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

Diagnosis: Systolic congestive heart failure.
Treatment: Inpatient admission.

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

The patient presented to the hospital complaining of shortness of breath, chest pain, orthopnea and pedal edema. Past medical history was significant for systolic heart failure with a left ventricular (LV) ejection fraction of 20-25%, diabetes mellitus, hypertension and substance abuse. Upon arrival, vital signs were stable, blood pressure was 139/78 and pulse was 91. Physical examination was significant for decreased breath sounds along both lung bases and pedal edema.  A 12-lead electrocardiogram revealed normal sinus rhythm with a prolonged QTc (interval on an electrocardiogram) interval of 522 and ventricular premature complexes (VPC). Serum blood testing was significant for elevated B (brain) type natriuretic peptide (4203) and troponin (39.2). Serum magnesium was 1 (low). A toxicology screen was positive for cocaine. The patient was admitted to the hospital and treated with intravenous diuretic therapy and guideline directed medical therapy for systolic congestive heart failure. She ultimately signed out against medical advice. 

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with decompensated congestive heart failure in the setting of cocaine use. She also had a prolonged QT (interval on an electrocardiogram) interval on electrocardiogram. Following initiation of medical therapy, the patient signed out against medical advice. This patient could not have been managed at an alternate level of care and required inpatient treatment/follow up. There have been several studies including a meta-analysis of more than 50,000 patients demonstrating poor outcomes for patients that are discharged from the emergency department after presenting with congestive heart failure (CHF). These findings were true in both systolic and diastolic CHF (Reference 1,2). In conclusion, it was medically necessary to manage this patient at an inpatient level of care.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Infectious Disease-Human Immunodeficiency Virus (HIV).
Treatment: Pharmacy/Prescription Drugs-Juluca.
The insurer denied Juluca.
The denial is upheld. 

The patient is a male diagnosed with human immunodeficiency virus (HIV), no history of opportunistic infection (OI)s. He also is stated to have dyslipidemia , insomnia, depression, and hypothyroidism. Medical note states the patient has been taking Atripla with a rare missed dose, and that he had been "on every antiretroviral (ARV) available." T cells (CD4) was 1045/45.8% (percent). Other medications included trazadone, Synthroid, Tricor and Lipitor.
The patient's provider ordered Juluca for him. It is stated in his letter that the patient has severe metabolic syndrome and lipodystrophy, and that he prefers to avoid Tenofovir regimens as it can adversely affect renal function, and Descovy can cause weight gain. The provider also stipulates that Juluca should be taken in the co-formulated pill and not as separate components, because separate pills will increase the patient's polypharmacy and pill burden, and that taking the separate components risks not taking the medications as they need to be, which could lead to viral resistance.
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, Juluca, or would have adverse effects.

The health plan's determination is upheld in whole.

The formulary drugs have not been ineffective and would be as effective as the non-formulary drug and would not have adverse effects.
There is nothing in the medical history and records provided that would indicate why any of the formulary drugs would be ineffective, or not as effective as the non-formulary drug, Juluca, or that any of the formulary drugs would have adverse effects. There are no records indicating which ARV therapy this patient has taken in the past and the reasons for changes in his regimen or whether he has had any drug mutations or resistance.
People with HIV may gain weight after starting antiretroviral treatment. Clinical trials of new HIV drugs introduced since 2003 show that people taking dolutegravir (one of the components of Juluca) are at higher risk of substantial weight gain than people taking other antiretroviral drugs. Dolutegravir may cause weight gain, one of the primary concerns of the prescribing provider. Depression, abnormal dreams, and difficulty sleeping are also noted side effects, and this patient is stated to suffer from insomnia and depression.
No history is provided about past ARV other than that he has been on other drugs, but it is not stated why his regimens were changed in the past, what, if any, adverse reactions the patient experienced on specific antiretrovirals, and/or if he developed resistance to any antiretrovirals.
Therefore, the formulary drugs have not been ineffective and would be as effective as the non-formulary drug.
Appeal type: Formulary Exception
Decision: Upheld

The insurer denied Juluca. The denial is upheld. 
The patient is a male diagnosed with human immunodeficiency virus (HIV), no history of opportunistic infection (OI)s. He also is stated to have dyslipidemia , insomnia, depression, and hypothyroidism. Medical note states the patient has been taking Atripla with a rare missed dose, and that he had been "on every antiretroviral (ARV) available." T cells (CD4) was 1045/45.8%. Other medications included trazadone, Synthroid, Tricor and Lipitor.
The patient's provider ordered Juluca for him. It is stated in his letter that the patient has severe metabolic syndrome and lipodystrophy, and that he prefers to avoid Tenofovir regimens as it can adversely affect renal function, and Descovy can cause weight gain. The provider also stipulates that Juluca should be taken in the co-formulated pill and not as separate components, because separate pills will increase the patient's polypharmacy and pill burden, and that taking the separate components risks not taking the medications as they need to be, which could lead to viral resistance.
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, Juluca, or would have adverse effects.

The health plan's determination is upheld in whole.

The formulary drugs have not been ineffective and would be as effective as the non-formulary drug and would not have adverse effects.
There is nothing in the medical history and records provided that would indicate why any of the formulary drugs would be ineffective, or not as effective as the non-formulary drug, Juluca, or that any of the formulary drugs would have adverse effects. There are no records indicating which ARV therapy this patient has taken in the past and the reasons for changes in his regimen or whether he has had any drug mutations or resistance.
People with HIV may gain weight after starting antiretroviral treatment. Clinical trials of new HIV drugs introduced since 2003 show that people taking dolutegravir (one of the components of Juluca) are at higher risk of substantial weight gain than people taking other antiretroviral drugs. Dolutegravir may cause weight gain, one of the primary concerns of the prescribing provider. Depression, abnormal dreams, and difficulty sleeping are also noted side effects, and this patient is stated to suffer from insomnia and depression.
No history is provided about past ARV other than that he has been on other drugs, but it is not stated why his regimens were changed in the past, what, if any, adverse reactions the patient experienced on specific antiretrovirals, and/or if he developed resistance to any antiretrovirals.
Therefore, the formulary drugs have not been ineffective and would be as effective as the non-formulary drug.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Humerus fracture
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
 
This is a female with no significant past medical history. She presented to the emergency department (ED) with complaints of right arm pain. Pain began in November after she was assaulted by a bus driver. Imaging of the arm revealed a right proximal humerus fracture. The patient was admitted for care. She underwent an open reduction internal fixation (ORIF) of the right proximal humerus. Pain medication was given as needed (PRN). Vital signs were monitored. The patient's condition was stabilized. She was discharged. 

The medical record showed admission was based upon referral and workup for surgery that took place the following day. There was no emergent condition. There was no documentation of a painful condition to require urgent assessment in ED. 

The requested service is elective where the person was brought in through the ED. People with nonunion are evaluated in the physician's office and a surgical date is selected. Preoperative testing is performed prior to admission and surgical date. 

Surgery was completed the day after admission. The procedure and blood loss were without complication. There was no evidence of fever, bleeding, need to treat other medical condition, requirements of additional testing nor inability to tolerate oral pain medication. There was no reason, discharge could not have been completed the day after surgery. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is upheld.

The patient is a male with history of (H/O) asthma. The patient presented to the emergency department (ED) with a 4-day H/O cough, wheezing and URTI (upper respiratory tract infection) symptoms. The patient took Albuterol at home but did not get relief so came to the ED.

Vital signs (V/S) at presentation were as follows: afebrile, blood pressure 118/76 mm Hg (millimeters of mercury), Heart Rate 126, Respiratory Rate 28, Oxygen (O2) sats (saturations) 99% (percent). The patient was in no acute distress (NAD) and Tachypneic. Lung exam revealed bilateral (B/L) diffuse wheezes.

The patient was treated with oral (PO) steroids and BD (bronchodilator) via Nebs (nebulizers) in ED.

The patient's RSV (respiratory syncytial virus) panel came back as positive. He was treated with oral (PO) steroids and BD after admission. He remained stable after admission. He was noted to have some mild hypoxia with O2 sats of 88%. The patient was placed on 2L (liters) NC (nasal cannula) with O2 sats improving to 94% and then was switched to 1L NC with stable O2 sats.

As per the history and physical (H&P) the patient was in NAD.

Lungs sounds were auscultated B/L (bilaterally), and a diffuse wheeze was heard. The patient alert and oriented [A x O X 3 (person, place, and time)] with a non-focal neurological exam.

The patient was weaned off O2. He remained stable and was tolerating PO (oral intake). O2 sats on Room Air were 93-95%. Lungs were described as clear.

The patient was medically cleared for discharge (DC) home on PO steroids and BD and maintenance inhalers.

This patient did not need acute inpatient hospitalization. He could have been placed on observation status while diagnostic testing and treatment were initiated. The observation period could be for up to 48 hrs (hours). The patient improved with treatment and was medically cleared for DC by the next day on PO Steroids, BD and maintenance inhalers. The patient could have been placed on observation and treated. 

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 hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: Inpatient admission 

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

This patient was sent to the emergency department (ED) by her gynecologist because of a hematocrit of 18.2 /hemoglobin of 4.7. The patient had a history of irregular vaginal bleeding. On presentation she was not bleeding. Her last bleeding episode was 2 days prior to presentation. She reported fatigue, generalized weakness, palpitations, and lightheadedness especially with walking and standing. Her vital signs were stable. She was admitted with a diagnosis of symptomatic anemia, with no active vaginal bleeding and for a blood transfusion. She received 3 units of packed red blood cells. 

The insurer has denied coverage for the inpatient admission as not medically necessary. In their Final Adverse Determination letter, they write that criterion for an inpatient level of care was not established; however, an observation level of care was approved.

This patient was referred by her gynecologist for a blood transfusion because of symptomatic severe anemia. Transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home), so the need for a transfusion is not a reason for admission. The patient could have been transfused as an outpatient. Note that the patient was not actively bleeding.

Milliman Care Guidelines (MCG) lists the clinical indication for inpatient care for patients with anemia. These include active massive hemorrhage, active hemolysis, cognitive impairment, heart failure, chest pain, and syncope. 

This patient was stable and did not have any of the above. Based on all of the above, the admission was not medically necessary.

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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Multiple Sclerosis
Treatment: Kesimpta, pre-service
The insurer denied the Kesimpta, pre-service.
The denial is overturned.

The patient is a female with highly active multiple sclerosis. She has poor prognostic factors including multiple active lesions, spinal cord lesions, and her race. Her provider wishes to start her on Kesimpta, which is a highly effective medication for multiple sclerosis. The request was previously denied as three or more of the following medications must be tried: Aubagio, Betaseron, Copaxone, Gilenya, glatiramer, Glatopa, Rebif, or dimethyl fumarate.

Yes, the health plan should cover the proposed treatment with Kesimpta.

Kesimpta is medically necessary and standard of care for this patient. She has highly active multiple sclerosis with poor prognostic signs including multiple active lesions, spinal cord lesions, and race. She is at very high risk for further relapses and disability progression. All of the medications in the formulary with the exception of Gilenya and dimethyl fumarate are low efficacy medications and Gilenya and dimethyl fumarate are medium efficacy medications and would not be appropriate for patient. It is standard of care and emerging evidence has shown that those with active disease and poor prognostic signs benefit from high efficacy therapy and Kesimpta is a high efficacy medication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Surgical Services. 
The insurer denied outpatient surgery services (shrink fibroids). 
The denial is upheld.

The patient is a female who had a prior myomectomy for fibroids which have now started to recur since ultrasound documentation. She is noted to have heavy bleeding for the first few days with a 7 day cycle. She had a pap that was normal. Her mammography was normal. She is a gravida (G)0para (P)0 patient. There is no prior pregnancy history noted. She carries a diagnosis of fibroids of the uterus. She had an open myomectomy. She is a non-smoker. An ultrasound was performed that noted the uterus to be 8.6 x 7.2 x 6.5 centimeters (cm) with two myomas of 5.4 x 5.0 x 5.1 cm in there anterior intramural/submucosal area and one of 2.1 x 1.5 x 1.7 cm in the lower uterine segment. The endometrium was 10 millimeters (mm) and there was no focal endometrial mass. Ovaries were normal with a complex ovarian mass in the left ovary of 3.1 x 2.3 x 2.1 cm. The patient was offered options for management and was interested in uterine sparing treatment and did not want laparoscopic or surgical interventions. She was also offered medications and declined hormonal therapy. She was also offered uterine artery embolization or Sonata procedure. She desired Sonata radiofrequency ablation. The subject under review is the medical necessity for outpatient surgery services.

The health plan's determination is upheld.

Although laparoscopic radiofrequency ablation (RFA) with a leiomyoma-specific FDA-approved device has been studied primarily in nonrandomized trials, two recent meta-analyses summarize long-term data on the use of RFA to treat a wide variety of leiomyoma types and sizes. In these two meta-analyses, which included over 1,800 patients, uterine leiomyoma volume reduction ranged from 32% to 66% at 12 months, and 77% at greater than 12 months follow up. The cumulative rate of postoperative surgical reintervention for leiomyoma-related symptoms was 4.2%, 8.2%, and 11.5% at 1, 2, and 3 years, respectively. Statistically and clinically significant improvements were observed in health-related quality of life and symptom severity in long-term follow up (up to 36 months). Complication reporting was highly inconsistent, but no serious procedural complications such as death or injury to visceral structures was reported in any of the included studies. Neither meta-analysis reported outcomes on menstrual bleeding.

In a case-series of 30 pregnancies after laparoscopic RFA, there were 26 full-term live births and four pregnancy losses. Although in this small case series there were no cases of preterm delivery, uterine rupture, placental abruption, placenta accreta, or intrauterine growth restriction, sample size precludes any definitive conclusions about risk or incidence of pregnancy complications.
Thus, in this case, the Sonata system is a new option in the management of leiomyomas that lacks long term outcomes to support this specific technology. Thus, it is not considered the standard of care until sufficient randomized controlled trials with long term outcomes are available.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cracked tooth.
Treatment: D2740 Porcelain Crown (Quads 02).
The insurer denied the D2740 Porcelain Crown (Quads 02).
The denial is upheld.

The patient is a male. The request is for a porcelain crown on tooth #2. The denial was due to no fracturing of 50% of the tooth, or being a root canal tooth, or having symptoms.

No, D2740 porcelain crown (quads 02) was not medically necessary.
Tooth #2 has a small, conservative composite restoration in it. As required by the community standards, no recurrent decay is seen on the x-ray, but there does look to be a small amount of decay on the margin of the filling. In addition, the photos and x-rays do not show 50% of the tooth missing; this tooth has not had root canal therapy either; and there is also no documentation of symptoms from "cracked tooth syndrome," which would necessitate a crown.

The photos presented do not show all the "cracks" (not fractures) that the provider says are there (i.e cannot see the "crack" on the buccal of the tooth). 

There is no medical necessity for crown benefits on this tooth based upon the submitted documentation.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Menorrhagia.

Treatment: Norethindrone ethinyl estradiol-iron (Lo Loestrin Fe (iron)) 1 milligram-19 micrograms (mcg) / 10 microgram.

The insurer denied coverage for norethindrone ethinyl estradiol-iron (Lo Loestrin Fe) 1 milligram-19 micrograms / 10 micrograms.

The denial is upheld.

The patient is a female with a history of heavy periods, cramps and acne. She has missed school because of her menstrual cycle. The provider prescribed Lo Loestrin Fe.

There are several types of combination pills. Monophasic pills contain the same dose of estrogen and progestin in each of the hormonally active pills. Biphasic or triphasic pills have varying doses of hormone across the cycle (usually the progestin). There are no proven advantages to the multiphasic regimens. 
The estrogen component of nearly all OCs (oral contraceptives) is ethinyl estradiol. Standard OCs today contain 30 to 35 mcg of ethinyl estradiol, but many pills now contain only 20 mcg or less. Contraceptive efficacy with the low dose pills is similar to the standard dose pills, as long as adherence is good. There are no proven benefits or fewer side effects with pills containing the lower dose of ethynil estradiol. Most available progestins have both progestogenic and androgenic activity. To date, they have no proven clinical advantages over traditional progestins, and some have been associated with a possible higher risk of venous thromboembolism. In summary, any oral contraceptive on the formulary should be adequate for contraceptive purposes for this patient, for management of dysmenorrhea, heavy bleeding, and acne and Lo Loestrin is not medically necessary.

Lo Loestrin Fe 1 milligram-10 micrograms / 10 micrograms or tabs is not considered medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Lo Loestrin Fe 1 milligram-10 micrograms / 10 micrograms or tabs is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic urticaria
Treatment: Xolair

The insurer denied the Xolair.
The determination is upheld.

This is a patient with idiopathic urticaria. The request is for Xolair. She is taking Doxepin, Montelukast and Singulair. She has tried other antihistamines but it is not clear the exact doses and time frame. At issue is the medical necessity of Xolair.

No. The Xolair is not medically necessary. The guidelines for the treatment of chronic spontaneous urticaria were updated with the publication of the 2018 international expert document on the definition, classification, diagnosis, and management of urticaria. These 2018 guidelines recommend that after the failure of high-dose (up to 4 times (x)) non-sedating second generation antihistamines, the third step of therapy is omalizumab. The older 2014 Joint Task Force on Practice Parameters (JTFPP) practice parameter on chronic urticaria had recommended alternative options. However, there is expert consensus that the recommendations of the 2018 international guideline should be followed. In this case, it is not clearly noted the dates and doses of high dose second generation histamine (H) 1 antihistamines used. Therefore, the Xolair is not medically necessary.