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

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a recent diagnosis of acute diverticulitis status/post (s/p) treatment who was admitted with complaints of recurrent severe left-sided abdominal pain associated with diarrhea. The patient's vital signs were notable for a temperature of 101.1 degrees Fahrenheit and heart rate of 115. The patient's physical exam was notable for abdominal tenderness to palpation (TTP) in the right upper quadrant (RUQ) and left upper quadrant (LUQ). The patient's laboratory values were significant for leukocytosis with left shift and elevated lactic acid. In addition, the patient had a stool sample that was positive for Clostridium difficile. A computed tomography (CT) of the abdomen and pelvis showed non-specific colitis without evidence of diverticulitis. The patient was diagnosed with Clostridium difficile colitis and treated with intravenous fluids (IVF) and intravenous (IV) antibiotics. At issue is the medical necessity of an inpatient stay.

The hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) severe left-sided abdominal pain associated with diarrhea. With appropriate work-up, there was evidence of sepsis secondary to clostridium difficile infection. Clostridium difficile colitis requires close observation for hypotension, hematochezia, signs of sepsis or toxicity, intractable vomiting, severe electrolyte abnormalities, and altered mental status. In addition, this patient's clinical course was complicated by concomitant sepsis. Moreover, the patient met the Infectious Diseases Society of America (IDSA) definition of severe clostridium difficile infection (CDI) due to the presence of significant white blood cell count (WBC) elevation. This patient required close clinical monitoring and aggressive management that could not be safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Facet Injections
The insurer denied the facet injections.
The denial is upheld.

This is a male diagnosed with low back pain. A letter of appeal from the treating provider states that the patient was seen with complaints of intractable axial low back pain rated at 8/10, present for years and not controlled with over three months of physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and over-the-counter painkillers. Physical exam findings included moderate to severe pain with palpation at lumbar (L) 3-L4, L4-L5 and L5-sacral (S) 1 facet joints, positive facet loading and pain on extremes of motion. The provider states they ordered and performed lumbar medial branch blocks on the left side and prior to the injection performed x-ray showing positive multilevel degenerative disc disease and facet arthropathy. The provider states there were no signs of fracture, tumor, infection or significant extraspinal lesion. They placed a request for authorization for lumbar medial branch blocks on the same day. Initially this was denied stating that there must be imaging studies that do not suggest any other obvious cause of pain and there were no imaging reports. The request was denied. The provider submitted an appeal outlining the plan part of medical reports where the impression of x-ray of lumbar specifically stated multilevel degenerative disc disease and facet arthropathy. Final adverse determination was issued despite the fact that the treatment plan addressed the x-ray of lumbar spine and it was denied for the same reason. The provider is requesting that this denial be overturned.

The health plan's determination is upheld.

The requested facet joint injections were not medically necessary for this patient. According to evidence-based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), facet injections/medial branch blocks can be considered when there are objective examination findings consistent with facet mediated pain, absence of radicular pain, spinal stenosis, previous fusion (same level), infection, tumor, coagulopathy, or anticipation of a surgical procedure, as well as failure of at least 3 months of conservative treatment including physical therapy or chiropractic treatment, home exercise, and medications such as nonsteroidal anti-inflammatory drugs. If a diagnostic medial branch block is performed, this should be performed at no more than two joint levels. There should be no history of prior fusion at the levels to be performed and imaging studies should rule out other obvious causes for the pain (such as fracture, tumor, infection, or significant extraspinal lesion). This request has repeatedly been denied as there are no official imaging studies submitted for review to rule out other obvious causes for the pain. The provider states that they performed x-ray at the time of the procedure that showed multilevel degenerative changes and facet arthropathy. However, x-ray alone does not rule out other causes for the pain and there is no radiology report/imaging submitted. Medical necessity is not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Back pain.
Treatment:  Lumbar Epidural Spinal Injection.
The insurer denied Lumbar Epidural Spinal Injection. 
The health plan's determination is overturned. 

This is a female who has lower back pain with radiating pain to both buttocks and numbness tingling in both buttocks, right more than left. Her pain is severe. She had similar episodes of pain two years for which she underwent three epidural injections with excellent results. Her electromyography (EMG) revealed findings consistent with bilateral L (lumbar) 4 and L5 radiculopathy. A magnetic resonance imaging (MRI) showed multilevel degenerative disc disease (DDD) with disc bulge at L4/5 and L5/S (sacral)1 levels, and stable perineural cysts at S2 and S3 levels. 

Pain Management: Lumbar Epidural Spinal Injection is medically necessary for this patient.

This patient has severe pain secondary to lumbar radiculopathy. She had epidural Lumbar epidural injections two years ago with excellent results. Lumbar epidural injection is an effective treatment for her radicular pain. Other treatments such as long-term use of pain medications and surgery carry significant more risks and complications than epidural injections. Therefore, it is medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent. 
The health plan's determination is overturned.

The patient is a female with atopic dermatitis, 40% (percent) body surface area (BSA), treated with topical steroids, tacrolimus, systemic steroids, antihistamines and antibiotics. The provider requesting Dupixent. 

Dupixent is medically necessary for this patient.
The patient has tried and failed the appropriate therapy and has severe disease. In May 2020, the Food and Drug Administration (FDA) also approved dupilumab for the treatment of patients aged 6 years and older with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. This approval followed a phase 3, randomized, double blinded placebo controlled trial that enrolled 367 patients to evaluate the safety and efficacy of dupilumab in children (ages 6-11 years) for treatment of atopic dermatitis (Paller et al). Significantly and clinically meaningful improvements in patients signs and symptoms of atopic dermatitis as well as quality of life were reported. As seen in adults, treatment in pediatric population was reportedly well tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis.
In addition, a randomized, double-blind, placebo-controlled, parallel-group, phase 3 trial (Paller et al) was conducted in 31 hospitals, clinics, and academic institutions in Europe and North America. Eligible patients were aged 6 months to younger than 6 years, with moderate-to-severe atopic dermatitis. At week 16, significantly more patients in the dupilumab group than in the placebo group saw improvement. No dupilumab-related adverse events were serious or led to treatment discontinuation.
Therefore, Dupixent is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hematuria
Treatment: Abdomen and Pelvis CT (computed tomography) scan
The insurer denied the Abdomen and Pelvis CT scan.
The health plan's determination is overturned.

The patient is a male who presents with gross hematuria. Symptoms have been ongoing. He has symptoms of urinary frequency but no other urinary symptoms.

Computed tomography (CT) of abdomen and pelvis is medically necessary for this patient. Hematuria in a patient such as this is not normal. Further evaluation for urinary pathology is warranted including imaging of the urinary tract system with a CT scan to rule out malignancy or stones.

In addition, the patient had a discrepancy in urine dipsticks which were done in the office versus a urinalysis which was done at a lab. These evaluations were done at different dates. Either way, hematuria would not be considered normal. It is important to rule out other pathology such as kidney stones or kidney or bladder malignancies. The workup for evaluation and to rule out stone/renal malignancies would be imaging of the renal system. This would include a CT scan with attention to the kidneys and urinary system.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Constipation
Treatment: Trulance (plecanatide)
The insurer denied coverage for Trulance (plecanatide).
The denial is upheld.

The patient was having rectal bleeding that was attributed to hemorrhoids. The bleeding had stopped since starting a high fiber diet. The patient was being treated for constipation with Linzess but was not tolerating it. They had previously been treated with Miralax and Lactulose. The physician's office writes that the patient is "unable to try any other alternatives due to a severe reaction of Penicillin/Percocet and certain dyes involved with it." 

UpToDate has an article titled "Management of chronic constipation in adults." The article discusses pharmacological therapy for severe constipation. Among the recommended treatments are Linaclotide, Plecanatide, Lubiprostone, and Prucalopride. Lubiprostone is a Food and Drug Administration (FDA) approved treatment based on two placebo-controlled trials that included a total of 479 patients with chronic idiopathic constipation. Significantly more patients receiving Lubiprostone achieved the primary endpoint with an increase in spontaneous bowel movements.

The FDA lists contraindications and drug interactions for Amitiza (lubiprostone). Mechanical bowel obstruction is a contraindication. Concomitant use of opioids such as methadone may interfere with the efficacy of Amitiza. The FDA prescribing information states that there is a low likelihood of pharmacologic drug-drug interactions. 

This patient has chronic constipation and has not tolerated Linzess. It is appropriate to change medications. The insurance company is offering a formulary alternative Amitiza. The physician's statement that the patient cannot take alternatives such as Amitiza due to a reaction to Penicillin, Percocet, and intravenous (IV) dyes is not consistent with the FDA prescribing information for Amitiza. Therefore, it has not been shown that the formulary drug Amitiza is likely to cause an adverse reaction. Amitiza has not been shown to be ineffective in this patient. It is not known that Trulance would be more effective than Amitiza. The formulary exception for Trulance is denied since Amitiza is a reasonable alternative.

The carrier's denial of request for formulary exception for Trulance (plecanatide) to treat chronic constipation is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Full hospital admission
The insurer denied the full hospital admission.
The denial is upheld.

The patient is a female with a history of bradycardia, intermittent chest pain, and recent Coronavirus 2019 (COVID) infection. She presented to the emergency room on advice of her cardiologist three days after she underwent an apparently abnormal stress echocardiogram test. The vital signs were normal except for a blood pressure of 169/94. She was well appearing and in no acute distress. Physical exam was normal. Labs and chest x-ray were non-contributory. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.

Upon admission to a monitored bed, the patient was treated with aspirin and other oral medications. The cardiologist reevaluated the patient and noted that the recent stress echocardiogram showed a severe cardiomyopathy with an ejection fraction (EF) of 30-35%. She underwent a cardiac catheterization, which was essentially normal. The remainder of the stay was clinically uneventful, and the patient was discharged.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested full hospital admission was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, severe metabolic disarray, or a cardiology condition that failed observation care. The services provided - cardiac catheterization, monitoring, oral medications - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature and Milliman Care Guidelines (MCG) Guidelines, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis. 
Treatment: Zilretta. 

The insurer denied: Zilretta 32 milligram (mg) vial. 
The denial is overturned. 

The patient is a female with a complaint of bilateral knee pain and known osteoarthritis proven by plain radiographs. The patient had undergone prior bilateral knee injections with Zilretta for pain relief. The patient reported months of good pain relief following these injections. The patient presented for follow up and complained of bilateral weight bearing knee pain. The provider recommended repeating the bilateral knee Zilretta injections. The patient's health plan, however, denied coverage of this medication with a determination that it was not medically necessary. At issue in this case is the medical necessity of the proposed bilateral knee Zilretta injections. 

The health plan's determination is overturned. 

The requested Zilretta 32 milligram vial is medically necessary for this patient. 
The provided records in this case document that this patient has bilateral knee pain from known moderate degree osteoarthritis in both of her knees. The patient had undergone prior injections of a long acting triamcinolone product (Zilretta 32 milligrams [mg]]) with excellent knee pain relief for multiple months. Her orthopedic provider has recently requested repeat bilateral knee injections with Zilretta, a long acting triamcinolone product. The provided records document moderate to advanced bilateral knee arthritis as a diagnosis for this patient. There is also documentation that prior Zilretta injections for both knees provided excellent pain relief in the past. Thus, the records clearly document the medical necessity of the proposed bilateral Zilretta injections. 

In addition, the current, peer-reviewed orthopedic literature does support the use of this long acting triamcinolone product for the relief of arthritic joint pain. A recent article published by Conaghan and colleagues in the Journal of Bone and Joint Surgery in 2018. Their study was a double-blinded, randomized and placebo controlled study which assessed the effect of a single intra-articular injection of a long acting formulation of triamcinolone acetonide. These authors concluded that "FX006, a novel, microsphere-based, extended-release triamcinolone acetonide (TA) formulation, prolongs TA joint residence and reduces systemic exposure compared with standard TA crystalline suspension (TAcs) provided significant, clinically meaningful pain reduction compared with saline-solution placebo at week 12 (primary end point)." Therefore, the proposed use of Zilretta, a long acting triamcinolone acetonide formulation, is supported in the peer-reviewed literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible Sepsis.
Treatment: Inpatient Admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

Patient is an adult with past medical history of immunocompromise and hypertension who presented to the emergency department with complaints of fever, right upper lip lesion, and neck lymphadenopathy.

Vitals on presentation included: Temperature 101.2 degrees Fahrenheit, Blood Pressure 123/91, Pulse 95, Respiratory Rate 18, oxygen (O2) saturation 99% on room air. Laboratory values were notable for the following: white blood cell count (WBC) 7.2, Hemoglobin 15.0, Hematocrit 44.5, glucose 95, creatinine 0.6, lactic acid 2.7.

Patient was empirically started on intravenous (IV) antibiotics (vancomycin and cefepime) for possible sepsis. Patient also received valacyclovir for likely herpes lesion. Computed tomography (CT) scan showed unspecific enlarged lymph nodes. Ear, Nose and Throat (ENT) specialist was consulted and deemed surgical intervention was not indicated. Chest x-ray was negative. Patient remained afebrile, hemodynamically stable, and clinically improved. He was discharged to continue oral antibiotics (Augmentin) as an outpatient.

According to documentation, patient presented with fever and a lip lesion. Patient had fever but hemodynamically stable. Laboratory results showed normal WBC. Patient was described in the emergency department as "sitting in chair, alert, oriented, ambulatory, no acute distress or complaints of pain..." Medical records indicate lip lesion was likely herpetic. ENT deemed no surgical intervention was required. Based on above findings, patient met criteria for observation level of management. Documentation does not support need for acute inpatient hospitalization.

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: Coronary Artery Disease
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is an adult who presented to the emergency department (ED) with a past medical history significant for hypertension, hyperlipidemia, coronary artery disease status post unsuccessful Percutaneous coronary intervention (PCI), along with a history of paroxysmal atrial fibrillation, paroxysmal supraventricular tachycardia (SVT), asthma, chronic obstructive pulmonary disease (COPD), and recent pulmonary embolism secondary to Coronavirus disease (COVID) infection. He was on apixaban and reported a one-day history of shortness of breath claiming that he was in his usual state of health when he developed sudden onset of shortness of breath as if the breath cannot go past his throat. Upon evaluation, he had associated palpitations and inspirational central, achy chest pain. The patient reported that he had walked approximately 8000 steps and was doing yard work and was outside smoking when the episode occurred. He stated that the shortness of breath and inspirational chest pain were similar to symptoms with COVID. He was previously found to have a pulmonary embolism and was adherent to his anticoagulation therapy. He reported a 12-pound unintentional weight loss over the past year and claimed that chronic chest pain had occurred for 2 years with the current chest pain feeling different. In the ED, the patient had tachycardia with his heart rate up into the 140s. He had initial inspiratory wheeze in the left upper quadrant that stopped after the patient cleared his throat. There were no crackles or rhonchi bilaterally. Hospital problems consisted of (principal) shortness of breath, tobacco use disorder, COPD, paroxysmal atrial fibrillation, chest pain, and pulmonary embolism.  

The Milliman Care Guidelines state that clinical indications for admission to inpatient care for those patients who are having chest pains include individuals with either hemodynamic instability, respiratory distress, chest pain indicative of serious diagnosis other than coronary artery disease, and those patients have severe pain requiring acute inpatient management. The information provided for the review noted the patient had multiple comorbidities to include a history of hypertension, hyperlipidemia, coronary artery disease, paroxysmal atrial fibrillation, paroxysmal SVT, asthma, COPD, pulmonary embolism, and COVID. However, upon arrival to the ED, he was saturating well on room air, was not hemodynamically unstable, and responded favorably to treatment. Given the provided documentation, the patient did not meet criteria for acute care on an inpatient basis. He could have had additional care and work-up safely and effectively rendered on either an observational basis or outpatient basis.  

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 the inpatient hospital admission is not substantiated.