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

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

The patient is a female who presented to the hospital with a complaint of abdominal pain of 4-days duration. Her past medical history includes prior episodes of biliary colic. She was admitted to the hospital. Her vital signs were normal at the time of presentation. She was tender in the right upper quadrant. A computed tomography (CT) scan on showed a gallbladder with stones. The surgical history and physical (H&P) states that the patient had cholecystitis for which a laparoscopic cholecystectomy was planned.
The records indicate that the patient remained clinically stable. Surgery was performed. The operative notes describes a laparoscopic cholecystectomy. Laparoscopic cholecystectomy was performed without complication. Following surgery, the diet was advanced and pain was controlled with oral medications. The vital signs were normal. The patient remained clinically stable and was discharged from the inpatient setting.
At issue is the medical necessity of an inpatient stay.
Inpatient care was not medically necessary in this case. The care provided could have been rendered with a lower level of care. The records support a delay in performance of cholecystectomy. A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of IV fluid, surgical consultation, performance of cholecystectomy, and overnight care. There were no peri-procedure complications or other clinical issues.
In this case, the patient presented with cholelithiasis/cholecystitis. Her evaluation and the indication for cholecystectomy was completed and established. The patient was stable and responded promptly to the provided therapy (cholecystectomy). These above noted conditions did not exist to warrant an inpatient level of care. The patient's presenting condition at the hospital, lab data and clinical course did not justify an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foreign body in esophagus

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

This is a case of a patient with foreign body ingestion and fishbone stuck in the proximal esophagus.  The patient was transferred from an outside hospital. On the same day of admission, the patient had successful removal of the fishbone via esophagogastroduodenoscopy (EGD) and was discharged.  No complications were noted.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient had successful removal of the foreign body the same day without any complications and was discharged home the same day.

Inpatient admission is not medically necessary as the patient did not have esophageal perforation or any other complications from the foreign body ingestion or removal via EGD.

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: Right lower quadrant pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female transferred from an outside hospital for evaluation and management of right lower quadrant pain. Imaging by pelvic ultrasound showed an ovarian mass. The patient had stable vital signs and underwent an uncomplicated laparoscopic salpingo-oophorectomy. She was admitted to the hospital and developed nausea and was treated for a presumed infection without source. The patient had a low sodium that was not life threatening and was continued on intravenous antibiotics despite no fever, no elevation in her white blood cell count, and a non-focal exam.

The requested health service was not medically necessary.

The patient had an uncomplicated laparoscopic procedure, which is an outpatient surgery. After the surgery, the patient remained afebrile with stable vital signs, normal bloodwork, and a non-focal exam. She did not have any medical conditions that justify inpatient level of care. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:	Psoriasis	

Treatment:  Otezla

The insurer denied a request is for Otezla

The denial is overturned.

The patient is a young adult with a diagnosis of psoriasis vulgaris affecting the scalp, 3-10% (percent) of the total body surface area. The patient has failed topical steroids.  Based on the documentation, the psoriasis appears to be predominately mild. The request is for Otezla.  

Based on the submitted documentation, the use of Otezla is medically necessary. The patient has mild to moderate psoriasis affecting the scalp. The involved areas makes the use of light therapy challenging. Otezla is Food and Drug Administration (FDA) approved for mild psoriasis, such as this case. Requested alternative systemic agents are not FDA approved for treatment of psoriasis and are not commonly used to treat mild disease. Calcipotriene and coal tar are not likely to be clinically more effective than already tried and failed topical steroids.  Otezla is the most appropriate systemic therapy for mild psoriasis and has an FDA indication for mild and moderate psoriasis. The patient has failed reasonable topical alternatives. The use of alternative systemic agents, such as methotrexate, cyclosporine, or biologics, are generally reserved for more moderate to severe disease. The use of Otezla is approved for use in the management of the patient's psoriasis based on the standard of care.

Based on the above, the insurer's denial is reversed. 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 Otezla 30 milligram (mg) tablet is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Strep pharyngitis and sepsis.
treatment: Inpatient stay.

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

This case involves a woman with a history of Streptococcus a pharyngitis four months before presentation, who was admitted with encephalopathy of unclear etiology. Additionally, she presented with pharyngitis symptoms and fever. The emergency department (ED) reported near obtundation on arrival. Mental status has waxed and waned for more than 24 hours. At the time of the presentation, she was no longer on antibiotics and denied any sick contacts or recent travel. There were no symptoms of headache, photophobia, or neck stiffness. Vital signs in the ED showed a temperature of 101.2, heart rate of 118, and blood pressure of 124/88 with normal O2 (oxygen) saturations. Examination showed a somnolent patient with no apparent distress. She had pharyngeal exudates on the exam and appeared tachycardic.

The inpatient hospital admission was medically necessary. Based on the initial presentation, the patient is suffering from sepsis, with severe encephalopathy, resulting in obtundation due to strep A pharyngitis producing fever and tachycardia. Sepsis is a qualifying diagnosis for inpatient level of care on admission, with associated severe encephalopathy. The medical team contemplated multiple etiologies for the severe encephalopathy, including bacterial meningitis retropharyngeal abscess. The ear, nose, and throat (ENT) consultants considered surgical intervention based on the imaging studies. In this case, the patient responded rather rapidly to initiating antibiotics, corticosteroids, and IV (intravenous) fluids, with resolution of encephalopathy and stabilization of the vital signs. However, the severity of the presenting illness pointed to a more prolonged hospital course, and the decision to admit under inpatient care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine.
Treatment: Emgality.

The insurer denied Emgality.  The determination is overturned.

This is a female patient, who has been diagnosed with chronic migraine without aura. The patient's headaches became constant and daily. Her pain level can be up to an 8-9/10 in severity. 
She has tried numerous abortive and prophylactic medications. Abortive medications have included Tylenol, ibuprofen, naproxen, Maxalt oral disintegrating tablet (ODT) and almotriptan. Maxalt reduced the severity of the headache, but was associated with dizziness. Prophylactic medications have included Migravent. Topiramate and cyproheptadine were ineffective, and the latter drug caused tiredness. Amitriptyline was ineffective. Nortriptyline at a dose of 50 milligrams (mg) helped the headaches, but the headache frequency was still daily, and the side effect of anxiety resulted in the patient having to decrease the dose of nortriptyline to 25 mg, which no longer was effective for headache prophylaxis.
The patient had a magnetic resonance imaging (MRI) scan of the brain, which showed no mass lesion. The patient is 5 feet (ft) 4 inches (in) tall. She weighs 186 pounds (lbs). General and neurological examinations were normal.
The patient started Emgality and the medication has been the most effective so far. She is tolerating it without side effects. At issue is whether Emgality is medically necessary for this patient.

The requested health service/treatment of Emgality Pen 120 mg/ml is medically necessary for this patient.
Emgality is an injectable medication, which blocks the activity of calcitonin gene-related peptide (CGRP). CGRP and its receptor play a key role in migraine. 
The patient is adult sized, weighing 186 lbs. She has had ineffective trials of at least 5 prophylactic medications from different categories. Propranolol is contraindicated as the patient already experiences dizziness. There is adequate support in the medical literature of the safe and effective use of anti-CGRP monoclonal antibodies including Emgality are safe and effective treatments for refractory chronic migraine in adolescents. Szperka [5] described that a consortium of pediatric headache specialists in the US supported the use of the drugs, and Greene et al. [6] demonstrated their safety and efficacy in a cohort of 112 adolescents.
Emgality is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: back pain
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female with a history of lower back and leg pain who presented to the emergency room (ER). A lumbar magnetic resonance imaging (MRI) showed a disc herniation at L (lumbar)5-S (sacral) 1 with bilateral S1 compression but no central stenosis. The neurologic exam shows no motor, sensory or reflex abnormalities. She was admitted for pain control. The patient was discharged in stable condition. 

The inpatient hospital stay was not medically necessary for this patient. The patient had back and bilateral leg pain. The lumbar MRI scan obtained showed a herniated disc at L5-S1, but there was no evidence of spinal stenosis or cauda equina syndrome. The patient was admitted for pain control and discharged home the next day. The patient would have more appropriately been placed at a lower level of care and did not require an inpatient setting.
Appeal type: Medical necessity
Decision: Upheld

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

This is a case of a male with no past medical history who was admitted for the diagnosis of cellulitis. The patient presented with chief complaint of lower leg pain/injury. There was bilateral lower extremity swelling with redness for three months prior to admission. There was no shortness of breath or calf pain. Vital signs demonstrated temperature 36.7C, pulse 92, respiratory rate 20, blood pressure 140/72 and O2 (oxygen) saturation 95%. Physical exam showed no altered mental status. There was bilateral leg edema. 

The inpatient hospital admission was not medically necessary.
The patient in this case was admitted for edema of the lower extremities and required treatment for cellulitis. There was no severe soft tissue infection such as toxic shock syndrome, necrotizing fasciitis, joint involvement, involvement of a vascular graft, pyomyositis, gas gangrene, deep vein thrombosis or compartment syndrome. The patient did not have fever, hypotension or sustained tachycardia. The patient did not have an immunosuppressed state. He was treated with routine measures including intravenous vancomycin and was then able to be converted to oral clindamycin without complication.
Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Fatigue and weight gain

Treatment:  Medication Wegovy (semaglutide)

Insurance Denial of coverage for a Formulary Exception for Wegovy (semaglutide) should be upheld.

The insurer has denied coverage for Wegovy (semaglutide). In their Final Adverse Determination letter, they stated that the plan approved criteria covers this medication when the drug is being prescribed for a condition that is a covered benefit. The request is for the treatment of a body mass index (BMI) of 29-29.9. Given the clinical information received, the insurance indicated they cannot provide formulary alternatives. 

The registered physician assistant is appealing. A provider appeal form stated that the patient is on medication for attention deficit hyperactivity disorder (ADHD) which causes weight gain. 

The patient has fatigue and weight gain. She was diagnosed with anxiety and attention deficit hyperactivity disorder (ADHD). The patient is requesting Wegovy for weight loss. The chart lists a Body Mass Index (BMI) of 28.04. She does not have cardiovascular disease or diabetes. 

UpToDate has an article titled "Obesity in Adults: Drug Therapy." The article states that a number of medications are approved by the Food and Drug Administration (FDA) for the treatment of obesity in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those with a BMI of 30 or over or a BMI over 27 with related comorbidities. Semaglutide is a glucagon like peptide 1 (GLP-1) agonist that is approved for the treatment of obesity when the patient meets the above criteria. It has demonstrated efficacy in weight reduction, as well as improvement in glycemia and lipids. It has also demonstrated cardiovascular benefits. 

This patient has a BMI under 30. She has a diagnosis of ADHD and anxiety but does not have comorbid conditions such as hypertension, dyslipidemia, diabetes, or cardiovascular disease. She does not meet the FDA indications or the UpToDate guidelines for treatment with Wegovy. 

The carrier's denial of a request for a Formulary Exception for Wegovy (semaglutide) to treat obesity is upheld. Formulary options to Wegovy were appropriately not provided as treatment with Wegovy is not supported in this patient's clinical status.
Appeal type: Medical necessity
Decision: Overturned

 
Diagnosis: Congenital sucrase isomaltase deficiency (CSID)

Treatment: Sucraid 8500 units/milliliter (ml) solution

The insurer denied coverage for Sucraid 8500 units/milliliter (ml) solution

The denial is overturned.

The patient has a past history of hepatic steatosis, colonic polyps, gastroparesis, diverticulosis, and gastric vascular ectasias. The physician reports that a Sucrose Breath Test was performed and showed no sucrase activity. The patient was previously going to take Sucraid enzyme supplementation but was turned down by their insurance company. The patient has 3-7 loose stools per day that are foul smelling. The patient is getting abdominal cramps. The patient's physician is now advising a trial of Xifaxan and giving Sucraid solution. 

The physician has provided a copy of the Sucrose Breath Test report. The sucrose digestion is 0.00% (percent). The result was read as low sucrose activity. 

UpToDate reviews the use of "Sacrosidase: Drug information." It is used for congenital sucrase-isomaltase deficiency. The labeled indication is for congenital sucrase-isomaltase deficiency. 

The Journal of Postgraduate Medicine Volume 55, Supplement 2 November 2012 has an article titled "Clinical Aspects and Treatment of Congenital Sucrase-lsomaltase Deficiency." An orphan drug grant from the Food and Drug Administration (FDA) examined the effect of sacrosidase. The conclusion was that using sacrosidase reduces symptoms of sucrose malabsorption with less diarrhea, cramps, and bloating. 

There is an article in Pharmacy Times September 7, 2022 that is titled "FDA Approves Sacrosidase to treat Congenital Sucrase-lsomaltase Deficiency." The review states that Sucraid is the only pharmaceutical treatment of congenital sucrase isomaltase deficiency (CSID) in children and adults with genetically determined sucrase deficiency. It relieves gastrointestinal symptoms which occur because the intestines cannot break down or absorb sucrose. 

The insurance company has denied the use of Sucraid since they state that there is no 
small bowel biopsy or positive sucrose breath test. However, in this case, the physician 
has submitted a copy of the breath test report. This supports the physician's diagnosis of congenital sucrase-isomaltase deficiency. In view of the positive breath test, the use of Sucraid is medically necessary for this patient. 

Based on the above, the insurer's denial must be reversed. 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 Sucraid 8500 units/milliliter (ml) solution is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral syndrome

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
Patient is adult male with a benign past medical history who presented to the emergency department with complaints of fever, weakness, and diarrhea. 

Vitals on presentation included: Temperature 97.5 degrees Fahrenheit, Blood Pressure 123/74, Pulse 86, Respiratory Rate 16, oxygen (O2) saturation 100% (percent) on Room Air. Laboratory results included the following: white blood cell count (WBC) 9.0, hemoglobin (HGB)-15.8, creatinine-1.35, glucose-107, C reactive protein (CRP)-50.24, Creatine phosphokinase (CPK)-92, viral panel was negative. Electrocardiogram (EKG) showed normal sinus rhythm and "acute pericarditis"; Chest x-ray (CXR) was negative.

Patient was admitted for possible viral syndrome versus pericarditis. Initial EKG showed "acute pericarditis", but follow-up EKGs showed non-specific changes. Echocardiogram showed normal left ventricular function, normal pericardium, no effusion. Rapid respiratory viral panel was negative. Patient remained afebrile, hemodynamically and clinically stable. He was discharged to continue outpatient management on ibuprofen.

According to documentation, patient presented with symptoms suggestive of viral syndrome. Otherwise, patient was afebrile and hemodynamically stable. Laboratory results were unremarkable including normal WBC and CPK. Follow-up EKG showed non-specific changes and echocardiogram was unremarkable. Patient did not require any intravenous antibiotics or any other acute intervention requiring acute hospital admission. The patient met criteria for observation level of management.  

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: Upheld

Diagnosis: hypertension, chronic back pain and osteoarthritis

Treatment: increase Personal Care Aide Services from 42 hours per week to 50 hours per week

The insurer denied coverage for increase Personal Care Aide Services from 42 hours per week to 50 hours per week

The denial is upheld 


This is an elderly female with chronic medical problems including hypertension, chronic back pain and osteoarthritis.  She lives alone in a 1-bedroom apartment.  The patient requested Personal Care Aide (PCA) service increase from 42 to 50 hours per week. 

The Uniform Assessment System (UAS) reports the patient's cognitive skills are described as minimally impaired.  The patient reportedly requires extensive assistance to total dependence for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing, personal hygiene, dressing and toilet transfer/use.  Limited assistance is reportedly needed for bed mobility, locomotion and ambulation.  Supervision is reportedly needed for eating.  

The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel.   There has been no change in the patient's Activities of Daily Living (ADL) status or self-sufficiency over the prior 90 days.   There has been 1 reported fall over the prior 30 days.  At that time, the patient was able to activate her Personal Emergency Response System (PERS).  The "911 team arrived and assisted member getting up from the floor.  Upon EMT  (emergency medical technician) post fall assessment, no injury/fracture sustained, member was not taken to ER (emergency room)." The patient's cognitive and functional ability are much the same; if not slightly functionally improved when compared to the assessment performed late the prior year. 
 
The patient's condition and functional deficits are not at a level or unpredictable as to require the requested increase in Personal Care Aide (PCA) hours to 50 hours per week.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved Personal Care Aide (PCA) services 42 hours/week.   

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 increase in Personal Care Aide Services from 42 hours per week to 50 hours per week is not substantiated.