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

Diagnosis: Rectal bleeding
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned.

The patient had a history of hemorrhoids and presented with rectal bleeding. He had a hemorrhoidectomy 10 days earlier. He was afebrile and the vital signs were stable. The abdominal exam was benign. A rectal exam revealed dark red blood. The hemoglobin was 8.8 and then went down to 7.5. He underwent a hemorrhoid procedure with oversewing of the suture line. He had some additional rectal bleeding but after the surgery the hemoglobin remained stable.

Clinical indications for admission for Lower Gastrointestinal Bleeding [MCG (Milliman Care Guidelines) M-182)] include having ongoing active bleeding as manifested by a decreasing hemoglobin. This patient was noted to be passing large amounts of rectal bleeding and had a decreasing hemoglobin. This continued until a surgical procedure was done and then the bleeding lessened.

The patient had a complication from a previous hemorrhoidectomy. Since he was having ongoing active bleeding, he met MCG criteria for admission for Lower Gastrointestinal Bleeding. He required surgery to get the bleeding under control and an inpatient admission was medically necessary.

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

Diagnosis:  Narcolepsy with Cataplexy.
Treatment:  Xywav.

The health plan denied Xywav. The health plan's determination is overturned.

This is the case of a male patient who suffers from Narcolepsy with cataplexy. A Multiple Sleep Latency Test (MSLT) showed reduced mean sleep onset latency down to 4.28 minutes and 2 sleep onset rapid eye movement (REM).

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

I overturn, in whole, the health plan's determination of medical necessity.

Yes. The requested health service/treatment of Xywav is medically necessary for this patient.

Narcolepsy is a serious, life-long, potentially disabling disorder. Symptoms are usually first noticed during the early teenage years. There is no known cure for narcolepsy and no completely adequate treatment is available.

Narcolepsy is a chronic neurological disorder caused by the brain's inability to regulate sleep-wake cycles normally. At various times throughout the day, people with narcolepsy experiences fleeting urges to sleep. If the urge becomes overwhelming, individuals will fall asleep for periods lasting from a few seconds to several minutes. In addition to excessive daytime sleepiness (EDS), three other major symptoms frequently characterize narcolepsy: cataplexy or the sudden loss of voluntary muscle tone; vivid hallucinations during sleep onset or upon awakening; and brief episodes of total paralysis at the beginning or end of sleep.

The MSLT is performed to evaluate the presence of pathological sleepiness and to confirm the diagnosis of Narcolepsy. These individuals are studied during 5 daytime naps taken 2 hours apart. The mean MSLT score is usually less than 8 minutes. Narcolepsy is excluded by the absence of sleep-onset REM (SOREM) periods on the 5-nap MSLT.

The review of the patient record revealed that the patient was referred to the sleep lab for evaluation of daytime sleepiness. The patient had MSLT that showed reduced mean sleep onset latency down to 4.28 minutes and 2 sleep onset REM confirming the diagnosis of Narcolepsy. The patient has also symptoms of cataplexy. The Xywav was approved for the treatment of Narcolepsy and cataplexy as in this patient case. The number of cataplexy episodes has no value in supporting the medical necessity of Xywav.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Side Facial Numbness
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female with prior history of stroke, TIA (transient ischemic attack), HTN (hypertension) and DM (diabetes mellitus). She presented with left-sided facial numbness.

It was noted that the patient had decreased left nasolabial flattening and decreased sensation on the left. EKG (electrocardiogram) showed possible atrial fibrillation. The patient was admitted for stroke workup as well as telemetry monitoring, given the possible atrial fibrillation.

The hospital admission was denied coverage by the health plan, as plan did not think that the patient met criteria for admission. The denial is being appealed.

Yes, the Inpatient Hospital Admission was medically necessary.
The patient had strong risk factors for stroke, including prior stroke. She was presenting with focal neurological deficits. According to the MCG (Milliman Care Guidelines) inpatient clinical guidelines for stroke, it is recommended for inpatient admission to be done in the setting of suspected stroke and given the need for continuous telemetry monitoring. Although deficits were mild, she was at risk for further worsening of stroke based on the information obtained at the time of admission.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Sending the patient home without doing a stroke evaluation, which cannot be done in the outpatient setting, could have led to catastrophic results, including a larger stroke with the inability to do timely interventional managements.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lower extremity hematoma.
Treatment:  Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is upheld.

The patient has a history of deep vein thrombosis (DVT), hemochromatosis, hypertension, heart failure and atrial fibrillation. He presented to the emergency department with complaints of increasing swelling and ecchymosis in the left gluteal area following a fall two weeks prior. The patient had a large left lower extremity hematoma. He was provided pain medication and was seen by hematology. His anticoagulation medications were held. The patient was discharged.

The inpatient admission is not considered medically necessary for this patient. Hematology and orthopedic consults recommended admission for pain control, to monitor bleeding, and to address his anticoagulation. Monitoring is an indication of an observation level and does not warrant an acute inpatient hospital admission. Soft-tissue hematomas are a common clinical entity often associated with trauma, surgery, and bleeding disorders. In the majority of cases, soft-tissue hematomas acutely appear and spontaneously resolve, but sometimes they present as swellings that slowly expand and progressively increase with time. In any case, the observation level for monitoring was the appropriate level. 

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

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

Diagnosis: Atypical Chest Pain

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This is a patient who was referred to the hospital after complaining of chest pain. Past medical history was significant for schizoaffective disorder, diabetes, and hypercholesterolemia. Chest pain developed on the day of presentation while doing push up exercises. He received a fourth COVID-19 (2019 Novel Coronavirus) booster shot one month earlier. Vital signs upon presentation were pulse 99 bpm (beats per minute) and blood pressure 115/76 mmHg (millimeters of mercury). No abnormal findings were noted on physical examination. A 12-lead electrocardiogram (EKG) revealed normal sinus rhythm with diffuse ST (interval on EKG) elevation in the anterior and inferior leads consistent with early repolarization. Serum blood testing revealed no elevation in troponin (< [less than] 0.012) and hyperglycemia. The patient was admitted to the hospital for work up. Chest pain resolved.

This patient presented with atypical chest pain and a past medical history of diabetes. His pretest probability of coronary artery disease was low (Reference 1). Utilizing the HEART (history, EKG, age, risk factors, and troponin) score, he was considered low risk (Reference 2). Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati, et al. (Reference 3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. EKG demonstrated ST segment elevation consistent with early repolarization. Moreover, serum blood test results were not consistent with an inflammatory state such as pericarditis (negative troponin and normal ESR [erythrocyte sedimentation rate] levels). In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care.

Based on the above, the insurer's denial must be upheld.

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for inpatient hospital admission services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The health plan denied coverage of the Inpatient admission.
The denial is upheld.

This patient is a previously healthy female who presented to the emergency department (ED) with the complaint of abdominal pain of two-days duration.

The patient's examination revealed right lower abdominal tenderness. Vital signs were normal at the time of presentation.  The white blood cell (WBC) count was normal at 8.69 thousand (K).  Surgical consultation was obtained. Computed tomography scan was completed showing findings of acute appendicitis.  The patient was started on intravenous antibiotics.  The patient underwent laparoscopy with appendectomy for the condition of appendicitis.  Surgical findings included acute nonperforated appendicitis.

Following surgery the patient was treated with intravenous fluid and analgesia.  Vital signs were consistently normal in the perioperative period.  She was transitioned to oral medications and diet.  She was discharged from the hospital following a period of recovery.  

Acute inpatient hospitalization was not medically necessary for this patient.  The medical records support that this patient could have been reasonably and safely monitored with an observational status.

This patient presented with abdominal pain.  The evaluation with examination, lab data, and computed tomography scan supported the diagnosis of acute appendicitis.  The patient underwent uncomplicated appendectomy.  She was admitted to an inpatient level of care and was discharged from the hospital on the first post-surgical day.

There is no clinical documentation to support the need for inpatient admission on these dates.  The patient remained hemodynamically stable throughout the perioperative period, there was no fever, or documented complication of surgery.  This patient's clinical needs could have been satisfied with an observational level of care.  This lower level of care would have provided for pre-surgical assessment, surgical treatment and post-surgical recovery including overnight observation (if required).
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hyperlipidemia.
Treatment: Formulary exception for Livalo 4MG (milligrams) TAB (tablet), pre-service.

The insurer denied the  Formulary exception for Livalo 4MG TAB, pre-service.  The denial is overturned.

The patient is a male with a past medical history significant for hypertension and hyperlipidemia. As per the letter submitted by the treating provider, the patient had prior intolerance to two statin drugs, including Lipitor (atorvastatin) and Crestor (rosuvastatin), as well as Repatha, and has been stable and controlled on current dose of Livalo (pitavastatin). The continuation of Livalo is requested.

Yes, the health plan should cover the Formulary exception for Livalo.

According to the submitted information, the patient had prior adverse effects with two alternative statin drugs and one non-statin lipid lowering drug and had good response to the requested medication. Continuation of the therapy with the requested medication, Livalo (pitavastatin), would be medically appropriate in this case.

Therefore, given the above, the health plan should cover the Formulary exception for Livalo.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mosaic Turner Syndrome
Treatment: Norditropin Flexpro 15MG (mg/milligrams)/1.5
The insurer denied coverage for Norditropin Flexpro 15MG/1.5.
The denial is upheld.

This is a female diagnosed with Turner syndrome. This request is for Norditropin. As reported, she has mosaic Turner Syndrome with 90% (percent) 45X [sex chromosomes) cells and 10% 46X + isodicentric Y (sex chromosomes) cells and clitoromegaly. She was growing at 5.48 cm/yr (centimeters per year) and was noted to have 2 periods and breast development since starting estradiol. Her current height velocity is reported to be 6.4 cm/yr. Her pubic hair was at tanner 1 and her pubic hair growth/distribution is at Tanner stage 3 with 9 cm (centimeters) bilateral breast diameter, 2.5 cm bilateral areola diameter, and moderate axillary hair. 

The Lawson Wilkins Pediatric Endocrine society is the relevant society and the literature, and their recommendations are reviewed here. According to the FDA (Food and Drug Administration) indication [1, 2] and the Lawson Wilkins Pediatric endocrine society [3, 4], recombinant human growth hormone therapy should be initiated as soon as the height of a girl with Turner syndrome falls below the fifth percentile for age [5], which usually occurs between two and five years of age [4]. Early initiation of growth hormone is necessary [6] to achieve normal adult height (159-162cm) [7]. None of these long-term studies showing efficacy of GH (Growth Hormone) in improvement of final height include girls with Y chromosome material or mosaic turner syndrome.

There are no studies showing safety or efficacy of growth hormone in patients such as this patient who has mosaic Turner syndrome and normal stature. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.

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

The insurer's denial of coverage for the Norditropin FlexPro 15mg/1.5 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis.
Treatment: Stelara 90MG/ML SC SOSY. 
The insurer denied Stelara 90MG/ML SC SOSY.
The denial is overturned. 

This male patient has severe ulcerative colitis. He has tried and failed conventional therapy with 5-aminosalicylic acid (ASA) agents and steroids. He has also failed an anti-tumor necrosis factor (TNF) alpha agent Humira (adalimumab). He was started on Stelara and his ulcerative colitis (UC) is in remission. Therefore, the attending gastroenterologist would like to continue Stelara to treat his severe ulcerative colitis.
At issue is the medical necessity of Stelara 90 milligrams (MG)/milliliters (ML) subcutaneous (SC) solution prefilled syringe (SOSY).

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

The requested health service/treatment of Stelara 90MG/ML SC SOSY is medically necessary for this patient.
This patient is already on Stelara for over a year and his UC is remission. Current guidelines do not recommend switching biological agents in patients in remission. Ustekinumab (Stelara), has emerged as a promising treatment for both psoriasis, Crohn's disease and UC. Ustekinumab offers a treatment option to these patients who have never responded to infliximab, primary non-responders, as well as patients who have attenuated anti-TNF response or become intolerant to anti-TNF therapy. One third of anti-TNF naive patients are primary non responders. Approximately one third of initial anti-TNF responders lose response or become intolerant over time, secondary non-responders, requiring dose escalation or switching to another anti-TNF agent. Typically, response rates among anti-TNF naive patients are higher than response rates among secondary non-responders who switch within the anti-TNF class. Since this patient has failed an anti-TNF medication for his UC, it is appropriate to use a biological agent with a different mechanism of action. Therefore, it is appropriate to use Stelara to treat this patient's severe UC. Moreover, since this patient has already been on Stelara for a year, the medication must be continued.
It is medically necessary to use Stelara to treat this patient's disease to prevent immunogenicity and hence loss of response to the medication. The only reasons to stop any biologic agent used for treatment of ulcerative colitis are; 1) an adverse reaction or 2) a contraindication or 3) loss of response to the medication.
Therefore, the requested health service/treatment of Stelara 90MG/ML SC SOSY is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol withdrawal
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with a past medical history significant for alcoholism, anxiety, depression, hypertension, hyperlipidemia, eczema, and gastritis who presented to the emergency department with symptoms of withdrawal. He reported alcohol abuse for at least 4 months after a period of sobriety. He reported drinking 24 cans of 12-ounce beer daily. When seen by the admitting physician he complained of being anxious, diaphoretic, having paresthesias in the face and extremities, also vomiting. Clinical Institute Withdrawal Assessment (CIWA) score at the time of admission was 10. The patient was in mild distress. He had some skin lesions. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The patient was alert, oriented times 3, and anxious. During the hospital stay, the patient's clinical condition gradually improved, he tolerated his diet and was discharged from the hospital.

The health plan's determination is upheld.

The inpatient stay was not medically necessary. The patient could have been managed at a lower level of care status. The review of the medical records clearly demonstrated that the patient initially had signs of alcohol withdrawal CIWA 10, however, his symptoms subsided relatively quickly. Specifically, there was no mention that the patient had sustained tachycardia, tremor, or increased perspiration beyond the observation period. Even though the patient initially complained of nausea and vomiting, these symptoms resolved relatively quickly, and he tolerated his diet. There was no evidence that the patient had sustained tremors.
Overall, the symptoms of alcohol withdrawal, which were present at the time of admission, improved relatively quickly. Nausea and vomiting were unlikely related to acute gastroenteritis but were part of alcohol withdrawal syndrome.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis
Treatment: inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This is a male infant who was born premature at 34 weeks and was admitted to the NICU (Neonatal Intensive Care Unit) and required surgery for duodenal atresia. He had been sick for 2 days with a cough, wheezing and difficulty breathing. He had also been vomiting and had no bowel movements for three days. Because of his difficulty breathing his mother brought the child to the emergency room (ER) for evaluation. 

In the ER, he was noted to have acute respiratory distress with tachypnea with increased work of breathing. His heart and respiratory rates were elevated, and the oxygen saturation was 89%. On examination, he was noted to have dry mucous membranes, respiratory retractions and bilateral wheezing. He was treated with oxygen, intravenous fluids and albuterol twice. His white blood count was elevated at 16,200 and a venous pH (potential of hydrogen) was significant for a pCO2 (partial pressure of carbon dioxide) level of 43. A chest x-ray was clear, and an abdominal film showed fecal material in the recto sigmoid region. When his respiratory distress and low oxygen persisted despite treatment in the ER, the decision was made to admit him with a diagnosis of bronchiolitis and a plan to continue IV (intravenous) fluids, solumedrol and albuterol every 3 hours.

The insurer has denied the medical admission as being not medically necessary.
The patient was treated appropriately in the ER for respiratory distress wheezing and hypoxemia. When his low oxygen saturation and respiratory distress persisted following treatment, it was medically necessary for him to be admitted for continued treatment with albuterol and oxygen supplementation. The decision to admit for continued oxygen supplementation, intravenous (IV) fluids and albuterol every 3 hours was consistent with the standard of care for a young infant with bronchiolitis.

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.