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

Diagnosis:  Depressive symptoms.
Treatment:  Mental Health Residential Treatment.

The insurer is denied coverage for Mental Health Residential Treatment.  The denial is overturned.

This is a female patient, who was admitted to inpatient mental health residential treatment due to severe mental symptoms and eating disorder symptoms.  She had depressive symptoms including depressed mood, suicidal thoughts, feelings of hopelessness, loss of interest, low self-esteem, isolation, decreased energy, poor concentration, anxious mood, obsessing and ruminating, worrying, somatic complaints, feeling overwhelmed, and panic like symptoms.  She had food restriction during the week, including calorie counting with no more than 900 calories per day, distorted body image, maladaptive eating behaviors, binging on weekends, and her lowest recent weight was 80 lbs on more than one occasion.  She currently reportedly weighed 106.6 lbs. and was 5"4" with a body mass index (BMI) of 18.3. She had reported diagnoses of Major Depressive Disorder-Recurrent, Generalized Anxiety Disorder, and Unspecified Eating Disorder.  She had a reported history of alcohol and cannabis use and experimentation with Xanax. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patient's safety, but also to promote improvement in the patient's condition.  It also states that the determination of an appropriate setting for treatment should include consideration of the patient's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning.

In this case this patient still had reports of depressive symptoms, including suicidal thoughts, during the denial period, and she still reportedly was considered at risk without learning more coping skills to better deal with her depressive, anxiety, and eating disorder symptoms. 

Notes reported increased anxiety, depressed mood, tearfulness, disappointment, fears, and she reported that she was not ready to leave this treatment setting yet, as she thought she needed more time.  It was reported that she needed more work on trust, resentment, and communication.  Notes reported that she had urges of high intensity to over exercise, had concerns about her home and being a burden on her family, and she reported feeling exhausted, stressed, and overwhelmed. 

Continued inpatient mental health residential treatment to the present and for another month until and including is medically necessary.  The patient can be reevaluated at that time to assess further treatment needs and also progress with treatment.  It did not appear that the health care plan acted reasonably or in the best interests of the patient.

The carrier's denial of coverage for continued Mental Health Residential Treatment is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Failure to Thrive, TBCK gene mutation
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is upheld.
 	
This is a female patient with a medical history of seizure disorder, TBCK gene mutation with associated failure to thrive (FTT), hypotonia, retrognathia, glossoptosis, Gastroesophageal Reflux Disease (GERD), severe laryngeal reflux, scoliosis, tracheostomy and Gastrostomy-Jejunostomy (GJ) tube dependence. She presented to the emergency room (ER) because of leaking around the GJ tube site for one day. The patient's mother noticed a small hole at the base of the MIC key button. She had an elevated heart rate (HR) of 133 beats per minute (bpm) respiratory rate of 28 breaths per minute.  The GJ site was noted to have erythema under the hub. The treatment plan was to provide a new G-J tube by Interventional Radiology (IR) under general anesthesia. She is totally dependent on fluids for the G-J tube. Intravenous ntravenous (IV) fluids were administered and she was maintained nothing by mouth (NPO) until the procedure was completed.  She was placed on Positive Airway Pressure (BIPAP) machine. The patient was admitted for Gastrostomy-Jejunostomy (GJ) tube exchange. The hospital course of treatment includes intravenous fluids, home Keppra converted to intravenous formulation, Levetiracetam, Budesonide nebulization, Albuterol nebulization and trach care. The patient underwent Gastrostomy-Jejunostomy (GJ) tube exchange without incident. After a period of medical stability the patient was discharged home with follow up instructions.

The patient needed to have the G-J tube replaced. Standard of care is that the procedure is done by IR under general anesthesia. While waiting for the procedure, the patient must be kept NPO [nothing by mouth] and must receive IV fluids for hydration. However, the formal inpatient admission is not medically necessary. The patient could have been admitted using observational status, not formal inpatient status. G-J tube exchanges are very common as noted by Wilson (2020) who reported 203 exchanges in 79 patients. The exchange requires a skilled team in IR as well as coordination with anesthesia, so the procedure is not trivial and can have complications as noted by Koo, K.S.H., et al, (2018).

Per Sheth, R.A., et al, (2016), "Between 2010 and June 2014, 1,144 primary PRG procedures and 442 replacement procedures were performed in 1,112 patients. Of the 442 exchange procedures, 289 were "rescue" procedures secondary to catheter malfunction. There was a statistically significant decrease in the number of rescue exchanges performed secondary to catheter malfunction (P = .036)."

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered medically necessary for this patient.

Based on the above, the medical necessity for inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Throiditis.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission.
The denial is upheld. 
This is a female patient with a past medical history of thyroid disorder who presented to the Emergency Department with complaints of fever, neck pain, weakness, and sore throat. Her presenting vital signs included a temperature of 37.9C, a blood pressure of 95/61, a pulse of 91, a respiratory rate of 16, and oxygen saturation of 94% on room air. Laboratory results included a white blood cell (WBC) count of 10.36, a hemoglobin of 11.9, a hematocrit of 36.9, a creatinine of 0.87, a glucose of 125, and a thyroid stimulating hormone (TSH) of 0.882. A computed tomography (CT) scan of the neck showed an ectopic thyroid gland and mildly enlarged lymph nodes. A chest x-ray was negative. A head CT scan was also negative. The patient was started empirically on intravenous antibiotics (meropenem) for possible thyroiditis. She also received Naprosyn, intravenous fluids, and lorazepam for anxiety. Endocrinology was consulted. They recommended outpatient management. Infectious Diseases also evaluated the patient and adjusted antibiotic coverage. The patient remained hemodynamically and clinically stable. She was discharged to continue outpatient management.
According to the documentation, the patient presented with fever and non-specific neck pain. Otherwise, she had a low-grade fever (100.4F) and remained hemodynamically stable. Laboratory results were unremarkable, including a normal WBC count and thyroid function tests. Moreover, a chest x-ray and CT scans of the head and neck showed no acute findings. 

Based on the above findings, the patient was clinically stable for observation level of monitoring. She had no evidence for a disseminated infection and was tolerating oral intake. The patient did not fulfill criteria for acute inpatient admission. The prior determination of denial of inpatient admission has been upheld. 

The insurer acted reasonably, with sound medical judgement, and in the patient's best interest. 

Based on the above, the medical necessity for inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia, vertigo, orthostatic hypotension
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a past medical history (PMH) of dementia, diabetes type II, nasopharyngeal mass, gastric adenocarcinoma, hyperlipidemia, iron deficiency anemia and vertigo.  She presented to the emergency department (ED) with complaints of (c/o) headache, dizziness, non-productive cough, generalized weakness and low-grade temperature since the day prior to arrival. Just before arrival she had a house call by her physician and was found to have orthostatic hypotension. At baseline, she was able to ambulate with a walker. The patient noted her dizziness is different than her usual vertigo and she was not able to ambulate. The daughter noted patient is more confused and weaker compare to baseline. The patient denies any other symptoms. 

Upon arrival, blood pressure (BP) was 129/80, heart rate (HR) was 78, respirations (R) were 20, pulse oximetry was 97% in room air (RA) and temp was 99 degrees Fahrenheit. Physical exam was significant for diminished musculoskeletal strength and range of motion, also stage I pressure ulcer on the coccyx.  Otherwise exam was normal including neurological exam. Blood work was significant for hemoglobin of 7.9; other labs including Troponin were normal.  Computed tomography (CT) of the head and electrocardiogram (EKG) were also normal. As the patient was not able to ambulate, she was admitted with a diagnosis of dizziness for further evaluation. The patient was found to have orthostatic hypotension and was continued on intravenous (IV) fluid. The patient underwent a physical therapy evaluation, gradually improved symptomatically and was discharged subsequently with advice to follow with primary care physician.

No, the inpatient admission was not medically necessary.

The patient is a female with multiple comorbidities who presented with sudden onset of dizziness when she was found orthostatic at home; she noted this was different than her vertigo. She was orthostatic in the hospital also. Physical exam, including neuro exam, was unremarkable except decreased muscle strength and range of motion.  Troponin, CT of the brain, and EKG as well as other blood work were unremarkable. The patient was continued on IV fluid for orthostatic blood pressure and improved gradually.  She was discharged the day after admission with advice to follow with her physician as outpatient. 

As per Medscape, most patients with only proven or suspected central vertigo should be admitted to the hospital for further evaluation and treatment. This patient's dizziness is likely related to orthostatic hypotension which is non-cardiac in origin and improved with hydration.  As per Emergency Department guidelines this should be treated with IV fluid. In this scenario, this patient could be managed at a lower level of care.  Therefore, the inpatient admission was not a medical necessity.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System.
Inpatient hospital.

Diagnosis: vertebral artery dissection.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male who was admitted to the hospital due to headaches. It is reported that the patient had the onset of what was called "thunderclap" headache 8 days prior to the admission. He was seen by a neurologist as an outpatient, but given persistence of such headaches, he was told to go to the emergency room. In the emergency room, imaging was obtained, and neurosurgery was consulted. Neurosurgery diagnosed a vertebral artery dissection. He was admitted to the hospital as such.
Under review is the medical necessity of the inpatient stay.

The inpatient admission was medically necessary for this patient. The submitted medical records clearly document the presence of a vertebral artery dissection as the cause of the patient's headaches. Such a condition may cause cerebrovascular ischemic events and is therefore a high risk situation that requires inpatient evaluation and treatment. Several options for treatment include neurosurgical/endovascular procedures, thrombolysis, anticoagulation, or antiplatelet agents.
Vertebral artery dissections are an acute cerebrovascular event that may lead to cerebral infarcts and other complications with a potential for permanent neurological deficits, disability and even death, and therefore, requires inpatient evaluation and management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Back Pain
Treatment: Saxenda 3 milligrams/0.5 milliliter pen injector
The insurer denied the Saxenda 3 milligrams/0.5 milliliter pen injector.
The denial was upheld.

This is a female patient with a history of hyperlipidemia, moderate recurrent major depression, postmenopausal state, and vitamin D deficiency. She had complaints of lower back pain. She was on Saxenda and weighed 153 pounds. There is no documentation in the medical records regarding a weight of 143 pounds. On both visits to her provider she weighed 148 pounds. Saxenda was denied because the patient gained weight.

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

Saxenda is to be denied or stopped if the patient does not lose 4-5% of body weight after taking the medication for 12-16 weeks.  The information in the medical records provided for review show a decrease of 3.3% (from maximum documented of 153 to 148lb).  Given this information, continued use would not have been appropriate.      

Saxenda 3 milligrams/0.5 milliliter pen injector is not considered medically necessary for this patient.  The records provided indicated patient was on Saxenda as of 11/12/18. No records are provided indicating clearly when it was started and the weight at the time. In summary,  we are not given enough documented clinical information to determine the effectiveness of the medication.  In fact, as noted the data in the medical chart do not support its effectiveness.

"Liraglutide helps to induce and sustain weight loss in patients with obesity. Its efficacy is comparable to other available agents but it offers the unique benefit of improved glycemic control.  Additional studies are needed to determine its long term efficacy and safety profile." (Mehta, A. et al. 2016)

"In this study, 3.0 mg of liraglutide, as an adjunct to diet and exercise, was associated with reduced body weight and improved metabolic control." (Pi-Sunyer, X. et al. 2015)                                                         

The carrier's denial of coverage for Saxenda 3 milligrams/0.5 milliliter pen injector is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pancreatitis.
Treatment:  Inpatient stay. 

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a man, who presented to the emergency department with a chief complaint of abdominal pain and vomiting.  He had a history of pancreatitis and stated that his symptoms were similar to prior episodes.  He denied binge drinking and daily alcohol intake, but he did drink alcohol over the weekend.  Review of systems was negative for chest pain, shortness of breath, syncope and rectal bleeding.  The patient was admitted for acute alcohol-related pancreatitis.

The inpatient hospital admission was not medically necessary.  In the case of this patient, the episode of pancreatitis was relatively mild, and he was able to be discharged shortly after admission.  In addition, the documentation indicates that his symptoms steadily improved during his time in the emergency department before he was admitted to the hospital.  Given his trajectory and the absence of acutely concerning imaging findings that would lead to a surgical intervention, he could have safely and effectively been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Problems. 
Treatment:  Dental/Orthodontic Procedure (braces). 

The insurer denied braces.  The denial is upheld in whole.

The patient in question is a female with a Class I occlusion and slightly high overjet and overbite.  The maxillary and mandibular arches have moderate crowding.  She is treatment planned for 24-30 months of orthodontics to correct her malocclusion, which was denied based on lack of medical necessity.

The patient has some maxillary and mandibular crowding.  Her bite is deep, but there is no indication of damage to the incisors or the palate in the photographs, and her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate.  There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient.

The patient does have a deep bite; however, that alone is not a medical necessity to treat.  The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position.  There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence (1).  The patient presents with none of those conditions. Furthermore, masticatory efficiency is highest in patients with a Class I occlusion (2).  If her teeth were aligned, it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health.  For these reasons treatment is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic migraines

Treatment: Cyclobenzaprine Extended Release

The insurer denied coverage for the medication cyclobenzaprine extended release

The denial is upheld.

This female patient presented to her neurologist for headaches and other neurologic issues.  The patient started having headaches.  The pain would come on gradually and that there was no prodrome or aura.  The patient reported photophobia, phonophobia, osmophobia, nausea, vomiting, lack of appetite, and neck stiffness.  The prior treatments included Topamax, Depakote, Fioricet, and Botox.  

Notes indicate the plan was to continue Ajovy as well as a trial of Amrix ER 50mg given that she had a good response to flexeril 10 and may benefit from an extended release (ER) medication. Note that flexeril is an immediate release (IR) form of cyclobenzaprine. The initial trial of Ajovy was unsuccessful due to a failed injection. Thus, the eventual role of Ajovy in her treatment regimen is unknown.

The patient's neurologist noted the patient suffered from severe cervical muscle spasms that could lead to chronic migraines.  The patient had tried and failed methocarbamol and tizanidine.  The patient was responding somewhat well to cyclobenzaprine, but the neurologist opined the patient would have significant improvement with ER cyclobenzaprine.  It was stated the patient had been suffering from chronic migraines for almost 2 years.

Weil, et al. in a pooled analysis of randomized studies compared cyclobenzaprine ER to the IR form of cyclobenzaprine and placebo.  Both the immediate and extended release forms were superior to placebo. However, "Improvements with CER 15 and 30 mg on most efficacy measures were similar to CIR" where CER is the extended release formulation and CIR is the immediate release formulation. 

Based on the above, the formulary exception for Cyclobenzaprine Extended Release is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Sepsis secondary left foot infection.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is overturned.

This is a male patient with past medical history significant for diabetes mellitus, hypertension, hyperlipidemia, and left foot ulcer status post debridement, who presented to the Emergency Department (ED) with complaints of weakness, abdominal pain and vomiting.  The patient's vital signs on ED presentation included:  Temperature 101.3 F, Blood Pressure 152/104, and Pulse 119, Respiratory Rate 19, and Oxygen (O2) Saturation 98% on Room Air.  The patient's laboratory results included the following: white blood cell (WBC) count 13, hemoglobin (HGB) 10.7, hematocrit (HCT) 36.8, creatinine 0.83, glucose 418, and lactate 3.3.  The patient was admitted for further evaluation and management of diabetic gastroparesis with vomiting and bloody diarrhea and sepsis.  The patient was started empirically on broad-spectrum intravenous (IV) antibiotics (i.e., vancomycin, Zosyn, metronidazole) for possible sepsis secondary left foot infection.  The patient also received 3-liters of IV fluids.  The patient's x-ray of the foot showed no osseous abnormality.  Podiatry evaluated the patient and recommended a wound VAC.  Gastroenterology was also consulted for bloody vomiting.  All of patient's cultures remained negative.  The patient remained afebrile, hemodynamically stable and was discharged to continue outpatient management. 

According to documentation, the patient presented to the hospital with fever (temperature of 101.3), hypertension (blood pressure of 152/104), tachycardia (heart rate of 119), and his laboratory results showed elevations in leukocyte (WBC), glucose, and lactate.  The patient had worsening foot ulcer despite outpatient treatment with double oral antibiotics (i.e., Levaquin and Augmentin).  Based on the above abnormal findings, as well as documented failure of outpatient management in a high-risk patient with multiple co-morbid conditions, literature review supports that this inpatient admission was medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be overturned.  The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Vision/keratoconjunctivitis 
Treatment: Pharmacy/Prescription drugs 
The insurer denied Xiidra  
The denial is overturned in whole

The patient is with long standing dry eyes who has been treated with a variety of topical tears and Restasis without resolution of her symptoms and signs including decreased tear break up time and corneal band development.
The formulary drug, Restasis, was stated to be ineffective after a 5-month trial for this patient. The formulary drug, Lacrisert is not possible for this patient given the  other medical problems including blepharospasm. In addition, it is noted that the patient  has been on multiple topical lubricating drops and tears without relief of  symptoms in this case.
Per the Preferred practice pattern for dry eyes published by the American Academy of ophthalmology, the algorithm for dry eye treatment starts with ocular lubricants and lid hygiene, then progresses to punctal occlusion or topical antibiotics, corticosteroids (for limited duration), topical immunomodulatory drugs such as cyclosporine , oral macrolides, or topical LFA1 antagonist drugs such as Liftegrast. Punctal occlusion, topical antibiotics, steroid and oral macrolides are not mentioned in the medical record, but neither is the formulary provided. Therefore, it is necessary and reasonable for the patient to be tried on Xiidra (Liftegrast) given her failure of topical lubricants and Restasis and the inability to use Lacrisert in this case.