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

Mental Health
Pharmacy/prescription drug

Diagnosis: attention deficit hyperactivity disorder (ADHD)
Treatment: Vyvanse
The insurer denied Vyvanse. The health plan's determination is upheld. 

The patient is a young male with a history of attention deficit hyperactivity disorder (ADHD). The patient has had trials of Concerta and Focalin XR but remained symptomatic. His provider recommended a trial of Vyvanse. This is under review.

Vyvanse is not medically necessary for this patient. The patient has not had trials of other amphetamine based products and there is no evidence that Vyvanse would be superior to other amphetamine products for his condition. Stimulants are first line medications to treat attention deficit disorder and in general children respond best to methylphenidate based medications. There is no evidence that Vyvanse would be superior to other amphetamine or methylphenidate medications that the patient has not trialed.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Alopecia Areata.
Treatment: Xeljanz 10MG (milligram) Tablet.

The insurer denied Xeljanz 10MG (milligram) Tablet.  The denial is upheld.

The patient is an adult female. She is diagnosed with severe alopecia areata. She has tried and failed intralesional steroid injections. She has now been prescribed Xeljanz. The request for Xeljanz was denied coverage by the health plan. The denial is being appealed. The request was denied because the use of Xeljanz is considered experimental/investigational for this condition.

The health plan should not cover the requested Xeljanz.

Xeljanz has not been approved for the treatment of alopecia areata, whereas there is another FDA (United States Food and Drug Administration)-approved medication for this condition. There is no indication that the patient has tried and failed other FDA (United States Food and Drug Administration)-approved treatments. In the records provided, there is no documented contraindication to a trial of other FDA (United States Food and Drug Administration) approved treatments for this condition. 

There is insufficient data in current medical literature that shows that use of Xeljanz is more beneficial than the current FDA (United States Food and Drug Administration)-approved Olumiant for the treatment of alopecia areata.
Per King et al (2022), "In two phase 3 trials involving patients with severe alopecia areata, oral baricitinib was superior to placebo with respect to hair regrowth at 36 weeks."

Olamiju B et al. (2019) writes "the treatment of AA [alopecia areata] with systemic medications is merited, and it has been shown that quality of life in AA [alopecia areata] can be restored with successful treatment. Although effective therapy for patients with severe disease has historically been elusive, the emergence of JAK [janus kinase] inhibitors is changing this."

Per Slomski A (2022), "Treatment with oral baricitinib, a Janus kinase inhibitor, resulted in hair regrowth among patients with alopecia areata, 2 phase 3 trials published in the New England Journal of Medicine demonstrated."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Alopecia Areata.
Treatment: Xeljanz 10MG (milligram) Tablet.

The insurer denied Xeljanz 10MG (milligram) Tablet.  The denial is upheld.

The patient is an adult female. She has a medical history of alopecia areata and atopic dermatitis. The patient has tried and failed intralesional Kenalog and topical steroids. This request for coverage of Xeljanz is under review.

The health plan should not cover the treatment with Xeljanz.

The requested drug is neither FDA (United States Food and Drug Administration) approved nor widely used medication in the clinical setting for treating alopecia areata. Additionally, there are other FDA (United States Food and Drug Administration) approved medications like Olumiant that have yet to be tried and failed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/ Musculoskeletal/ Back Pain/ Low back Pain
Treatment: Surgical Services  (All)/ Intracept Procedure
The health plan has denied the requested treatment, Intracept Procedure, as not medically necessary. The health plan's determination is upheld. 

The patient is a male with complaints of low back pain. The pain began some  years ago. Prior treatment has included home exercises, lumbar spine surgery, as well as physical therapy and medications. The patient's pain impacts his activities of daily living (ADL). The patient reports his pain can be rated as high as 9 out of 10. Magnetic resonance imaging of the lumbar spine showed Modic changes at lumbar (L)5-sacral (S)1.

At issue is the medical necessity of an Intracept Procedure.
I uphold the health plan's determination, in whole.

The requested health service/treatment of Intracept Procedure is not medically necessary for this patient.

There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. An Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. Therefore, the requested health service/treatment of Intracept Procedure is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a medical history hypertension, hypercholesterolemia, diabetes mellitus and Bipolar 1 disorder who was admitted for a pneumonia and possible colitis with symptoms of nausea, vomiting, generalized weakness and cough. Her computed tomography (CT) chest demonstrated pneumonia but did not demonstrate evidence of an empyema/abscess/necrotizing pneumonia. 

Based upon the severity of illness, intensity of required therapy and criteria provided, the inpatient level of care was not medically necessary. This patient with a medical history of hypertension, hypercholesterolemia, diabetes mellitus and Bipolar 1 disorder was admitted for pneumonia and possible colitis with symptoms of nausea, vomiting, generalized weakness and cough. Of note, the patient was diagnosed with Influenza A and was treated with Tamiflu. As per the clinical documentation, on admission, the patient was afebrile, hemodynamically stable, with a respiratory rate of 18 breaths per minute, oxygen saturation 99% (percent) on room air, and had normal breath sounds without rales/rhonchi/wheezes on auscultation of the chest. Her computed tomography (CT) chest demonstrated pneumonia but did not demonstrate evidence of an empyema/abscess/necrotizing pneumonia and she was treated with antibiotics (Ceftriaxone & Azithromycin). She was alert, awake and oriented throughout her stay, she did not have a documented immunosuppressed state, bacteremia, or dehydration, acute kidney injury, she was able to take oral medications and feeds and her CURB-65 score was 0 and Pneumonia Severity Index score was a risk class 2 and outpatient treatment would be considered reasonable. In addition, she did not have any decompensation of her comorbidities, did not require supplemental oxygen for hypoxia/hypoxemia and did not require isolation for her condition. Therefore, the Inpatient hospital stay was not medically necessary for this patient and a lower level of care would have been appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath. 
Treatment: Inpatient hospital admission. 
The insurer denied the inpatient hospital admission. 
The determination is overturned. 

This is a female patient with a past medical history (PMH) of human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART) and asthma who was admitted with complaints of (c/o) fevers, a cough, and shortness of breath (SOB). Imaging studies included a computed tomography (CT) scan of the chest which showed bilateral lung infiltrates concerning for pneumonia. The patient was diagnosed with coronavirus (COVID)-19 complicated by community acquired pneumonia (CAP) and treated with antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care. 

The hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with a complaint of (c/o) fevers, a cough, and SOB, and was found to have bilateral lung infiltrates concerning for pneumonia. This patient with multi-lobar pneumonia with a known respiratory history of asthma, as well as an immuno-compromised state with HIV, met systemic inflammatory response syndrome (SIRS) criteria, and the clinical status was complicated by hypercarbia, and metabolic and lactic acidosis. Furthermore, the patient's SMART-COP [systolic blood pressure, multilobar infiltrates, albumin, respiratory rate, tachycardia, confusion, oxygen, and potential hydrogen (pH)] score was considered high-risk, indicating a high-risk for intensive respiratory or vasopressor support. Overall, this medically complex and immunocompromised patient with pre-existing respiratory disease was considered high-risk for decompensation for multi-lobar pneumonia and could not have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrolithiasis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

According to the documentation submitted, this is the case of a patient with a history of hypertension, hyperlipidemia, asthma, and renal stones. The patient presented to the Emergency Department (ED) due to right lower quadrant and right flank pain. The patient was admitted for pain control and further management of bilateral nephrolithiasis. The patient was evaluated by urology who recommended outpatient follow-up. The patient was discharged.

The insurer has denied coverage for inpatient hospital admission. In their Final Adverse Determination letter, they write that the patient presented to the emergency room with kidney stones. All of the testing done in the emergency department did not identify any condition that required the patient to stay in the hospital. The treatment in the emergency department was sufficient to manage the patient's condition at that time. 

In an appeal letter, the hospital writes that the patient presented with a two-day history of worsening right lower quadrant/flank pain with nausea and fever. The patient was admitted for diagnoses of nephrolithiasis and COVID-19 infection. The patient required continuous intravenous (IV)  fluids, IV pain management for right abdominal/flank pain of 10/10, IV Remdesivir, Lovenox, Flomax, and medical imaging. The patient was not considered medically optimized by the Attending Physician and Urologist.

This is a patient with past medical history of hypertension, hyperlipidemia, asthma, renal stones. Patient presented to emergency department (ED) due to 2 days of right lower quadrant (RLQ) abdominal pain and right flank pain. Computed tomography (CT) scan revealed an 8 millimeter (mm) right distal urethral stone, bilateral non obstructing renal calculi. The patient was given intravenous (IV) fluids, parenteral analgesics in the emergency department, and was admitted for pain control and possible urologic intervention. The patient passed the stone and was discharged home with outpatient follow up. The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health (26th) Renal Colic and Kidney Stones RRG, the patient fails to meet guidelines for inpatient care, but does meet guidelines for observation care. 

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

Diagnosis: Knee Problem/Pain
Treatment: Inpatient Admission
The health plan denied: Inpatient Admission
The determination is: Upheld

The patient is a female who sustained a fall onto her right knee. She tripped on a shopping cart and fell directly onto her right knee resulting in pain and inability to bear weight on the right leg. She was evaluated in the emergency department (ED), where a computed tomography (CT) scan of the right knee was obtained. This study revealed advanced medial compartment degenerative arthritis but no evidence of fracture or dislocation. There was an old patella fracture identified from a fall the patient had a year prior. The patient was then admitted to the hospital for further work up and care. The patient was subsequently managed with oral medications to control her pain and physical therapy for gait training. She was deemed stable for discharge.

At issue is the medical necessity of the inpatient admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient. The provided records document that this patient sustained a trip and fall onto her right knee and was seen in the ED for evaluation. A CT scan of the right knee revealed arthritic changes and evidence of an old patella fracture. No surgical intervention was required for this patient, and she improved with oral medications and physical therapy for gait training. This care is consistent with the current standard of care as documented by Brophy and colleagues in the Journal of the American Academy of Orthopedic Surgeons. The patient had normal lab values and vital signs during her inpatient stay, and there was no need for any surgical procedures. Therefore, the medical necessity for the inpatient hospital admission is not established in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper respiratory tract infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is a patient with a history of thyroid cancer status post thyroidectomy. The patient presented to the emergency department (ED) with complaints of fever, chills, headache, body ache, shortness of breath (SOB) and symptoms of an upper respiratory tract infection (URTI). The patient had been seen at an Urgent care center 4 days prior and was released on Mucinex. COVID test was negative.

Vital signs in the ED were: temperature 101.9 Fahrenheit, blood pressure (BP) 133/76, respirations 18, oxygen saturation on room air was 99% and there was no acute distress. The patient was alert and oriented x 3, lungs were clear and there was no respiratory distress. Heart sounds were normal and there was a non-focal neurologic exam. Labs showed white blood cells (WBC) of 11.5, Hemoglobin of 11.5, and Sodium of 138.  Blood urea nitrogen and creatinine were normal.

The patient was admitted for community acquired pneumonia, rule out sepsis. The patient was started on intravenous (IV) Levaquin and was given an IV fluid bolus as BP was on the lower side. Chest x-ray was positive for right lower lobe airspace disease consistent with pneumonia.

This patient was treated with Levaquin IV initially and was hemodynamically stable except for some transient low BP's which responded to fluids.  There was no acute distress or hypoxia.
CURB 65 (Confusion, Uremia, Respiratory Rate, BP, Age greater than or equal to 65) score was zero. The patient remained stable and was switched to oral (PO) antibiotics and discharged home the next day. 

This patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic studies and treatment were initiated. The patient responded well to treatment and was discharged home the next day. Observation could be for up to 48 hours and this patient was discharged home before that.

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumothorax
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a male with no significant medical history who presented to the emergency department (ED) via Emergency Medical Services (EMS). He reported the acute onset of severe left sided chest pain rated 8 out of 10. He reported that the pain was worse with deep inspiration and worse with movement. He complained of tachypnea and shortness of breath. He was administered intravenous (IV) Morphine in the ED for persistent pain with relief but not resolution. His evaluation included an electrocardiogram (EKG), chest x-ray, computed tomography pulmonary angiogram (CTPA), and laboratory studies.
The patient had a sudden onset of persistent left sided chest pain noted as 8 out of 10 associated with tachypnea and shortness of breath, worsening pain on inspiration and movement and a small apical left pneumothorax showed on the CTPA.

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

The requested service/treatment of an inpatient stay was medically necessary and in the best medical interest of the patient. Significant findings were a left apical pneumothorax on the CTPA that was not visualized on the chest x-ray. Thoracic Surgery was consulted. He was placed on a non-rebreather mask (NRB) and continued to endorse shortness of breath and pleuritic chest pain. He was admitted to the hospital/progressive care unit with a pneumothorax. He was treated with continuous telemetry monitoring and pulse oximetry, repeat chest x-ray in the am or sooner if any change in respiratory status, continue non-rebreather mask at 12 liters, nasal cannula at 6 liters for meals, incentive spirometry, and pain management including intravenous (IV) Toradol every 6 hours. He continued to have pleuritic pain, but his oxygen saturations were stable. The repeat chest x-ray revealed that the pneumothorax was resolving. His pain was controlled by analgesics, and he was tolerating his diet. According to the records reviewed, he clinically improved and was stable for discharge home with follow up.

The patient was managed according to contemporary optimal management. Ambulatory intervention was an option after intervention. In this case the pneumothorax resolved with discomfort and the patient was discharged. An alternate level of care cannot be safely accomplished at home in this case given the pain medicine and the treating teams that acted in the patient's best interest.

The team treated the patient effectively with a larger magnitude of benefit.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The health plan denied: Inpatient Admission
The determination is: Upheld

The patient is a male who presented to the emergency department (ED) complaining of one day of chest pain, dyspnea, and vomiting. His medical history was remarkable for hypertension, hyperlipidemia, and chronic kidney disease. In the ED, his blood pressure was 133/90 millimeters of mercury (mmHg) with a heart rate of 75 beats per minute. His room air oxygen saturation was 100 percent (%). His electrocardiogram (EKG) showed sinus rhythm and was a normal tracing. His serum troponin level was 0.03. The chest x-ray showed no acute pathology. His serum creatinine level was 3.2; his baseline level was 2.3. His brain (or B-type) natriuretic peptide (BNP) level was normal. The patient's pain improved with sublingual nitroglycerin. He was treated with aspirin, clopidogrel, and intravenous (IV) fluid and was admitted to the hospital. He had no further chest pain. His second troponin level was 0.04. His creatinine level was 2.62. He was seen in consultation by a cardiologist who recommended IV heparin and myocardial perfusion imaging (MPI). The MPI was performed and showed no evidence of ischemia. The patient's creatinine level was 1.18. He was discharged.

At issue is the medical necessity of the inpatient admission.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of inpatient admission was not medically necessary for this patient.

This patient presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with a normal EKG. There were no signs of decompensated heart failure. He did not require intensive monitoring or infusion of IV antiarrhythmic or vasopressor medications. While his serum troponin level was minimally elevated, this was likely due to his kidney disease, and there was no significant delta troponin. The care this patient received for his chest pain did not require an inpatient admission and could have been provided at an alternate level of care. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the Guideline for the Evaluation and Diagnosis of Chest Pain and the American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.

Upon admission, the patient had acute kidney injury (AKI), presumably due to volume depletion. He did not have significant electrolyte or acid-base perturbations, and his renal function improved with hydration. An inpatient level of care was not medically necessary based on his AKI.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient admission
The health plan denied inpatient admission. The health plan's denial is upheld.

The patient is an adult female with a past medical history of coronary artery disease and myocardial infarction complicated by ventricular fibrillation arrest, hypertension, hyperlipidemia, and benign paroxysmal positional vertigo. She presented to the emergency department for evaluation of progressively worsening exertional dyspnea associated with diaphoresis, lightheadedness, and non-radiating chest pain.

On arrival to the ED (emergency department), the patient was afebrile and hemodynamically stable. She was saturating well on room air. Initial EKG (electrocardiogram) showed sinus rhythm with occasional PVCs (premature ventricular contractions) and nonspecific ST/T wave abnormalities. proBNP (prohormone brain natriuretic peptide) was 25, and troponins x2 were within normal limits. She was admitted to the inpatient unit and was evaluated by cardiology. She was ruled out for acute coronary syndrome and was ultimately discharged with outpatient follow-up.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. There was no evidence of acute coronary syndrome or acute heart failure. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. Observation level of care would have been appropriate in this case.