This patient had mild pneumonia (PNA) with low PSI (pneumonia severity index). His CURB-65 score (confusion, urea, respiratory rate, blood pressure was Zero. He could have been in observation initially (observation could be for up to 48 hours). He could have been given some IV (intravenous) Abx initially if needed and then subsequently switched to PO meds and discharged home with close follow up as outpatient.

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

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

The patient presented to the emergency department with left-sided chest pain, nausea, diaphoresis, dyspnea and lightheadedness. Her medical history was remarkable for a mitral valve prolapse, anxiety, obesity, gastric bypass surgery, asthma and gastroesophageal reflux disease. Her electrocardiogram showed sinus rhythm with mild nonspecific T wave changes. Her serum troponin level was normal and remained normal when repeated. Myocardial perfusion imaging was performed and suggested anterior ischemia. The patient was transferred to another institution for a cardiac catheterization. She was hemodynamically stable upon transfer. The procedure was performed and showed normal coronary arteries. The patient was discharged. The medical necessity for an inpatient admission is at issue. 

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented to the hospital with atypical chest pain. Her electrocardiogram showed no acute ischemic changes and her serum troponin level was normal. While myocardial perfusion imaging was abnormal, based on her HEART [history, electrocardiogram (EKG), age, risk factors, troponin] score, she was at low risk for major adverse cardiac events. She remained hemodynamically stable and did not require intensive monitoring or continuous intravenous infusion and titration of cardioactive medication. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines, including the 2021 American Heart Association (AHA)/ American College of Cardiology (ACC) / American Society of Echocardiography (ASE)/ American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/ Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus

Treatment: Inpatient Admission	

The insurer denied coverage for inpatient admission

The denial is overturned

This is a patient with a history of asthma when he was a baby. He was noted to have fever, chest pain and a cough for one day. When his breathing became more difficult, and he felt chest tightness his mother brought him to the ER (emergency room) for an evaluation.  In the ER, he was noted to be in respiratory distress with increased work of breathing, retractions and wheezing. On physical exam, the child had diffuse wheezing upon auscultation of the chest and decreased air movement over the posterior chest. There was also evidence of respiratory distress with accessory respiratory muscle retractions. He was treated with three treatments with DuoNeb and Decadron and magnesium sulfate. Following treatment, he continued to have work of breathing and an oxygen saturation of 93% (percent). Blood testing showed an elevated white blood count of 20,000. A blood gas showed a metabolic acidosis with a pH (potential hydrogen)
7.28 and an elevated pCO2 (partial pressure of carbon dioxide) of 41. His serum bicarbonate was low at 17. Following treatment in the ER, the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus and a metabolic acidosis for continued treatment with albuterol every 3 hours.

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

This patient was treated appropriately in the ER for an acute episode of wheezing, metabolic acidosis and difficulty breathing. The child has a history of previous treatments for asthma. When he did not respond to treatment in the ER and he was noted to have an elevated pCO2 on a blood gas, low oxygen saturation and retractions, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol every three hours. He was not stable enough to be safely discharged.
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: Diabetes
Treatment: Ozempic Inj (injection) 2/1.5ml
The insurer denied Ozempic Inj 2/1.5ml.
The health plan's determination is upheld. 

This is a female with history of type 2 diabetes. The request is for Ozempic. The request was previously denied because the patient has not tried and failed formulary drugs Adlyxin and Trulicity.
Per the office notes, the patient is on Alogliptin. She has heart failure, type 2 diabetes, hypertension (HTN), CKD3 (chronic kidney disease stage 3), HL (hyperlipidemia), and neuropathy. Blood sugar was in the low 100s.

Ozempic is not medically necessary.
There are few head to head quality randomized controlled trials comparing efficacy of different GLP1 (Glucagon-like peptide-1) agonists; however, generally as a class they have similar efficacy in glycemic control, with monotherapy Victoza and Bydureon lowering Hemoglobin A1c by about 1.2%, with dulaglutide and injectable semaglutide lowering up to 1.6-1.7% at the 1.5 and 1 milligrams (mg) weekly doses respectively, oral semaglutide lowering hemoglobin A1c up to 1.1%, and Byetta and Lixisenatide lowering A1c slightly less than 1% (Feingold et al. 2019) .
Ozempic at the recently approved 2 mg weekly dose was able to lower hemoglobin A1c further by 2.1% (Frias et al. 2021). In the AWARD-11 trial in type 2 diabetes patients - higher doses of Trulicity up to 4.5mg weekly - was able to further lower A1c by 1.9% (Frias et al. 2021). The American Diabetes Association (ADA) 2021 standards of care and the American Association of Clinical Endocrinologists (AACE) 2020 diabetes type 2 management guidelines do not differentiate between different types of GLP1 agonists in terms of glycemic-lowering efficacy.
This patient has not tried and failed formulary GLP1 agonists or have medical contraindication to their use, thus the patient does not meet plan criteria or standard of care guidelines for medical necessity for Ozempic.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Sided Weakness and Numbness
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult female. She was admitted for right-sided weakness that had been occurring for ten days prior. The weakness was associated with pain. The patient's examination noted 2/5 weakness in the right upper and lower extremity. She was admitted to rule out a stroke versus MS (multiple sclerosis). CT (computed tomography) of the head showed microvascular disease, but no acute process. MRI (magnetic resonance imaging) of the brain was normal.
The health plan denied coverage of the inpatient hospitalization, as it was not deemed medically necessary. The denial is being appealed.

The inpatient admission was medically necessary.
According the MCG (Milliman Care Guidelines) Guidelines 25th edition, inpatient admission is warranted when there is new onset severe neurological symptoms, which include weakness. The patient was documented to have 2/5 strength, which is considered to be severe.

Therefore, given the above, the inpatient admission was medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin/Plaque Psoriasis.
Treatment: Pharmacy/Prescription Drugs/Taltz.
The health plan denied the requested exception for a prescription drug because it did not meet the plan's criteria. 
The health plan's determination is upheld.

The patient is a male with psoriasis. The patient has tried and failed topical agents such as 0.05% augmented Betamethasone Dipropionate cream, 0.1% Tacrolimus ointment, and 0.1% Triamcinolone Acetonide cream, Taclonex Scalp, and Olux-E. The patient has tried and failed Humira, Stelara, and Ilumya, but has had good improvement on Cosentyx, but it did not clear his psoriasis, according to the clinic records.

The health plan's determination of Taltz is upheld.

The patient has no documented treatment failure with, or true medical contraindication to, either Otezla, Cimzia, Skyrizi, or Tremfya. These alternative medications are as medically appropriate for the treatment of this patient's particular clinical condition, as is the requested Taltz. 
Modern dermatology literature [2-5] supports the use of the health plan-covered and preferred medications as similarly efficacious to the requested Taltz, particularly for a patient with this particular history of systemic psoriasis therapy previously utilized and recommend the use of these preferred agents as appropriate for this patient's clinical scenario. There is documentation of improvement while on Cosentyx, but the failure of this medication, which has a very similar level of efficacy and mechanism of action as the requested Taltz, to clear this patient's psoriasis suggests that this patient (who is starting the lower/monthly maintenance dosing of Taltz) has significant risk of treatment failure while on the maintenance dose of Taltz.
Taltz appears to being used out of convenience. Therefore, as per current medical standards of care, Taltz is neither likely to be more effective than formulary alternatives, or have less adverse effects than formulary alternatives.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin/Plaque Psoriasis
Treatment: Pharmacy/Prescription Drugs/Taltz
The health plan denied the requested exception for a prescription drug because it did not meet the plan's criteria. 
The health plan's determination is upheld.

The patient is a male with psoriasis. The patient has tried and failed topical agents such as 0.05% augmented Betamethasone Dipropionate cream, 0.1% Tacrolimus ointment, and 0.1% Triamcinolone Acetonide cream, Taclonex Scalp, and Olux-E. The patient has tried and failed Humira, Stelara, and Ilumya, but has had good improvement on Cosentyx, but it did not clear his psoriasis, according to the clinic records.

The health plan's determination of Taltz is upheld.

The patient has no documented treatment failure with, or true medical contraindication to, either Otezla, Cimzia, Skyrizi, or Tremfya. These alternative medications are as medically appropriate for the treatment of this patient's particular clinical condition, as is the requested Taltz. Therefore, as per the patient's health plan policy language, [1] the requested Taltz is not medically necessary.
Modern dermatology literature [2-5] supports the use of the health plan-covered and preferred medications as similarly efficacious to the requested Taltz, particularly for a patient with this particular history of systemic psoriasis therapy previously utilized and recommend the use of these preferred agents as appropriate for this patient's clinical scenario. There is documentation of improvement while on Cosentyx, but the failure of this medication, which has a very similar level of efficacy and mechanism of action as the requested Taltz, to clear this patient's psoriasis suggests that this patient (who is starting the lower/monthly maintenance dosing of Taltz) has significant risk of treatment failure while on the maintenance dose of Taltz.
Taltz appears to being used out of convenience instead of true medical necessity. Therefore, as per current medical standards of care, Taltz is neither likely to be more effective than formulary alternatives, or have less adverse effects than formulary alternatives, and is therefore not medically necessary for health plan coverage.
Appeal type: Medical necessity
Decision: Upheld

Cancer
Radiation Therapy

Diagnosis: breast cancer
Treatment: proton beam therapy
The insurer denied proton beam therapy. The health plan's determination is upheld.

This patient is a woman with a left breast invasive ductal carcinoma. She had neoadjuvant chemotherapy followed by lumpectomy and axillary nodal sampling. On pathologic review, she had a complete response. Radiation therapy is recommended to the left breast and nodal regions to decrease her risk of recurrence and the proton beam approach is requested to deliver 60 Gy in 30 treatments. 

Proton beam therapy is not medically necessary for this patient. There are lack of any significant clinical trials published in peer reviewed journals supporting the benefits or safety of proton beam radiation therapy as compared to standard of care photon beam radiation therapy for breast cancer patients. There are ongoing clinical trials accruing patients that need to mature and be evaluated and published to assist in determining the possible benefits and safety of proton beam radiation therapy for breast cancer patients. Until these studies are completed with appropriate follow up time, proton beam therapy is not indicated for this patient and her clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vitiligo
Treatment: Rinvoq 15 mg (milligrams)
The insurer denied Rinvoq 15 mg.
The denial is upheld.

The patient is a male with vitiligo. His hands, face, groin, and right foot are affected. He has tried and failed Excimer laser and narrowband ultraviolet B therapy. He has failed tacrolimus and Eucrisa. He has been recommended for Rinvoq 15 milligrams (mg).

At issue is the medical necessity of Rinvoq 15 mg.

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

The requested health service/treatment of Rinvoq 15 mg is not medically necessary for this patient.

The patient has none of the diagnoses, such as rheumatoid arthritis, psoriatic arthritis, or atopic dermatitis for which Rinvoq is considered medically necessary. Additionally, according to the dermatologic literature, vitiligo is a pigmentary skin condition. (1-3) Bolognia, et al writes in Disorders of Skin Pigmentation that "The most common presentation of vitiligo is totally amelanotic (i.e. ["that is"], milk- or chalk-white) macules or patches surrounded by normal skin... Vitiligo is usually asymptomatic." (1) Its treatment is not medically necessary because it is considered a cosmetic skin condition. Therefore, the requested health service/treatment of Rinvoq 15 mg is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Xeljanz
The health plan denied the requested medication, Xeljanz as not medically necessary.
The health plan's determination is overturned.

The patient is a female with Ulcerative Colitis. She has failed Infliximab and Stelara. Flexible sigmoidoscopy showed severe Ulcerative Colitis (Mayo 3); biopsies showed mild chronic active colitis. The coverage is requested for Xeljanz 10 mg (milligrams) twice daily for the treatment of Ulcerative Colitis. The request was not approved, as Humira has not been attempted.

At issue is the medical necessity for the requested medication, Xeljanz.

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

Yes, the request for Xeljanz is supported as medically necessary. Current medical literature supports the use of Xeljanz for Ulcerative Colitis in this case after failure of multiple other therapies. Notably, the patient failed Infliximab. Xeljanz has a different mechanism of action than aminosalicylates, immunomodulators, anti-tumor necrosis factor therapies, Entyvio, and Stelara (Sandborn, et al 2014; Bressler, et al; Sandborn, et al 2012; Rubin, et al). Xeljanz is Food and Drug Administration (FDA) approved for the treatment of Ulcerative Colitis, and has proven effective in a double-blind, placebo-controlled trial of patients with moderate-severe Ulcerative Colitis, with up to 78% (percent) clinical response and 41% clinical remission at 8 weeks, both significantly higher than placebo. Endoscopic remission rate was also significantly higher than placebo. A second randomized study showed significant improvement in health-related quality of life and patient-reported outcomes with Xeljanz in moderate-severe Ulcerative Colitis (Sandborn, et al 2014; Bressler, et al; Boland, et al). American Gastroenterological Association (AGA) guidelines for the treatment of Ulcerative Colitis state that "In adult outpatients with moderate to severe Ulcerative Colitis who have previously been exposed to Infliximab... the AGA suggests using Ustekinumab or Tofacitinib rather than Vedolizumab or Adalimumab for induction of remission" (Feuerstein, et al). As the patient has already failed Infliximab and Stelara for the treatment of Ulcerative Colitis, and has ongoing active disease on biopsies, the use of Xeljanz is supported as medically necessary for the treatment of this patient's Ulcerative Colitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Cosentyx Sensoready (300 milligrams [mg]) 150 mg/ milliliter (ml) subcutaneous (SC)
The insurer denied coverage for Cosentyx Sensoready (300 mg) 150 mg/ ml SC
The denial is upheld

This is a patient with a diagnosis of psoriasis affecting the scalp and arms, 20-30% total body surface area (TBSA). The patient has failed topical steroids, calcipotriene topical, as well as intra-lesional and oral steroids. The requested medication is Cosentyx.  

Based on the submitted documentation and the standard of care, Cosentyx is not medically necessary. The patient has failed topical therapy and has no true contraindications to numerous appropriate available treatment modalities which would make the use of Cosentyx medically necessary. There are no definitive, comparative, controlled head-to-head studies showing that Cosentyx has a superior efficacy or safety profile to reasonable alternatives such as Humira or phototherapy. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, alternative effective treatments for the management of psoriasis are available and appropriate for this patient.  

There is no documentation to suggest that Cosentyx would be more effective than available formulary alternatives or that the patient has an absolute contraindication to a preferred medication which would specifically necessitate Cosentyx.  

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

The insurer's denial of coverage for Cosentyx Sensoready (300 milligrams [mg]) 150 mg/ milliliter (ml) subcutaneous (SC) is upheld. Medical Necessity is not substantiated.