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

Diagnosis: Charcot deformity. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This patient is an adult female with Charcot arthropathy of the right lower extremity and diabetes. She underwent the first stage of reconstruction 5 months ago (calcanectomy, arthrodesis, external fixator). The patient was admitted to the hospital for modification of external fixator (i.e. pins were backed up). 

The inpatient hospital admission was not medically necessary. 

There was no indication for the acute level services provided. The records show the procedure completed was not complex nor extensive. A small skin incision was placed over the protruding Steinman pin. The pin was repositioned. There was no blood loss. There was not a need for subspecialty consolation, imaging studies nor special wound care. This type of procedure is performed as an ambulatory surgery unit (ASU) setting. The underlying infection and diabetic management were being treated as an outpatient. There were no extenuating circumstances to substantiate admission and length of stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine.
treatment: Emgality 120 mg/ml Pen Injector.
The insurer denied Emgality 120 mg/ml Pen Injector. 
The health plan's determination is overturned. 

The patient is a female who has chronic migraine without aura, and postural orthostatic tachycardia syndrome (POTS). She has a history of depression.

She has experienced chronic headaches since early childhood. She was initially diagnosed with cyclic vomiting and abdominal migraine. Her headaches do not occur at a particular time of day, and there are no known triggers. She does not experience a preceding aura. The headache is behind her eyes or at the back of her head. It is described as stabbing, squeezing and pulsatile, and is often rated at 9/10 in severity. 

After a trial dose of the medication, she had a significant reduction in headache frequency and severity. Prior to receiving the medication, she was having daily headaches, up to a 9/10 in severity. After one dose of Emgality, her headache frequency decreased to 2 troublesome headaches and two milder headaches per week. After a subsequent dose of Emgality was over 2 weeks late, her headache frequency and severity returned to baseline.

The patient has failed to respond to multiple appropriate medications for both prophylaxis and acute treatment of migraine in the past. Emgality was the first effective medication for her, and as such, is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis vulgaris. 
Treatment: 4 per 28-day supply of Humira 40 mg (milligram)/0.4 mL (milliliter) pen. 

The insurer denied coverage for 4 per 28-day supply of Humira 40 mg/0.4 mL pen. 

The denial is overturned. 

The patient is an adult with a diagnosis of psoriasis vulgaris.  The patient previously had >20% total body surface area (TBSA) involvement but is now at 5% TBSA involvement on Humira therapy.  The request is to increase dosing to weekly therapy to achieve complete remission. 

Based on the provided medical records and appeal letter, the patient has had partial response to Humira 40mg treatments every 2 weeks.  The request is for Humira 40mg weekly.  Based on the medical literature weekly dosing to improve efficacy is within the standard of care and is supported by the medical literature.  It is reasonable to maximize dosing of a biologic therapeutic to determine if complete response may be achieved prior to switching to a completely different agent.  As such, the decision is overturned and the use of Humira at the requested dose is medically necessary at the medical discretion of the providing physician based on the unique circumstances required for the care of this patient. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 4 per 28-day supply of Humira 40 mg/0.4 mL pen is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention-Deficit Hyperactivity Disorder
treatment: Vyvanse
The insurer denied Vyvanse. 
The health plan's determination is overturned. 

This case involves an emerging adult female diagnosed with attention deficit hyperactivity disorder (ADHD)-predominantly inattentive type. Comorbid psychiatric disorders include major depressive disorder and generalized anxiety disorder and there is report of a co-occurring alcohol use disorder with a binge pattern of use. There is no general medical condition that is a focus of treatment, nor is there a diagnosis of narcolepsy or binge eating disorder.
The patient has been prescribed Vyvanse 40 milligrams (mg) caps daily with titration as clinically appropriate with a positive clinical response and tolerability. The patient's symptoms of ADHD included attention and concentration problems, problems completing tasks, and distractibility with associated functional impairments.

A formulary exception is indicated in this case.
In this case scenario, the formulary drugs Adderall extended release (XR) and Ritalin has been ineffective, and the remaining formulary drugs would not be as effective as the non-formulary drug currently prescribed. Moreover, the non-formulary drug, Vyvanse, is tolerated without adverse effects as opposed to any formulary alternatives that would pose risk for adverse effects.
The requested benefit with Vyvanse is provided for the purpose of treating ADHD, and is clinically appropriate and indicated; and is entirely consistent with nationally recognized scientific evidence and prevailing medical standards and clinical guidelines. To switch this patient from a medication that is known to be effective and well-tolerated is not in the best interest of the patient. There is no evidence that the remaining formulary alternatives will be as effective for this patient or would be well tolerated compared to the current treatment with Vyvanse. Moreover, taking the patient off a medication that is known to have been effective and tolerated would place this patient at risk or would be detrimental to this patient.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
inpatient hospital

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

This case involves a man admitted to the hospital with diarrhea. The patient reported mild fatigue, weight loss, loose stools three times daily, and dark urine for several months. He experienced concurrent nausea on the day of the presentation. The patient reported he has a known pancreatic cystic mass. 

The inpatient hospital stay was not medically necessary. The patient had painless jaundice and chronic diarrhea and presented with an episode of nausea. There is no documentation to support persistent nausea and vomiting, with the inability to tolerate a diet. There is no documentation describing intractable pain caused by the obstructing pancreatic mass. There is no documentation to support secondary complications of an obstructive common bile duct process, such as ascending cholangitis, cholecystitis, or severe pancreatitis.
This patient has jaundice, with elevated liver enzymes, due to an obstructive pancreatic mass. However, this condition is chronic and can be treated in an outpatient setting. Endoscopic evaluation, and treatment with the common bile duct stent do not necessitate an inpatient admission. There is no evidence of hemodynamic compromise or a secondary systemic illness. The documentation describes chronic diarrhea without severe electrolyte derangements for the past year. Again, this chronic condition is not severe enough to warrant an inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

respiratory
home health care

Diagnosis: chronic obstructive pulmonary disease (COPD)
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 77 Hours per Week 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 77 Hours per Week. The health plan's determination is overturned. 

The patient is a male with past medical history of osteoarthritis, diabetes mellitus type 2, hypertension, bladder incontinence, benign prostatic hyperplasia (BPH), coronary artery disease, hyperlipidemia, chronic obstructive pulmonary disease (COPD), and chronic anticoagulation who was assigned PCA (personal care assistant) services.

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 77 Hours per Week are medically necessary for this patient.
There is documentation from the patient's medical provider of worsening cognitive and physical functioning. There is documentation of progression of chronic kidney disease and patient's refusal of hemodialysis with plan for palliative care. The patient's physical functioning will only worsen over time given his current and projected clinical status. The patient requires at least extensive assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's family is not able to provide informal support outside of the PCA hours currently assigned. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 77 Hours per Week are medically necessary for this patient. Assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems/Other/Heart Transplant Status; pre-operative heart transplant backup recipient
Inpatient Hospital Stay
The health plan denied the requested inpatient hospital stay as not medically necessary. The health plan's determination is overturned.

The patient is a female who was listed for heart transplant status four who was admitted to the intensive care unit for a home right heart catheterization and assessment for suitability for a potential heart donor.
The patient's right heart catheterization showed an arterial pressure 88/65 with a mean of 51, the right atrial pressure of 7, a right ventricular pressure of 26/70, and a pulmonary artery pressure of 28/12 with an arterial saturation of 99% a pulmonary artery saturation of 73% and a cardiac output of 3.89.
The patient was held nothing by mouth and when the heart was not suitable or was not directed to this patient, the patient was discharged from the hospital.
The issue under review is the medical necessity for the requested health service/treatment of the inpatient hospital stay.

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

The requested health service treatment of an inpatient hospital stay was medically necessary, given her status as a transplant recipient on the waiting list. It is beyond the control of the transplant center to determine whether a donor will be viable for a given recipient. It is standard practice to bring patients in for hemodynamic assessments to assess suitability for transplant with specific donors. If the donor had been available, this would have allowed the patient to receive a heart transplant.
The process of cardiac transplantation frequently requires reassessment and preoperative hemodynamic determination for candidacy in the setting of a potential donor. In this case the patient was called in to have a right heart catheterization and assess the pulmonary vascular resistance in the setting of a potential donor. Although the donor was not able to be secured for this patient, the care and admission were appropriate for this patient and was medically necessary, had the donor been available.
These services are medically necessary in order to transplant patients in areas such as this state where there are many patients listed for heart transplantation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoglycemia. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is overturned. 

This is the case of a female with Type 1 diabetes mellitus (DM) who presented to the emergency department (ED) with symptomatic hypoglycemia. Blood sugar control had been poor for 2 weeks prior. Review of symptoms (ROS) was positive for lightheadedness but otherwise negative. Home medications are metformin and insulin. The patient was accompanied to the ED by her non-custodial parent who staff believed to be intoxicated.

Inpatient hospitalization is medically necessary for this patient with T1DM (type I diabetes mellitus) and symptomatic hypoglycemia. The patient's condition and low BGs (blood glucose) warranted close monitoring with necessary medication adjustments and possible emergency response to hypoglycemic episodes. The patient was believed to be incorrectly using or non-compliant with proper medication regimen at home. Additionally, the accompanying caregiver was unsafe to discharge the patient home with. Thus, inpatient hospitalization was medically necessary for patient safety and care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tertiary Hyperparathyroidism
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The health plans determination is overturned.

The patient is a female with a history of hypertension, end stage renal disease (ESRD) (on dialysis) and tertiary hyperparathyroidism. The patient underwent a subtotal parathyroidectomy and was admitted as an inpatient. The patient was admitted following the surgery for hypomagnesemia with a magnesium level of 1.0 to 1.4 milligrams per deciliter (mg/dl). The patient was treated with magnesium repletion (Magnesium (mg) Sulfate). In addition, the patient was noted to have a decreased calcium level of 8.3, which was also treated with repletion (Calcium Gluconate intravenous (IV)).
Following the surgery, the patient did experience some symptoms of hypocalcemia (tingling of the fingertips) at the level of 8.3 - however the symptom did resolve after the IV (intravenous) Calcium which was corrected to 10.8.
The inpatient admission was denied as not medically necessary based on Milliman Care Guidelines (MCG) (26th) edition. Fidelis Care recommended an "ambulatory level of care".
The criteria on the condition for inpatient admission included:  1) a disease or condition like an active infection, bleeding disorder, dangerous heart rhythm, or unstable blood pressure, 2) complex surgery that required a longer recovery after surgery than usually expected, or 3) severe complication from the procedure.

The inpatient admission was medically necessary. The patient required IV (intravenous) Calcium and IV Magnesium for correction postoperatively. A patient that has chronic renal failure is placed at a greater risk for electrolyte abnormalities. Inpatient admission was needed following the subtotal parathyroidectomy.
 
The patient had severe renal disease and tertiary hyperparathyroidism. This patient's condition "placed the patient at increased anesthetic risk that prolonged postoperative inpatient monitoring or treatment."
In addition, the inpatient care was needed because of the "serious condition that required ...inpatient care." Also, the procedure did indicate "a need for longer than usual post-operative monitoring."

The health plan's determination is overturned in whole.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis: Growth hormone deficiency. 
Treatment: Skytrofa. 
The insurer denied Skytrofa. 
The health plan's determination is overturned. 

This is a male diagnosed with growth hormone deficiency (GHD). This request is for Skytrofa. As per a letter; he was started on GH therapy. During this time, he and his family have found that administrating the GH on a nightly basis has become exceedingly more difficult and painful which has resulted in missed doses and gaps in GH therapy. 

Skytrofa is medically necessary for this patient. 
The requested medication has been shown to be safe and effective for the treatment of growth hormone deficiency. Using the medication shows that the medication is clinically equivalent to daily injections of growth hormone in terms of efficacy and safety. The literature shows a slight advantage of Skytrofa over daily somatropin but only went for 1 year and did not show improved final height. It has the advantage of being a weekly medication. 
The requested medication is a weekly injection. The formulary alternative is a daily injection. There has been difficulty with adherence and compliance with the formulary alternative. Continuing with the formulary alternative will likely worsen the patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID, viral gastroenteritis, dehydration and acute kidney injury (AKI). 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient was an adult male admitted for nausea and vomiting. He was noted to have elevated creatinine with hypercalcemia. Computed tomography (CT) of the Abdomen/Pelvis showed fluid filled colon which may represent diarrhea, small hiatal hernia. 2.4 cm (centimeter) hypoenhancing lesion in right hepatic lobe with mild peripheral enhancement which may represent a hemangioma.

He was started on intravenous (IV) fluid and anti-emetics. He was evaluated by infectious disease specialist and nephrology and was discharged in stable condition.

Per Milliman Care Guidelines (MCG) criteria, Admission is indicated for 1 or more of the following:  1) Suspected severe infection (e.g., bloody diarrhea), 2) Severe abdominal pain, 3) Peritoneal signs, 4) Toxic megacolon, 5) Hemodynamic instability, 6) Vomiting that is severe or persistent, 7) Dehydration that is severe or persistent, 8) Electrolyte or metabolic abnormality that is severe or persists despite observation care (e.g., acidosis, alkalosis, hyponatremia, hypernatremia), 9) Hemolytic uremic syndrome, or 10) Inability to maintain oral hydration (e.g., needs IV fluid support) that persists after observation care. None of these indications were met.

The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per Kidney Disease Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent ATN, this patient's kidney function improved back to baseline in 48 hours, which is not consistent with serious, irreversible acute tubular necrosis which may benefit from inpatient admission to monitor kidney function and the need for renal replacement therapy.

In addition, he was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function.
He did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration.

There was no documentation of refractory pain, and he was able to tolerate oral diet and did not require total parenteral nutrition. This condition could have been treated safely under lower level of 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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient for whom an inpatient hospitalization is under review. He had been transferred from another hospital for a cardiac catheterization. He had intermittent exertional chest pain relieved with rest. He was a former smoker. His vital signs were normal. He was in no distress. The creatinine was normal. The electrocardiogram (ECG) was reported as nonacute. The troponin increased to 0.4. The left ventricular ejection fraction (LVEF) was 55 percent (%). He underwent a successful percutaneous intervention of an obtuse marginal artery stenosis. There were also stenoses of the left anterior descending (LAD) and right coronary artery (RCA). Medical therapy was initiated. He remained stable and was discharged. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. This patient presented with chest pain and remained stable. The troponin was minimally elevated. There was no congestive heart failure (CHF), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, need for prolonged intravenous (IV) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, severe catheterization related complication (i.e. severe bleeding, cerebrovascular accident (CVA), need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal electrocardiogram (ECG). An acute inpatient level hospitalization is therefore considered not medically necessary in this case.