Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Genitourinary/Kidney Disorder/Other/Urgency of urination
Pharmacy/Prescription Drugs/Myrbetriq
The health plan denied the requested medication Myrbetriq because it did not meet the health plan criteria. The health plan's determination is overturned.

The patient with long-standing history of overactive bladder. She has previously tried Trospium, Solifenacin and Oxybutynin without success. She has beenon Myrbetriq with success.
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

Yes. One study that helped answer this question was a systematic literature review and network meta-analysis of randomized controlled trials (2000-2017) assessing eligible treatments for overactive bladder (OAB). A total of 64 studies were included in the network meta-analysis. Comparable overall efficacy was observed for Mirabegron 50 milligrams (mg) versus most active treatments. Mirabegron 50mg was significantly better tolerated regarding dry mouth, constipation, and urinary retention than 21/22, 9/20, and 7/10 active comparators, respectively. Adverse effects were more common in anticholinergics, and all of the formulary alternatives are anticholinergics.
Formulary alternatives are Darifenacin ext-rel, Oxybutynin ext-rel, Solifenacin, Tolterodine, Tolterodine ext-rel, Trospium, and Trospium ext-rel. Requirement: 3 in a class with 3 or more alternatives, 2 in a class with 2 alternatives, or 1 in a class 1 alternative. Note: Formulary alternatives may require a prior authorization.
The appeal documentation states the patient has tried and failed three of the formulary alternatives. As such, the patient meets criteria. Furthermore, all of the formulary alternatives would have more adverse effects than Mirabegron as noted above.

I would overturn, in whole, the health plan's determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal bleeding at 34 weeks gestation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.


The patient presented at 34.5 weeks gestation with complaint of vaginal bleeding associated with intermittent pelvic pain.  Fetal heart rate was category I. 
Monitoring showed frequent but irregular contractions. The patient was given a dose of terbutaline and was hydrated.  Repeat evaluation showed a reactive non-stress test (NST) and no evidence of abruption.  It is unclear if there were any cervical changes.

According to the progress note the patient was admitted to be transferred to another facility.

This patient presented with bleeding. Ultrasound ruled out placenta previa. It is unclear if any cervical changes occurred. There were no signs of active bleeding. There was also no evidence of premature rupture of membranes, fetal jeopardy or maternal disease warranting admission.

In summary, admission for this patient was not medically necessary. The patient could have been observed for a few hours, hydrated and once the provider ascertained that the fetus was doing well, that there was no evidence of worrisome vaginal bleeding, the patient could have been transferred.  

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

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

This is the case of a young female who presented to the emergency department (ED) with vomiting, 1-3 episodes per day. Symptoms were present for 3 days with refusal to eat and occasional holding the stomach. Review of symptoms (ROS) was negative for fever, cough, diarrhea, and shortness of breath (SOB). The patient was positive for decreased bowel movements and decreased appetite and sleeping more than usual.

The inpatient hospital stay was not medically necessary. Based on the patient's presentation and initial work-up and treatment in the ED, full inpatient admission was not medically necessary for this patient. This otherwise healthy child with mild to moderate dehydration was anticipated to improve with intravenous fluids (IVF) and had stable vital signs with good response to ED treatment. Therefore, she could have been safely and appropriately admitted at a lower level of care for further management.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Sickle cell disease
Treatment: Inpatient stay
the insurer denied the inpatient stay. The health plan's determination is upheld. 

This is a case of a male admitted for diagnosis of sickle-cell disease with crisis. The patient presented with chief complaint of chest pain, groin pain, left facial pain, nausea and vomiting. He had history of avascular necrosis and sickle-cell anemia. Symptoms started two days prior to admission. Vital signs demonstrated pulse 112, temperature 37.8C (degree Celsius), respiratory rate 18, and O2 (oxygen) saturation 97% (percent). Physical exam showed tachycardia, wheezing and chest wall tenderness. There was no altered mental status. White blood cell count was 12.8 with hemoglobin 8.9 and platelet count 486,000. Glucose was 128. Chest x-ray showed no acute disease. 

The inpatient hospital stay was not medically necessary. 
The patient in this case was admitted for sickle-cell disease with crisis. The patient did not have acute chest syndrome, bone complications, stroke, liver disease, pregnancy, pulmonary hypertension, acute kidney injury, or require blood transfusion. He had a mild temperature elevation but was noted to not have a fever. He required intravenous pain medications which was indicated to be the reason for his prolonged stay. The patient eventually left against medical advice despite his pain status. There were no positive blood cultures. His chest x-ray did not show infiltrator or consolidation. There was no hypoxia. 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: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis, Possible Opiate Withdrawal
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the hospital with a one-day history of nausea, vomiting, and loose brownish stools. She admitted to using heroin on the day of admission and denied a headache, chest pain, presyncope, shortness of breath, dysuria, hematemesis, or melena. She had a past medical history of hypertension, type 2 diabetes mellitus, and polysubstance use. She also endorsed noncompliance with her antihyperglycemic and blood pressure medications at home.
The abdominal exam showed a soft abdomen with no masses, tenderness, guarding, or rebound. An abdominal hernia was present, and the patient had a skin lesion on the left lower side of the abdomen.
A chest x-ray showed no evidence of active cardiopulmonary disease, and the electrocardiogram (EKG) demonstrated sinus bradycardia and right bundle branch block.
The patient was admitted to the hospital with a diagnosis of acute gastroenteritis and possible opioid withdrawal, along with a history of a nonobstructing interim umbilical hernia. She received treatment with intravenous fluids, antiemetics, thiamine, and folic acid supplements. Methadone was administered for opioid withdrawal, and she was started on Losartan for hypertension and an insulin sliding scale for diabetes mellitus.
During the hospital stay, the patient's Clinical Opiate Withdrawal Scale (COWS) score was 5. 
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care.
Admission to an acute inpatient level of care for patients with opioid withdrawal may be considered in specific situations where the severity of withdrawal symptoms or other factors warrant more intensive medical and psychological support. The decision for admission is made by healthcare professionals based on the patient's clinical condition and individual needs.
In this particular case, there was no mention that the patient had a high Clinical Opiate Withdrawal Scale (COWS) score. The score was documented at 5, which was quite low.
There was no mention that the patient had medical comorbidities requiring admission at the acute inpatient level of care. Even if her blood pressure was a little on the high side, there was no evidence of a hypertensive emergency. There was no mention of co-occurring mental health disorders or safety concerns. There was no documentation of severe withdrawal symptoms.
Taking into consideration these facts, an acute inpatient level of care was not medically necessary. Overall, this patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness and Vertigo
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of hypothyroidism, and lumbosacral spine fusion who presented with the sudden onset of dizziness and vertigo right after eating sushi. In the emergency room (ER), she was hemodynamically stable. She had no focal abnormality. She underwent a computed tomography (CT) scan of the head that showed an external capsule hypodensity that may represent an infarct. Neurology evaluated the patient. She had horizontal and conjugate nystagmus. The Dix-Hallpike maneuver was positive. She was diagnosed with benign paroxysmal postural vertigo (BPPV). A repeat CT scan of the head was unremarkable. She was given intravenous (IV) hydration and meclizine. She also received magnesium sulphate. She eventually improved and was discharged. At issue is the medical necessity of an inpatient stay.

The requested inpatient admission was not medically necessity. The patient had BPPV that require occupational therapy referral and supportive care. She did not have any neurological symptoms, concern for a cerebrovascular accident (CVA), or arrhythmias that would make her a candidate for inpatient admission.
The patient's presentation was classic with nausea, vomiting, vertigo and unsteadiness that was positional in nature [1]. Typical management is supportive with Dix-Hallpike maneuver and the occupational therapy sessions to improve the vertigo [2]. She was seen by neurology and no neurological deficit was found. She did not have a stroke, transient ischemic attack (TIA), seizures, meningitis, encephalitis, altered mental status lasting beyond the period of observation [3]. Overall, the patient was stable and typically BPPV is an outpatient disease with the outpatient management. The patient was hemodynamically stable, had no significant electrolyte abnormalities and no prolonged neurological symptoms. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: Home health care (HHC)
The insurer denied HHC level 2 personal care services, per 15 minutes increase to 24 hours/day (split shift).
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for Parkinson's disease, urinary incontinence, dementia, arthritis, and type 2 diabetes mellitus. The patient's physician provided a letter of support for this appeal. The letter states that the patient has had a rapid deterioration in her cognitive and physical health. She is immobile and has been bedbound for the past 6 months. She has urinary and fecal incontinence and requires assistance multiple times per day in changing diapers. She requires human assistance for all personal care activities including transfers, toileting, and bed mobility. 

The requested home health care (HHC) level 2 personal care services, per 15 minutes increase to 24 hours/day (split shift) is medically necessary for this patient.

The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5 hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate.

The patient is bedbound. She has severely limited mobility due to her medical conditions and requires maximal assistance for bed mobility. She is frequently incontinent of urine and stool and unable to direct her own care for diaper changes. A live-in personal care aide would not be able to receive adequate rest at night, as the patient will require frequent checking, diaper changes, and turning/repositioning. Therefore, the request for split-shift care is reasonable and medically necessary for the patient. Failure to tend to her personal care needs overnight could lead to infection and/or skin breakdown.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient with a past medical history of gastroesophageal reflux disease (GERD), gastritis, prediabetes and prior cholecystectomy who presented to the emergency room (ER) with epigastric abdominal pain of two day's duration and nausea. She had been taking a proton pump inhibitor (PPI) with partial relief of her symptoms. She was hemodynamically stable and was afebrile. She had epigastric abdominal tenderness without rebound, guarding or rigidity. She had abnormal liver tests in a cholestatic pattern and borderline leukocytosis. The rest of her labs were unremarkable. A right upper quadrant (RUQ) ultrasound showed intra and extra hepatic biliary dilation with post cholecystectomy changes. Magnetic resonance imaging (MRI) / magnetic resonance cholangiopancreatography (MRCP) of the abdomen revealed choledocholithiasis with a distal duct stone. She was treated with intravenous fluids, analgesics, a proton pump inhibitor (PPI) and antiemetics. She was evaluated by a gastroenterologist and underwent an endoscopic retrograde cholangiopancreatography (ERCP) with a biliary sphincterotomy and balloon extraction of a stone. She improved clinically and her abdominal pain gradually resolved. She was discharged home with outpatient follow up. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient admission was not medically necessary for this patient.
She did not have a fever or peritoneal signs or symptoms of cholangitis or pancreatitis or evidence of hemodynamic instability to warrant acute inpatient admission.
Inpatient admission for acute abdominal pain is medically necessary for one or more of the following:
-	Inability to maintain oral hydration
-	Fever
-	Severe pain (eg, not controllable with oral medication or oral medication not tolerated)
-	Hypoxemia
-	Hemodynamic instability
The patient had none of these.
Cholangitis is an infection of an obstructed biliary system, most commonly due to common bile duct stones. Treatment includes fluid resuscitation and antimicrobial agents that cover enteric flora. Biliary decompression is required when patients do not rapidly respond to conservative therapy. Definitive therapy can be performed by a surgical, percutaneous, or endoscopic route; the last is favored because it is the least invasive and has the lowest complication rate. Overall prognosis depends on the severity of the illness at the time of presentation and the cause of the biliary obstruction.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vitiligo. 
Treatment: Xeljanz 10mg (milligrams) tablet. 
The insurer denied the Xeljanz 10mg tablet. 
The determination is upheld. 

This is a male patient with moderate to severe vitiligo (over 10 percent body surface area involvement) as well as a past medical history of psoriasis. The patient has not responded to either topical steroids, tacrolimus, or Opzelura, or to oral dexamethasone, or to light therapy. At issue is the medical necessity of Xeljanz. 

The requested Xeljanz is not medically necessary at this time, and merits further study before being presumed acceptable for widespread clinical use. At this time, the long-term efficacy safety of this medication is not as confirmed as short-term efficacy in the use of Xeljanz for this condition, and the evidence for even short-term efficacy is too preliminary to conclude any clinical utility or appropriate use of Xeljanz in the treatment of vitiligo.
Vitiligo is notoriously difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, and numerous topical therapies have all resulted in variable and unsatisfactory outcomes, and self-resolution (if not no resolution altogether) are often the only outcomes a patient has (along with cosmetic repigmentation applications on a daily basis) for severe cases. 
Xeljanz was denied Food and Drug Administration (FDA) approval for use in the cutaneous diagnosis of psoriasis, in large part for safety reasons, and is not without a significant risk of side effects that preclude an acceptable risk for use for the condition of vitiligo. 
At this time, Xeljanz is only FDA-approved for rheumatoid arthritis patients who have failed methotrexate, for juvenile idiopathic arthritis, for psoriatic arthritis, and for ulcerative colitis--all four conditions have indications whereby the safety risks of not using treatment are significantly greater than treatment itself. The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of vitiligo, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of vitiligo with a specific dosing of Xeljanz. 
Therefore, as per the evidence-based literature, Xeljanz is not medically necessary for less-monitored outpatient clinical use.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholecystitis. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is overturned. 

This is a female patient who presented with right upper quadrant abdominal pain, nausea, vomiting and irregular bowel movements. She had a subjective fever and was unable to keep anything down. She was hemodynamically stable in the emergency room (ER) but had right upper quadrant (RUQ) tenderness with a positive Murphy's sign. Her lab results showed a white blood cell count (WBC) of 11.1. Her urinalysis (UA) was positive with white blood cell (WBCs) and squamous cells. A computed tomography (CT) scan of the abdomen and pelvis showed gallbladder wall thickening and a stone in the gallbladder fundus without any obstruction. She was given intravenous (IV) morphine, IV fluids and antibiotics. General surgery was consulted, and they recommended admission and possible surgery. An ultrasound (US) of the abdomen was also recommended. However, the patient had a family emergency and decided to leave against medical advice (AMA). She was prescribed antibiotics and was discharged. At issue is the medical necessity of an inpatient stay. 

Based on a review of the medical records and the literature, the inpatient admission was medically necessary and supported by the literature. The patient had classic symptoms of acute cholecystitis that were confirmed by abdominal imaging. She had nausea, vomiting and poor oral intake. She left against medical advice but she was a good surgical candidate and admission and laparoscopic cholecystectomy was recommended and standard of care. Ideally, a cholecystectomy should be performed within 3 days of symptom onset. According to a review, following diagnosis, early (performed within 1-3 days) versus (vs) late (performed after 3 days) laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications (11.8 percent (%) for early vs 34.4% for late), a shorter length of hospital stay (5.4 days vs 10.0 days), and lower hospital costs. According to this study, the average length of stay was 5.4 days in patients undergoing laparoscopic cholecystectomy [1]. Per Milliman Care Guidelines (MCG), patients who have classic cholecystitis symptoms as this patient had and who have signs of systemic illness (WBC greater than (>) 10 thousand (K)), inpatient admission is recommended. Although the patient left AMA, the inpatient admission was indicated and a medical necessity. The patient had classic symptoms of cholecystitis, and had radiographic evidence and an indication for urgent cholecystectomy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a past medical history (PMH) of bipolar disorder, seizure disorder, hypertension (HTN), hepatitis C, intravenous drug use (IVDU) on methadone who was admitted with complaints of (c/o) left lower extremity (LLE) erythema and swelling after injecting behind her left knee. The physical exam was notable for ill-appearing, no apparent distress (NAD), left lower extremity (LLE) swelling and erythema. Lab work was notable for leukopenia. An electrocardiogram (EKG) showed left ventricular hypertrophy (LVH) and prolonged QTc. The patient was diagnosed with cellulitis and treated with intravenous (IV) antibiotics. The hospital stay was complicated by lethargy associated with hypoxia and a Narcan requirement. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o LLE erythema and swelling after injecting behind her left knee. Given the patient's presentation, she met all sepsis criteria, met the Infectious Diseases Society of America (IDSA) definition of severe cellulitis, and the expected length of stay was greater than 48 hours. In addition, the presence of lethargy, hypotension, and concern for use of outside medications requiring Narcan administration further indicates that the patient was high risk for complications and required close clinical monitoring for safe medical treatment. Overall, this patient with severe sepsis presented with LLE cellulitis, hypotension, and lethargy suggesting that the patient required immediate treatment for her infection with intravenous antibiotics and work-up for possible infective carditis and bacterial cultures, and that an inpatient level of care was required for safe medical evaluation and treatment.