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

Endocrine
Pharmacy/prescription drugs

Diagnosis: obesity
Treatment: Saxenda
The insurer denied Saxenda. The health plan's determination is overturned. 

The patient is a female with history of obesity. Per prior authorization, the patient suffers from obesity after diet, exercise, lifestyle modification. Her body mass index (BMI) is 30.6. The patient does not have complications of obesity. The patient is able to take a stimulant. Per an office note, the patient follows monthly weight checks. She is eating small meals high in protein. She was not able to lose weight. She also usually works out but due to recent excisions of skin lesions she has not been able to. She had gastric bypass. The request is for coverage of Saxenda. 

Saxenda is medically necessary.
Lifestyle changes remains the first line therapy according to the American Heart Association (AHA) / American College of Cardiology (ACC) 2013 obesity guidelines. For obese and overweight individuals, the guidelines recommend a comprehensive lifestyle program including lower calorie diet and increase in physical activity (strong recommendation with strong level of evidence, and which benefits significantly outweigh risks). The 2015 Endocrine Society Obesity Guidelines and the 2016 American Association of Clinical Endocrinologists (AACE) Obesity Guidelines, they recommend consideration of weight loss medication in patients with BMI > (greater than or equal to) 27 with comorbidity or BMI over 30, but only as adjuncts to reduction of food intake and increased physical activity.
In patients who have tried and had inadequate response to lifestyle modification, consideration of obesity medication such as Saxenda is appropriate. Therefore, in this patient's case, the use of Saxenda is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebrovascular accident
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient is an adult who presented to the emergency room complaining of lightheadedness and slurred speech. He had a past medical history significant for hypertension and morbid obesity and was subsequently worked up for a cerebrovascular accident (CVA). On presentation to the emergency department, the patient displayed no signs or symptoms of CVA. He was alert and oriented x3, with a nonspecific electrocardiogram (ECG), and computed tomography (CT) stroke angiogram of the head and neck revealing streak artifact, which was limiting the neck vessel. Blood pressure was elevated at 187/93, with the remainder of his vital signs stable. Urine toxicity screen was positive for cannabinoids. Orders were placed to admit the patient for at least 2 midnight stays based upon the patient's admitting diagnosis, severity of signs, symptoms, and laboratory data and the patient's contributing comorbidities and risk of adverse events. The denial was based upon medical notes that failed to support the need for acute level of care. The indication was that after the patient was given intravenous fluids and medication, his symptoms began to resolve.  

The Milliman Care Guidelines (MCG) state that hospitalization to address hypertension is indicated when the patient is having a hypertensive emergency indicated by systolic blood pressure greater than 180 millimeters of mercury (mmHg) or diastolic blood pressure greater than 120 mmHg with evidence of acute or worsening target organ damage. The patient's blood pressure was initially 187/93 but improved with intravenous fluids and medication while in the emergency department. Additional diagnostic testing did not reveal any significant abnormalities that would justify inpatient care. ECG was normal and CT was negative for any abnormalities that would cause the patient's symptoms. Evidence noted that he was positive for cannabinoids, with no confirmation that this drug may have caused symptoms. Given that the patient responded favorably to treatment in the emergency department, it was determined that his condition could have been managed effectively on an outpatient or observational basis. He did not require an acute level of care throughout the timeframe in question.

The health plan acted, with sound medical judgment and 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: Diffuse body aches, neck, and knee pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This patient has chronic medical problems including hypertension, stroke, and chronic pain. She presented to the hospital emergency department, 2 days after falling at home, complaining of diffuse body aches, neck, and knee pain. The eventual recommendation for discharge to a rehabilitation facility was declined by the patient and she was subsequently discharged home.    

The enclosed clinical information does not support a level of medical acuity or complexity that warranted acute inpatient hospital admission. She reportedly fell at home (2 days prior to admission) with no reported head injury or loss of consciousness. She was not taking any anticoagulant medication. Clinical workup performed in the emergency department included physical examination, electrocardiogram (ECG) and laboratory blood studies. Imaging studies were negative for acute pathology and recent prior imaging was reviewed, which again did not demonstrate evidence of acute pathology. Pain management and neurology consultations could have been provided as an outpatient.  

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations. All decisions are evidence-based.

From a physical medicine and rehabilitation/pain management perspective as well as within a reasonable degree of medical certainty, inpatient admission was not medically necessary.  

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: Hypertension. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient was admitted after he missed hemodialysis treatment for end stage renal disease. He was also found to have elevated blood pressure secondary to poor compliance with medications and dialysis. Nephrology service was consulted for resuming dialysis therapy and the patient was given an intravenous (IV) anti-hypertensive. He left against medical advice. His condition could have been treated safely under a lower level of care. 

An evidence-based specialty society guideline concludes that adult patients with severe hypertension (e.g. systolic blood pressure (SBP) greater than 180 millimeters (mm) mercury (Hg) or diastolic blood pressure (DBP) greater than 120 mm Hg) without acute or worsening target organ damage (sometimes deemed a hypertensive urgency) can be treated with oral medication, and do not require inpatient care. 

Database analysis of a cohort of 552,569 patients (mean age 58 years) discharged from an emergency department with a primary diagnosis of hypertension found that in the weeks after discharge the rate of intracerebral hemorrhage was exceedingly low (less than 0.02%), and not elevated to a statistically significant degree compared to the rate the same patients experienced over the same time period a year later.[2] In the same analysis, among the 10,288 patients discharged with a diagnosis of malignant hypertension, the rate was similarly low (0.03%), and also not different from the same time period a year later. 
 
A multiyear database analysis of patients seen in a Canadian emergency department with a primary diagnosis of hypertension found in the last year of the study (25,950 patients, median age 64 years) that over 92% of patients were treated without admission to inpatient care. [3] 

The health plan acted reasonably, with sound medical judgment and 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

Endocrine
inpatient hospital

Diagnosis: hyperglycemia
Treatment: inpatient stay
The insurer denied an inpatient stay. The health plan's determination is upheld. 

The patient is a female with history of hypertension, and hyperlipidemia. The patient presented with hyperglycemia. The patient went to the emergency department (ED) after her PCP (primary care provider) told her she had elevated blood sugars. Blood pressure (BP) was 105/76, heart rate (HR) 86, temperature 98.4oF, and O2 (oxygen) saturation 96%. Mental status is normal. The patient was not found to be in diabetic ketoacidosis (DKA). Glucose was 669 which improved to 436 after 3L (liters) of intravenous (IV) fluids and insulin. Bicarbonate was 25, Creatinine 1.54 and Na (sodium) was 125. Endocrinology was consulted. The patient was started on subcutaneous insulin. The patient was discharged with followup.

The inpatient hospital admission is not medically necessary. The patient did not meet criteria for an inpatient admission as she did not meet criteria for diabetic ketoacidosis requiring inpatient management (no evidence of acidosis or ketonemia). She did not meet criteria for hyperglycemic hyperosmolar state (neurologic dysfunction), and she did not meet criteria for hyperglycemia complicated by persistent/severe altered mental status, dehydration, vomiting or electrolyte abnormality. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis.
Treatment: Xeljanz 10 milligrams (mg) twice daily.
The insurer denied Xeljanz 10mg twice daily.
The denial is overturned.

The patient is a male with severe steroid-dependent ulcerative colitis, anemia, and primary sclerosing cholangitis. He was tried on Mercaptopurine (6MP) initially with suboptimal response. He was on Apriso. Endoscopy showed ongoing moderate to severe pancolitis. Since the patient is not a candidate for anti-tumor necrosis factor (TNF) drugs due to increased risk for hepatocellular T cell lymphoma in males who have used 6MP in the past, he was started on Xeljanz 10 milligrams (mg) twice daily. On the current maintenance regimen, the patient has had significant improvement in his symptoms with a decrease in stool frequency. A recent lab test showed elevated erythrocyte sedimentation rate (ESR)- a marker of ongoing inflammation. The patient is also underweight, which may be related to persistent bowel inflammation. The recent authorization of Xeljanz was for a reduced dose of 5 mg daily. The subject under review is the medical necessity for Xeljanz 10 mg twice daily.

The health plan's determination is overturned.

Continuation of Xeljanz 10 mg twice daily is medically necessary for this patient. A dose decrease in a patient with persistent inflammation would likely lead to worsening disease.

Xeljanz 10mg twice daily is medically necessary for this patient, as the recent test shows ongoing inflammation and clinical notes are concerning for continued inflammation. Decreasing the dose at this point is not in the patient's best interest. Constant et al. in their article in showed that treatment with Tofacitinib (Xeljanz) was efficacious for children with severe steroid colitis and biologic refractory ulcerative colitis with dose de-escalation attempted when inflammation is controlled to prevent colectomy. Moore et al. also showed that 4/5 patients whose dose was deescalated from 10 mg twice daily (bid) to 5 mg bid had worsening symptoms and needed dose escalation back to 10 mg twice daily. In this patient who has ongoing inflammation, a dose decrease is not in the patient's best interest. The patient should be continued on 10 mg twice daily until clinical evidence shows improvement in bowel inflammation.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Glaucoma
Treatment: Lumigan (bimatoprost)
The insurer denied the Lumigan (bimatoprost).
The health plan's determination is overturned.

The patient is currently being treated, for the past several years, with bimatoprost for primary open angle glaucoma. The patient has had allergic reactions to travatan and latanoprost, both of which were tried prior to the current therapy started several years ago. They were denied coverage of bimatoprost. 

At issue is the non-formulary medication, bimatoprost.

The formulary drug (latanoprost, travapost [generic TravastanZ) has been ineffective, has not be as effective as the non-formulary drug (Lumigan), and has caused adverse effects. The patient cannot tolerate the formulary medications as evidenced by adverse drug reactions in the past.

Glaucoma is second only to cataract as a leading cause of blindness worldwide. Early detection and prevention of progression are the standard of care to prevent irreversible loss of vision. Therapy involves reducing the intraocular pressure (IOP) with eye drops or laser. This patient has tried and failed several classes of eye drops including prostaglandin analogues, beta blockers and alpha-2 adrenergic agonists. Bimatoprost 0.03 % (Lumigan 0.03 %) is an effective, prostamide analog, topical treatment with superior intraocular pressure (IOP) -lowering effects (compared with other prostaglandin analog monotherapies) and a favorable tolerability profile with long-term use.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Constipation. 
Treatment: Pharmacy/Prescription Drugs - Motegrity 1 milligram (mg) daily. 

The insurer denied Pharmacy/Prescription Drugs - Motegrity 1 milligram (mg) daily. 
The determination is overturned. 

The patient has chronic idiopathic constipation. They presented with constipation, gas, and bloating; they tried Dulcolax, senna, magnesium hydroxide, and magnesium oxide. An x-ray of the abdomen showed dilated mid-small bowel loops, moderate stool in the left and rectosigmoid colon without distention of the right colon, and possible partial or intermittent small bowel obstruction. They failed prescription Linzess and Amitiza samples. Coverage is requested for Motegrity 1 milligram (mg) daily for the treatment of chronic idiopathic constipation. 

At issue is the non-formulary medication, Motegrity. 

The formulary drugs in this case have been reported ineffective and would not be as effective as the non-formulary drug (Motegrity). The patient has already reportedly failed Linzess and Amitiza; the formulary alternative lactulose, an osmotic laxative, was not attempted due to lack of coverage. However, the patient has already attempted magnesium-based osmotic laxatives (as well as the stimulant laxatives Dulcolax and senna). The most recent American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as lubiprostone (Amitiza) or Linzess should be used if non-pharmaceutical laxatives fail, which has been documented in this case [1]. Motegrity is an effective therapy for the treatment of constipation and has demonstrated efficacy in high-quality clinical trials [2-5]. As the patient has failed Amitiza, Linzess, and stimulant and osmotic laxatives, the request for Motegrity is supported.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Crohn's ileocolitis
Treatment: Formulary Exception for Uceris foam (budesonide)
The insurer denied coverage for Formulary Exception for Uceris foam (budesonide)
The denial is upheld

The patient has Crohn's ileocolitis and failed to respond to mesalamine. A colonoscopy last year showed active disease in the ileum and colon. The biopsy of the terminal ileum was read as active chronic ileitis. The rectal biopsy showed moderately active chronic proctitis. Her physician writes that she has tried Cortifoam but did not have improvement in her symptoms. She previously had a good response to Uceris. 

The American Journal of Gastroenterology April 2018 Volume 113 has published an article titled "American College of Gastroenterology (ACG) Clinical Guideline: Management of Crohn's Disease in Adults." The article discusses medical management of mild to moderately severe disease. The article states that 5-aminosalicylic acid (5-ASA) suppository and enema preparations are effective for ulcerative colitis but the role of topical mesalamine in Crohn's disease is of limited benefit. Corticosteroids are often used as a bridge to permit symptom control. Controlled ileal release budesonide may be effective for short term relief of symptoms for patients with disease in the ileum and right colon. The recommended treatments for mild to moderately severe Crohn's disease include both Sulfasalazine and controlled ileal release budesonide. There is no recommendation to give steroid foams via the rectum. 

Gastroenterology and Hepatology January 2020 Volume 16 Issue 1 has an article titled "A Comprehensive Review of Topical Therapies for Distal Ulcerative Colitis." The article discusses steroid foams. It states that a comparison of budesonide foam with classic corticosteroid rectal foam therapies demonstrated similar efficacies. 

This patient has a diagnosis of Crohn's disease. The use of steroid rectal foams for Crohn's disease is not well established which is different from the treatment of ulcerative colitis. The physician in this case wants to give topical therapy for the rectal disease. However, the medical literature does not support that Uceris foam gives superior results as compared to Cortifoam. The formulary alternatives are not likely to cause the patient to have an adverse reaction. The Cortifoam has been reported to be ineffective. However, rectal foams are generally not effective for Crohn's disease. The ACG guideline advises controlled ileal release budesonide for patients with active ileitis. 

It has not been shown that Uceris foam is superior to Cortifoam for Crohn's disease. 

The carrier's denial of Request for Formulary Exception for Uceris foam (budesonide) to treat Crohn's is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Dental Issues
Treatment: Dental/Orthodontic Procedure/Braces (comprehensive orthodontic treatment)
The Health plan denied Dental/Orthodontic Procedure/Braces (comprehensive orthodontic treatment)
The denial is overturned.

The patient in question is a female with impacted tooth #21. This tooth is unable to erupt due to crowding. She presents with a skeletal Class II malocclusion and significant crowding. She is missing teeth 4 and 13, and teeth A and J are retained. The patient is treatment planned for orthodontics to address the crowding and to create space to bring the impacted tooth into the arch.
At issue is the medical necessity for the requested service/treatment of braces (comprehensive orthodontic treatment).

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

It is in the best interest of patients to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered. [1]
Approximately 10%(percent) of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. [2] The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. [2] If left untreated, the damage that can occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient who presented to the emergency department (ED) with the complaint of abdominal pain for one day. Comorbid health conditions included diabetes and hypertension. A computed tomography (CT) scan at the showed pelvic fluid and the appendix was not well seen. She was transferred to another facility for further assessment and monitoring. The vital signs at the time of presentation were normal. The heart rate was 88 beats/minute. The examination revealed no abdominal tenderness. The white blood cell count (WBC) was normal. Surgical and gynecology consultations were obtained. The patient was monitored overnight. The differential diagnosis included ruptured ovarian cyst and appendicitis. Serial examination showed improvement in her pain complaints. She remained clinically stable and was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.

Inpatient care was not medically necessary.
The medical records support that this patient could have been reasonably and safely monitored with at a lower level of care.
This patient presented with abdominal pain and was admitted to the hospital. Her evaluation with examination, lab data, and a computed tomography (CT) scan did not identify a definitive etiology. She was monitored overnight. She was clinically stable during the period of monitoring and was able to be discharged with arrangements for outpatient follow up.
This patient's clinical needs could have been satisfied at a lower level of care. This level of care would have provided for clinical assessment, monitoring, and arrangements for subsequent outpatient follow up.