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

Diagnosis: Mild Range Blood Pressure (elevated), Leg Swelling (during pregnancy)
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female with a history of second pregnancy, no deliveries, one miscarriage or abortion (G2P0010). She was sent to the hospital from clinic with mildly elevated blood pressure to rule out preeclampsia. Upon first evaluation, the patient had normal blood pressures and labs, suggesting that she had chronic or gestational hypertension, but not preeclampsia. The former was favored given that she had a diastolic blood pressure of 93 at five weeks gestation. It was noted that she was significantly anemic, and so she was given a blood transfusion. Toward the end of her transfusion, she had one blood pressure in the severe range, and so she was admitted for further observation and monitoring. Throughout the period of observation, no further severe range blood pressures were observed, and the only further workup and treatment was 24-hour urine collection, a hematology consultation, and administration of intravenous iron. The facility contends that the hospitalization was medically necessary because anemia has serious consequences for pregnancy and that, based on the treating practitioners, admission was medically necessary and reasonable. The health plan contends that the admission did not meet criteria because only mild range blood pressure readings were observed, and InterQual 2022 criteria were not met for Acute Hypertensive Disorders of Pregnancy including severe range blood pressures (higher than 160/110) and that the care could have been given during an observation admission for up to 48 hours to determine if admission was necessary.

The inpatient admission was not medically necessary.

The patient never met criteria for preeclampsia with severe features. Therefore, hospitalization was not required. The blood pressure observation, hematology consultation and workup, 24-hour urine collection, and iron infusion could have been accomplished without requiring hospital admission. Therefore, the admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: coughing and nasal congestion

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 


This is an infant male who had coughing with nasal congestion for 7 days. The sibling had also been sick with a cold. The mother noted that the cough was getting worse, and the child had post-tussive vomiting multiple times, so she was concerned and brought the child to the emergency room (ER) for evaluation.

In the emergency room (ER) the child was noted to have respiratory distress with coughing and an elevated respiratory rate of 47 breaths per minute. The oxygen saturation was 99% (percent) on room air. On physical examination the child was noted to have noisy breathing with abdominal retractions. Testing for respiratory syncytial virus (RSV), influenza and COVID-19 viruses were negative. An intravenous (IV) was placed for fluid administration and the child was treated with saline via a nebulizer on several occasions. A venous blood gas showed a pH of 7.36 and a pCO2 level of 45.3. When the child continued to have an elevated respiratory rate, the decision was made to admit the child to the hospital for ongoing treatment with saline nebulization treatments every 3 hours and IV fluids with a diagnosis of bronchiolitis.

This patient was treated appropriately in the emergency room (ER) for coughing, and increased work of breathing. The increased work of breathing persisted despite treatment with saline administered via a nebulizer. There was no hypoxemia during the time in the emergency room (ER) and the record indicated that the baby was feeding and voiding well in the emergency room (ER). There was no ongoing vomiting. The child was not administered a bolus of intravenous (IV) fluids and there was no indication for treatment with oxygen. The medical record does not document whether treatment was administered into the nose with saline and whether suctioning of the nose was attempted.

The decision to admit the child with a diagnosis of bronchiolitis for ongoing treatment with saline nebulizer treatments every 3 hours was not medically indicated and the child could have been safely discharged to home with nasal saline treatments and a plan for a follow up visit with the pediatrician in 24-48 hours.

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: Overturned

Diagnosis: Hyperglycemia, Chest Pain
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with Type 1 diabetes mellitus (DM) 1 who presented to the emergency department (ED) with hyperglycemia and chest pain. The patient reported no insulin at home and no access to follow up care. The review of symptoms (ROS) was negative for abdominal pain, gastrointestinal (GI) illness, or visual changes.
The emergency department (ED) vital signs were temperature (T) 98 degrees Fahrenheit (F), heart rate (HR) 95, respiratory rate (RR) 22, blood pressure (BP) 120/86, and oxygen saturation (O2 sat) 100 percent (%).
The initial capillary blood glucose (BG) was 533. Sodium (Na) was 129 and glucose 582. 10 units of Humalog insulin was given in the ED with response. She was admitted for further care and management. At issue is whether inpatient hospitalization was medically necessary.

The requested inpatient hospital admission was medically necessary., This patient required additional support and assistance to ensure safe discharge to home. This is a patient with known DM who presented with hyperglycemia and chest pain. An emergency department (ED) work-up showed hyperglycemia and was complicated by the patient's social situation. Given the likelihood of failure of outpatient treatment (no insulin at home), inpatient level of care was necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility
Treatment: Personal Care Aide (PCA) Services: 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week
The insurer denied Personal Care Aide (PCA) Services: 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week
The health plan's determination is overturned.

The requested Personal Care Aide (PCA) Services: 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week are medically necessary for this patient.

The patient has had a decline in functional status and requires assistance with all personal care tasks, including transfers, locomotion, and toileting. She also has incontinence and requires assistance with managing incontinence care. Her care needs can be reasonably expected to be unscheduled throughout the day. Her recent falls are evidence of unmet personal care needs. Therefore, the requested increase to 12 hours per day is medically necessary and reasonable for the patient. It will allow her to have adequate coverage during the daytime hours to meet her personal care needs. Failure to provide for her personal care needs could result in further injury, skin breakdown, and/or infection.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II Diabetes

Treatment: Mounjaro 15/0.5 Pen

The insurer denied coverage for Mounjaro 15/0.5 Pen

The denial is upheld 

This is an adult diagnosed with Type 2 diabetes mellitus. This request is for Mounjaro. As per the appeal letter, the patient experienced severe diarrhea with Trulicity, Bydureon and Ozempic. The patient is reported to have tolerated Mounjaro well for the past year and to finally have control of their diabetes. 

The formulary drugs are not expected to cause adverse effects. The patient is reported to have failed Trulicity. The remaining formulary alternative, Victoza, is not likely to cause the patient an adverse reaction.

The formulary drug Victoza is not noted to have been tried.

The formulary drug is not expected to be ineffective. The patient is reported to have failed Trulicity. There is no documentation of the trial and failure of Victoza.

The non formulary drug is not expected to be more effective than the formulary alternatives. The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon-like peptide one (GLP-1) and gastric inhibitory polypeptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss (1-3).

There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 receptor agonists as a first-line agent. There is no preference for the requested medication over GLP-1 receptor agonists (4). 

The patient can try Victoza. The requested medication would not be more effective than the formulary alternative.

The carrier's denial of a request for a Formulary Exception for Mounjaro 15/0.5 Pen to treat type 2 diabetes is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Diabetes Mellitus Type 2
Treatment:  Mounjaro
The insurer denied Mounjaro.
The determination is upheld.

This is a patient being prescribed Mounjaro for the diagnosis of type 2 diabetes mellitus without complications. Coverage for this medication was denied by the health plan.

The patient is currently being treated with the requested medication. The patient's hemoglobin A1c was 5.9 percent (%) and 5.3%. The diagnosis associated with the lab order was dyslipidemia. The request form from the provider states that the patient has a diagnosis of diabetes type 2 and obesity and that "she has tried and benefited with Mounjaro and would like to continue therapy." There were no office visit notes or other clinical information provided for review.

The health plan denied coverage for the requested medication because it did not meet their prescribing criteria for a non-formulary medication. The plan formulary was provided and reviewed. For antidiabetic agents in the incretin mimetic category, Trulicity is listed as the preferred brand and Victoza is the non-preferred brand. The plan requires a trial with documented intolerance or ineffectiveness of the formulary medications before considering treatment with a non-formulary agent. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

Based on the information provided, there is insufficient evidence that the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

There is no documentation of a trial of any other medications in the glucagon like peptide 1 (GLP-1) agonist receptor class. There are no office visit notes provided for review. There are no head-to-head clinical trials which have compared the formulary medication and the requested non-formulary medication; both have demonstrated efficacy in achieving glycemic control in patients with type 2 diabetes.

Additionally, there is no clear documentation that the patient has a diagnosis of type 2 diabetes mellitus given the hemoglobin A1c values that were provided, which improved from the prediabetic range with treatment. The diagnosis associated with the lab test was dyslipidemia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Rinvoq
The health plan denied: Rinvoq
The determination is: Overturned

The patient is a male with fistulizing Crohn's disease status post ileocolic resection with subtotal colectomy, seton placement, and Hartmann's pouch and ileostomy revision. He has had high ostomy output and bleeding; an ileoscopy showed inflammation, erosions, and ulcers in a long ileal segment and colitis. He has failed 6-mercaptopurine, Remicade, Humira, Entyvio, Stelara, and Xeljanz. His provider has ordered Rinvoq (to be used with Skyrizi) for the treatment of Crohn's disease.
At issue is the medical necessity of Rinvoq.
The health plan's determination of medical necessity is overturned in whole.
The requested health treatment of Rinvoq is medically necessary for this patient. Current medical literature supports the request for Rinvoq (to be used with Skyrizi) for the treatment of Crohn's disease. The patient's disease is severe and anatomically extensive, with history of complications requiring surgical resection, and he has failed all recommended primary therapeutic medication classes recommended by guidelines for the treatment of Crohn's disease.[1] Several studies have assessed the use of multiple therapies concurrently, including biologic therapy (such as Skyrizi, or Stelara, which as a similar mechanism of action) with small molecule therapy (such as Rinvoq).[2-9] In aggregate, no significant safety issues were attributed to combination therapy, and the therapy was broadly successful in improving response in patients who had failed biologic therapy.[2-9] Rinvoq is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and has demonstrated safety and efficacy.[10-13] In this case, the patient has both ongoing disease symptoms and objective evidence of active disease (including ileal ulceration on colonoscopy). He has failed Stelara, which has a similar mechanism of action to Skyrizi. Inadequate therapy can result in uncontrolled disease, flare, hospitalization, need for surgery, fistula, and stricture. Alternative options are limited given failure of 6-mercaptopurine, Remicade, Humira, Entyvio, Stelara, and Xeljanz. For these reasons, the request for Rinvoq (to be used with the standard dose of Skyrizi) is supported as medically necessary for the treatment of this patient's Crohn's disease.
Appeal type: Formulary Exception
Decision: Overturned

Endocrine/Metabolic/Nutritional
Pharmacy/Prescription Drugs

Diagnosis: Morbid obesity due to excess calories.
Treatment: Wegovy (semaglutide) 

The health plan denied:Wegovy (semaglutide)
The determination is: Overturned 

The patient is a male being prescribed Wegovy for the treatment of morbid obesity due to excess calories.
The patient was started on Ozempic to promote weight loss. This resulted in a loss of greater than 50 pounds from his starting weight. The patient still has a body mass index (BMI) of 42, obstructive sleep apnea, and hyperlipidemia.
At issue is the medical necessity of Wegovy (semaglutide).

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

The non formulary drug that is being denied is clinically appropriate for the patient's treatment of obesity. Wegovy has been Food and Drug Administration (FDA) approved for weight loss in patients with obesity. It has demonstrated efficacy in clinical trials in promoting weight loss in individuals with obesity and obesity related comorbidities. It is an appropriate pharmacologic adjunct to promote weight loss when used in conjunction with lifestyle changes such as a healthy diet and exercise plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion. 
Treatment: Braces, monthly visits, and retainer. 
The insurer denied coverage for braces, monthly visits, and retainer. 
The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as 
well as insurer correspondence, it appears that this patient presented for evaluation for 
orthodontic care. The orthodontist recommended comprehensive orthodontics due to impacted permanent anterior teeth among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors (#22, #27) where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 13 points on review by internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds this criterion is not met and the HLD index attains 13 points which is below the threshold of 26 or more points which is necessary for approval of orthodontic care. 

Regarding the validity of the Handicapping Labio-Lingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Braces, monthly visits and retainer are not considered medically necessary for this patient. 

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 braces, monthly visits, and retainer is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity
Treatment: Formulary exception for Mounjaro
The insurer denied: Formulary exception for Mounjaro
The denial is upheld.

The patient is an adult female with diagnosis of morbid obesity due to excess calories and obstructive sleep apnea. She has body mass index of 43.1. According to the patient, she has been trying to lose weight for years and has been unsuccessful. The provider prescribed Mounjaro.

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

The request is for an off-label indication. Mounjaro is indicated only for type 2 diabetes. Although the medication has been subjectively effective for the patient, there is no objective record of weight pre therapy and post therapy provided. Furthermore, the other formulary drugs would reasonably be expected to be as effective and would be expected to have similar adverse effects.
According to the patient's letter, the patient provides a letter and records to show that she was prescribed Ozempic before, but the health plan would not cover it because she does not have T2DM (type 2 diabetes mellitus). The plan formulary alternatives (Ozempic, Trulicity, etc.) are also for type 2 diabetes. The standard of care for obesity includes drugs such as Wegovy or 
Saxenda. In patients with type 2 diabetes, tirzepatide was non-inferior to Semaglutide (Frias 2021). According to Al-Horani, R. A., & Chedid, M. (2022), "Tirzepatide (Mounjaro) is a derivative of the human glucose-dependent insulinotropic polypeptide (GIP) hormone with a position-20 is being modified with 1,20-eicosanedioic acid via a chemical linker. It is acting as glucagon-like peptide-1 (GLP-1) receptor and GIP [glucose-dependent insulinotropic polypeptide] receptor agonist. It has recently been approved by FDA [United States Food and Drug Administration] as an adjunct therapy to exercise and diet to improve glycemic control in patients with type II diabetes mellitus (T2DM). It represents a new transforming paradigm in the management of 
T2DM [type 2 diabetes mellitus]. This mini review will shed light on its different pharmacokinetic and pharmacodynamic aspects."
The most common adverse events were gastrointestinal and were primarily mild to moderate in severity in the tirzepatide and semaglutide groups (nausea, 17 to 22 percent (%) and 18%; diarrhea, 13 to 16% and 12%; and vomiting, 6 to 10% and 8%, respectively). Of the patients who received tirzepatide, hypoglycemia (blood glucose level, <54 milligrams per deciliter) was reported in 0.6% (5-milligrams group), 0.2% (10-milligrams group), and 1.7% (15-milligrams group); hypoglycemia was reported in 0.4% of those who received semaglutide. Serious adverse events were reported in 5 to 7% of the patients who received tirzepatide and in 3% of those who received semaglutide. (Frias 2021).