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

Diagnosis: Congestive Heart Failure (CHF)
Treatment: Inpatient Hospital Admission 
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult female with a past medical history of hypertension, hyperlipidemia, obesity, anxiety, and bipolar disorder. She also has a history of heart failure with reduced ejection fraction with the most recent echocardiogram demonstrating an EF (ejection fraction) of 25% (percent). She presented to the emergency department (ED) for evaluation of bilateral leg swelling and exertional shortness of breath.

On arrival to the ED, she was afebrile, blood pressure was 137/79, heart rate was 67 bpm (beats per minute), respiratory rate was 20, SPO2 (pulse oximetry) was 99% on room air. Initial EKG (electrocardiogram) showed normal sinus rhythm with minimal voltage criteria for LVH (left ventricular hypertrophy). Chest x-ray showed bilateral perihilar vascular congestion. Labs were notable for a BUN (blood urea nitrogen) of 25, creatinine of 1.2, mildly elevated AST (aspartate aminotransferase) and ALT (alanine aminotransferase), elevated alkaline phosphatase, troponin of 0.1, BNP (brain natriuretic peptide) of 20,700. Bilateral lower extremity duplex did not demonstrate evidence of deep venous thrombosis.

The patient was given IV (intravenous) Lasix x (times) 2 and was admitted to the inpatient unit for further care. On exam, she was noted to have bilateral rales and evidence of lower extremity edema. She was started on IV Lasix for treatment of acute on chronic heart failure exacerbation and a transthoracic echocardiogram was obtained which demonstrated reduced LVEF (left ventricle ejection fraction). She was evaluated by electrophysiology and underwent implantation of an ICD (implantable cardioverter defibrillator) for primary prevention of sudden cardiac death as well as for sinus bradycardia. Her symptoms improved with IV diuresis, and she was ultimately discharged with outpatient follow-up with cardiology.

The inpatient hospital admission was not medically necessary.

This patient with known history of heart failure with reduced EF presented with signs and symptoms consistent with acute heart failure exacerbation. The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and evidence of cardiogenic shock. She did not have acute ischemia, sustained ventricular arrhythmias, or advanced conduction disease such as complete heart block. She responded well to the initial dose of IV diuresis and was never hypoxic during her hospital stay. There were no urgent/emergent indications for implantation of the ICD, and she did not have any periprocedural complications. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatic cancer
Treatment: Xpovio
The insurer denied Xpovio.
The health plan's determination is upheld. 

This is a female with metastatic pancreatic cancer. The patient has previously received Folfirinox and gemcitabine+Nab-paclitaxel (Abraxane); the patient is responding to the latter. Xpovio has been requested as an addition to therapy. 

Xpovio is not medically necessary for this patient. 

There is a paucity of evidence that Xpovio improves outcomes in patients with pancreatic cancer at any stage of disease. The data referenced by the provider has not been clinically validated in full and the authors state "... The complete phase I trial is part of our forthcoming publication and is beyond the scope of this article. Collectively, these in vitro, ex vivo and early phase clinical data support the expansion phase of SINE (Selective inhibitors of nuclear export) compounds for the treatment of PDAC (Pancreatic ductal adenocarcinoma)...". At no point in this article do they recommend routine use of this agent in the treatment of patients with pancreatic cancer. This agent is not recommended by the National Comprehensive Cancer Network (NCCN), the peer reviewed literature, nor by the authors of UpToDate for use in this clinical scenario as it is not known to be safe nor effective.
Appeal type: Medical necessity
Decision: Upheld

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


The patient presented with the chief complaint of a cough. The records note that the patient had 4 days of a cough, fever, vomiting and diarrhea. A plan was made for labs, normal saline (NS) bolus, intravenous (IV) Zofran, and an Albuterol/Atrovent treatment.

A chest radiograph reported no findings concerning for a bacterial pneumonia. The patient received oral Motrin, a normal saline (NS) 300 milliliter (ml) intravenous (IV) bolus, Zofran 2.3 milligrams (mg) IV. 
The patient was admitted to the general pediatrics service. 
During her hospital course, the patient had a recurrent fever requiring Tylenol. She was described as exhibiting a dry cough but no signs of respiratory distress. She had no further emesis but an episode of diarrhea.  She was discharged home with the diagnosis of "dehydration". At issue is the medical necessity of an inpatient stay.
The health service/treatment of inpatient hospital admission is not medically necessary for this patient.
This patient received IV fluids and was monitored as her diet advanced. There is not clear documentation from the ED record that oral rehydration therapy (ORT) was tried and failed. At the time of admission, she had stable vital signs, no respiratory distress and no altered mental status. Following admission, the patient had minimal continued diarrhea and vomiting and did not require additional intravenous medications. While her low bicarbonate likely indicated metabolic acidosis from dehydration, this was resolved with IV fluids and did not require IV electrolyte correction, telemetry, nor repeat labs. 
The patient had tachycardia and tachypnea while febrile but these vital signs improved with antipyretics and fever resolution. While she had diarrhea and vomiting at home, she tolerated sufficient oral intake after intravenous (IV) fluids and Zofran. She did not have severe persistent vomiting and did not require re-administration of Zofran after admission from the emergency department (ED). Lastly, she did not have abnormal sodium or glucose levels. Her low bicarbonate level of 14 was indicative of mild to moderate dehydration but did not require electrolyte supplementation, telemetry or even repeat labs during hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vascular dementia, depression, anxiety, insomnia, hypertension, aortic valve stenosis, anemia, hypothyroidism, dizziness, and unsteady gait.
Treatment: Increase in Consumer Directed Personal Assistant Service (CDPAS) from 49 hours/week to 24 hour live-in
The insurer denied the increase in CDPAS from 49 hours/week to 24 hour live-in.
The denial is upheld.

The patient is an elderly male with a history of vascular dementia, depression, anxiety, insomnia, hypertension, aortic valve stenosis, anemia, hypothyroidism, dizziness, and unsteady gait.

The Uniform Assessment System (UAS) earlier this year notes needing assistance with bathing, toileting, transferring and walking. The patient uses a walker to transfer. No significant changes in functional status are noted. Cognitive skills are minimally impaired. The patient is total dependence in meal preparation and ordinary housework, extensive assistance in transportation, bathing, personal hygiene, dressing, and toilet use. The patient is independent in eating and uses a Rollator for ambulation. Prior assessment from 2 years ago noted extensive assistance with activities of daily living, which is evidenced to have improved.

The request is for an increase in Consumer Directed Personal Assistant Service (CDPAS) from 49 hours/week to 24 hour live-in.

The requested increase in CDPAS from 49 hours/week to 24 hour live-in is not medically necessary.

The patient's cognitive skills are minimally impaired. The patient is total dependence in meal preparation and ordinary housework, extensive assistance in transportation, bathing, personal hygiene, dressing, and toilet use. The patient is independent in eating, and the patient uses a Rollator for ambulation.

The patient's assessment has minimally improved from a previous assessment to the most recent one. The patient uses a walker to ambulate. Extended hour care is in excess of the patient's needs.

Therefore, given the above, the requested increase in CDPAS from 49 hours/week to 24 hour live-in is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cellulitis

Treatment is an inpatient admission 

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

The patient with a past medical history significant for substance abuse, hypertension, and benign prostatic hyperplasia, presented to emergency department with complaints of left lower leg swelling and pain. 

Vitals on presentation included: Temperature 98.1 degrees F (Fahrenheit), Blood Pressure 144/91, Pulse 108, Respiratory Rate 17, and oxygen saturation 100% on room air. Laboratory results included the following: WBC (white blood cell count) 6.3, HGB (hemoglobin) 11.5, HCT (hematocrit) 35.6, creatinine 0.93, glucose 98, and lactic acid 0.96.

The patient was administered Narcan while in the emergency department for lethargy. He started empirically on intravenous antibiotics (vancomycin and cefepime) for left leg cellulitis. An X-ray of the leg showed mild degenerative changes and soft tissue swelling but no osteomyelitis. He remained afebrile and hemodynamically stable and left the hospital against medical advice (AMA).

According to documentation, the patient was admitted for a possible cellulitis. Otherwise, he was afebrile, hemodynamically stable. Laboratory results were unremarkable including a normal WBC. There was no evidence of a disseminated infection, no surgical intervention was required, and the patient was not immunocompromised. 

Prior determination of denial of coverage for inpatient hospital services is upheld. 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 hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: nasal polyps
Treatment is Dupixent Syn 300
The insurer denied coverage for Dupixent Syn 300
The denial is overturned

This is an adult male with a long history of nasal polyps refractory to medical and surgical interventions. A medical note documented the following: "This patient has massive polyps completely including both of his nasal cavities, he already has had multiple surgeries and has had multiple rounds of oral steroids and the polyps persist. Looking inside of his nose on routine rhinoscopy reveals complete occlusion of the nasal cavity by his polyps."

The insurers criteria for reimbursement for Dupixent therapy as is:

"...current plan approved criteria only allow coverage of Dupixent if the patient had polyps reaching below the lower border of the middle turbinate or beyond in each nostril."

This patient fulfills these criteria as his nasal polyps were documented to be beyond the lower border of the middle turbinate in both nostrils.

Dupixent Syn 300 is considered medically necessary for this patient as documented in the peer reviewed literature (1-4) and that the patient fulfilled the insurers criteria for Dupixent therapy. Dupixent has been approved by the FDA (food and drug administration). The peer reviewed literature attests to the efficacy of Dupixent therapy for nasal polyps1-4. This patient fulfills the insurers criteria as his nasal polyps were documented to be beyond the lower border of the middle turbinate in both nostrils. 

The health 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 Dupixent Syn 300 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  High Blood Sugar Levels.
Treatment:  Inpatient Hospital Admission.
The insurer denied the Inpatient Hospital Admission.  
The denial is upheld.

The patient is an adult male with type 2 diabetes and with a history of non-adherence, hypertension, and hypothyroidism. He presented with subjective fever and abdominal pain for three days.

The patient's glucose was 303 mg/dL (milligrams per deciliter), CO2 (carbon dioxide) 15, venous pH 7.35, lactate 2.22, A1C (glycated hemoglobin) 9.8%, and beta-hydroxybutyrate 3.06. His heart rate was 131, temperature 100.6, respiratory rate 20, and BP (blood pressure) 143/86. He was alert and oriented.

The patient was admitted to the intensive care unit and treated with insulin drip and intravenous fluids. He was transitioned to subcutaneous insulin. He was started on levothyroxine and fenofibrate.

Inpatient stay is under review.

The Inpatient Hospital Admission was not medically necessary.

This patient presented with hyperglycemia and dehydration in the setting of known type 2 diabetes with non-adherence. He had tachycardia that improved with hydration. He was hemodynamically stable. He presented with a fever but did not have evidence of sepsis, and no infection was found. He had hyperglycemia with a reduced CO2 (carbon dioxide) level but with a normal pH of 7.35, which is not consistent with diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar state. His glucose improved with hydration and insulin therapy with a glucose of 148 mg/dL (milligrams per deciliter). Therefore, no, the requested inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: seizure
treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns of a seizure. Pertinent history included depression, asthma, and syncope. Initial vital signs revealed a temperature of 97oF, heart rate (HR) 91, blood pressure (BP) 133/101, respiratory rate (RR) 18, and SpO2 100% on room air. Initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a white blood cell count (WBC) 5.1, HGB 11.3, platelets (Plt) 307, Na (sodium) 138, K (potassium) 4.2, carbon dioxide (CO2) 22.8, Ca (calcium) 8.9, Glucose 73, blood urea nitrogen (BUN) 10, Cr (creatinine) 0.8, and Tbil (total bilirubin) 0.3. Urine drug screen was negative. Two episodes of seizure-like activity was noted in the ED and treated with lorazepam. Following administration, activity stopped and the patient was immediately alert and oriented. Neurology was consulted and recommended admission overnight for observation.

The inpatient admission was not medically necessary. In this particular situation, the patient had a history of depression and presented with concerns for seizure-like activity. An outpatient evaluation for such had already been scheduled but not completed. Upon arrival, the patient was alert and oriented. Multiple jerking episodes were noted without post-ictal periods. An extensive evaluation including an echocardiogram, MRI brain, and EEG were performed and essentially unremarkable. Following observation care, the neurologist, psychiatrist, and attending physician had an impression of pseudoseizures. No anti-epileptic drugs were initiated or felt to be indicated. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis
Treatment: Inpatient Hospital Admission
The insurer denied coverage for inpatient hospital admission
The denial is overturned

The patient is an adult female who presented to the emergency Department (ED) with complaint of (C/O) chest tightness and neck pain which was radiating to the left arm. The patient also complained of sore throat and dry cough. The pain was pleuritic type in nature. Past medical History (PMH) included anxiety and gastroesophageal reflux disease (GERD). The patient took some antacid with no relief, so she came to ED.  Vital signs at presentation were temperature 97. 4 Fahrenheit (F), heart rate (HR) 118, respiratory rate 20, blood pressure 135/90 Mm Hg (millimeters of mercury), oxygen (O2) saturations 98 % (percent) on room air. The patient was able to speak full sentences and had non labored respiration. Lungs were clear. Cardiovascular system (CVS) S1 S2 N and she was noted to be tachycardic.  White blood cell count (WBC) was 18 with 88% Poly's hemoglobin (Hb) 14.8.  Liver function test (LFT's) were elevated. Procalcitonin was mildly elevated initially.

The patient underwent a computed tomography (CT) angiogram which revealed left upper lobe (LUL) and lingular patchy infiltrates. In addition, a filling defect was noted in a small RL (right lower) pulmonary artery branch consistent with pulmonary embolism (PE).  The patient was admitted to hospital with pneumonia (PNA) and PE. Started on intravenous (IV) Azithromycin and Rocephin. As per history and physical, the patient was Febrile to 101.1F with HR 122. The patient was admitted for Sepsis/Pneumonia/Pulmonary Embolism, possible Vaping pneumonitis.

The patient was seen by Infectious Disease (ID) and Pulmonary. The patient continued to spike temperatures to 103 F the following day. Her WBC was also increasing to 21 with left shift and Bandemia of 11%. The patient was evaluated by ID who recommended broadening intravenous (IV) Antibiotics to Ceftazidime, Vancomycin and Doxycycline in view of worsening signs of Sepsis. The patient's Procalcitonin increased to 3.06 and C-reactive protein (CRP) was 273. The patient continued to be febrile. She was continued on broad spectrum antibiotics. Ultrasound of liver revealed hepatic steatosis.  The patient became afebrile and WBC started trending lower along with down trending of inflammatory markers and patient was discharged home on oral antibiotics and anticoagulants.

Given the patient's presentation with signs of sepsis and high fevers with bandemia, and increased LFT's and other markers of inflammation it was appropriate to admit the patient for treatment and close monitoring.

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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous ablation of basivertebral nerve (64629)
The insurer denied: Intraosseous ablation of basivertebral nerve (64629)
The denial is upheld.

The patient is an adult female with chronic low back pain for over six months not responsive to conservative management (physical therapy, medication management - Gabapentin and Tramadol, interventional procedures - trigger point injections, epidurals, and lumbar spine surgery (lumbar laminectomy and discectomy). The patient's treating provider diagnosed her with vertebrogenic low back pain confirmed by Modic changes at the L3/L4 (lumbar three/lumbar four) level, but not at the L4/L5 (lumbar four/lumbar five) level as stated in the progress note. The Intracept procedure was recommended; however the procedure was only recommended at the L3/L4 (lumbar three/lumbar four) level and denied at the L4/L5 (lumbar four/lumbar five) level since no Modic changes were identified at that level.

The proposed Intracept procedure to L4/L5 (lumbar four/lumbar five) is not medically necessary.
The Intracept procedure is indicated for people with chronic low back pain secondary to a vertebrogenic source confirmed by Modic type I or II changes in the vertebrae of L3 - S1 (lumbar three to sacral one) on magnetic resonance image (MRI). This patient's magnetic resonance image only showed Modic changes at the L3/L4 (lumbar three/lumbar four) level, but the Intracept procedure was requested for the L3/L4 (lumbar three/lumbar four) and L4/L5 (lumbar four/lumbar five) levels. Therefore, the Intracept procedure at the L4/L5 level is not medically necessary. The plan has approved CPT 64628 at the L3/L4 (lumbar three/lumbar four) level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia
Treatment: Olumiant 2MG (milligrams) tablet
The insurer denied the Olumiant 2 MG tablet.
The denial is upheld.

The patient is a male with alopecia. He has hair loss on the beard and eyebrows. He has failed intralesional Kenalog. He was prescribed Xeljanz.
The subject under review is the medical necessity for Olumiant 2MG tablet.

The health plan's determination is upheld.

The requested health treatment of Olumiant 2 MG tablet is not medically necessary for this patient. There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Olumiant for this patient's condition as an accepted standard of practice in the United Stated prior to the standard alternatives. There is no documentation the patient has exhausted all standard options, and that it would therefore be medically necessary to start systemic treatment with Olumiant, which would carry a higher side effect profile. Within the peer-reviewed literature, there are other effective first-line treatments for the management of severe alopecia. (4)
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis; Migraine
Treatment: Nurtec
The insurer denied Nurtec.
The health plan's determination is overturned.

The patient is a woman diagnosed with acute migraine, hypertension, and coronary artery disease. Treatment with Nurtec ODT (oral disintegrating tablet) is the subject of this review. The drug was denied because the patient has not tried and failed 3 formulary alternatives.

A formulary exception is indicated in this case. The patient is diagnosed with acute migraine. Nurtec ODT is prescribed for treatment of acute migraine. Other indications for Nurtec ODT include episodic migraines.

The drug was denied because the patient has not tried and failed triptans as these are the only medications from the available formulary alternatives that are safe and effective for treatment of migraine. There is no documentation that the patient has tried and failed these drugs.

However, the provider indicates that treatment with triptans, due to their vasoconstrictive mechanism of action, are inappropriate and contraindicated as the patient is diagnosed with hypertension, coronary artery disease, and vertebrobasilar syndrome. Of these, coronary artery disease is a medical contraindication to the use of triptans and hypertension is a relative contraindication. As such, the available formulary alternatives would have adverse effects to the patient's health.