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

Diagnosis: Type 2 Diabetes Mellitus
Treatment: Mounjaro 7.5mg/ 0.5ml
The insurer denied: Mounjaro 7.5mg/ 0.5ml
The denial is overturned.

This is an adult female patient with type II diabetes and obesity. The request for continuation of Mounjaro is under review. The prior request was denied as the patient has not tried and failed Trulicity and Victoza. The provider is appealing this determination as the patient has tried and failed Ozempic 2 milligrams (mg) weekly.

The health plan should cover the proposed treatment.

This request is for Mounjaro for the treatment of type two diabetes. The prior request was denied as the patient has not tried and failed Trulicity and Victoza. This patient has tried and failed Ozempic. Mounjaro has been shown to be superior to Ozempic [1]. The mean change from baseline in the glycated hemoglobin level was 2.01 percentage points, 2.24 percentage points, and 2.30 percentage points with 5 milligrams, 10 milligrams, and 15 milligrams of Mounjaro, respectively, and 1.86 percentage points with Ozempic; the estimated differences between the 5 milligram, 10 milligram, and 15 milligram Mounjaro groups and the Ozempic group were 0.15 percentage points (95% confidence interval [CI], 0.28 to 0.03; P=0.02), 0.39 percentage points (95% CI, 0.51 to 0.26; P less than 0.001), and 0.45 percentage points (95% CI, 0.57 to 0.32; P less than 0.001), respectively. Given this patient has already tried and failed Ozempic, which is similar to the formulary alternatives, she can be expected to fail the other formulary alternatives, particularly given Ozempic has been studied head to head and been shown to have superior glycated hemoglobin (A1c) lowering to Trulicity and Victoza. In addition, the American Diabetes Association clinical guidelines support the use of Mounjaro over Trulicity and Victoza in this clinical situation where weight loss is desired.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Kidney Injury

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a medical diagnosis of diabetes mellitus. She is on Glipizide and presented to the Emergency Department (ED) with a chief complaint of hyperglycemia. The patient reported a fever and chills about one month ago which has resolved. The patient reports decreased taste and decreased oral intake. The patient has fatigue and elevated blood sugar. Vital signs were blood pressure 141/84, Pulse 80, Respiratory Rate 18, Oxygen Saturation 99%. The patient was placed on Lactated Ringers Bolus via intravenous (IV) and insulin lispro. The patient was diagnosed with acute kidney injury and hyperglycemia. The patient had an inpatient admission.

Medical records provided for review do not support the inpatient level of care. The patient was diagnosed with acute kidney injury and hyperglycemia. It was noted the patient was alert and oriented times four to person, place, time and event. Blood sugar was noted as 518 upon arrival. Comprehensive metabolic panel (CMP) notes glucose as 588, blood urea nitrogen (BUN) 30, Creatinine 1.79, Sodium 1132 and Chloride 95. There were trace Ketones and moderate urine blood. Estimated glomerular filtration rate (EGFR) was 32 and her urine pH was 6.0. Lab values noted Sodium as 140, Potassium 3.7, BUN 19, Creatinine 1.28 and Chloride 102. Glucose was 324. Exam notes the patient is alert and oriented. Blood glucose was noted to have ranged from 127 to 224 in the past 24 hours. However, there was no hemodynamic, pulmonary, or neurological reason to treat the patient at an acute level of care. The patient does not satisfy the Milliman Care Guidelines 25th Edition (M-130-RRG Diabetes RRG), inpatient admission for uncontrolled diabetes to support an inpatient status. She could have been managed under observation. 


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: Overturned

Diagnosis: Pneumonia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is a pre-school male child with medical history significant for moderate persistent asthma, eczema, allergic rhinitis, and bronchiolitis. He presented to the ED (emergency 
department) with two-week history significant for cough and sneezing and four-day history of fever to 103.2 Fahrenheit, post-tussive vomiting, rapid breathing, and poor intake. The patient's vital signs included temperature 37.6, heart rate 145, respiratory rate 24, and 97% oxygen saturation in room air. The patient's examination was significant for no acute distress, moist mucous membranes, tachycardia, tachypnea, decreased air movement over the posterior lower lobes, no wheezing, benign abdomen, and non-focal neurologic exam. Chest x-ray revealed airspace 
opacities in the right upper lobe and bilateral lower lobes suspicious for pneumonia. Laboratory evaluation was significant for negative rapid viral screen, glucose 66, WBC (white blood count) 6.7 thousand, hematocrit 60.9 with hemoglobin 19.7, CO2 (carbon dioxide) 19, potassium 6.2. He was treated with a normal saline bolus and a dose of ceftriaxone prior to admission for further management. Admission orders included continuous cardiorespiratory monitoring, regular pediatric diet, maintenance IV (intravenous) fluids, follow-up blood culture, Miralax routine, ceftriaxone every 24 hours, budesonide twice daily, albuterol every four hours, and montelukast daily. Following admission, the patient remained hemodynamically stable with no further tachycardia. Repeat CBC (complete blood count) revealed normalization of his hematocrit to 34.6. Initially, he was only able to tolerate sips, with ongoing vomiting. By day two he had an episode of vomiting in the morning but no further episodes throughout the day. Repeat potassium had also normalized to 3.7. Blood culture remained negative. He was deemed stable for discharge on day #3 to complete seven days of amoxicillin-clavulanate and continue with budesonide, cetirizine, fluticasone, 
montelukast, and albuterol.

The Inpatient Hospital Admission was medically necessary and 
appropriate for this child.

This young male child with significant atopic disease including moderate persistent asthma presented with fever, cough, post-tussive emesis, poor intake, and decreased urine output. 
Laboratory evaluation revealed hypoglycemia, 
 hemoconcentration, and metabolic acidosis. Chest x-ray revealed multifocal infiltrates. He was admitted for management of pneumonia, acute asthma exacerbation, and dehydration. He was treated with parenteral antibiotics to treat the pneumonia, intravenous (IV) fluids and anti-emetics to address vomiting and dehydration, and bronchodilators along with his preventive medications to manage his acute asthma exacerbation. The level of care required to manage multiple medical problems or complications is most consistent with acute inpatient level of 
care. He could not have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated Potassium
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of hepatitis C, anxiety, depression, stimulant use, tobacco use disorder, anemia of chronic disease, chronic kidney disease (CKD) stage 4, and neurogenic bladder who presented to the hospital for a potassium of 6.4 noted on outpatient lab results. His lab results showed a potassium of 5.5, a creatinine of 4.42. a carbon dioxide (CO2) of 17, a blood urea nitrogen (BUN) of 50, a potential hydrogen (pH) on venous blood gas of 7.33. An electrocardiogram (EKG) showed peaked T waves in V2-V4 but unchanged from prior, his QRS (ventricular activity of the heart in an electrocardiogram) was normal and he was in sinus rhythm. He was admitted for further management of hyperkalemia, he was given intravenous (IV) calcium gluconate, intravenous (IV) Rocephin, oral lokelma, oral rocaltrol and oral sodium bicarbonate. His potassium improved. He was discharged home with continuation of lokelma for chronic hyperkalemia and a low potassium diet. At issue is the medical necessity of an inpatient admission.

The inpatient admission was not medically necessary based on the documentation provided. The patient presented with an outpatient lab result showing a potassium of 6.4. He was hemodynamically stable and asymptomatic. His potassium was 5.5 on a check in the emergency room without new, acute EKG findings. His renal function was at baseline and he did not have a documented complicated infection that required inpatient admission. His potassium improved expectantly and he did not have respiratory distress or cardiac arrhythmias of clinical concern. He could have been managed at a lower level of care, rather than by an admission to an inpatient level of service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned. 

The patient is a female with past medical history (PMH) of diabetes mellitus type 2 (DM2), HLPD (hyperlipidemia), and proctitis who was admitted with complaints of abdominal pain. Of note, the patient was diagnosed with proctitis and hyperplastic polyp one week prior and started on intravenous (IV) and oral antibiotics. Vital signs were notable for blood pressure (BP) 87/46, pulse 91, and reported fever of 102. Physical exam was notable for no apparent distress (NAD), and LLQ (left lower quadrant) abdominal tenderness to palpation (TTP). Lab work was notable for white blood cell count (WBC) 16.3, and thrombocytosis. 

The inpatient hospital stay was medically necessary. This patient presented to the emergency department (ED) with complaints of abdominal pain after another recent admission with several days of IV antibiotics and then transition to oral antibiotics, with recurrence of her abdominal pain associated with systemic inflammatory response syndrome (SIRS) criteria and sepsis as indicated by significant leukocytosis, thrombocytosis, and abnormal vital signs. In addition, the patient was not hemodynamically stable with volatile BP on admission, consistent with a presentation of severe sepsis in light of SIRS criteria. Overall, the patient was diagnosed with an intra-abdominal infection with failed outpatient treatment, severe sepsis, and hemodynamic instability/hypotension requiring aggressive broad-spectrum IV antibiotics, with peripherally inserted central catheter (PICC) and prolonged treatment, IV fluids, infectious cultures, and expert consultation to ensure no need for acute surgical intervention. Overall, this patient could not have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female with hypertension, hyperlipidemia, and major depressive disorder. She presented to the emergency room with right lower quadrant pain and loose stools for three days. The patient had a computed tomography (CT) scan of the abdomen / pelvis and was found to have acute diverticulitis. Labs showed a white blood cell (WBC) count of 14.3 and urine white blood cell (WBCs) of 5-10. The patient was treated with intravenous fluids, intravenous Flagyl, and ciprofloxacin. Her diet was advanced to clear liquids. The patient required Tylenol, Ultram, and morphine for pain control and Zofran for nausea. 
On day #3, there were no acute events. The patient's abdominal pain had improved to 7/10. The white blood cell count was 13.7. Potassium was 3.2. Her diet was switched to clear liquids as tolerated.

The Inpatient admission was not medically necessary.

An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. 
The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. Therefore, based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question as it exceeded in scope and intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

This patient is an adult female with a history of lobular carcinoma. She presented from oncology clinic after losing consciousness. The event occurred when she was standing in the subway. It was precipitated by headache, nausea, and shaking. She complained of headache, backache, and rib pain.
The patient's vital signs were stable and afebrile. Her oxygenation was 97%. There were negative orthostatics. Pertinent labs noted D dimer 1061, lactate 1.2, hemoglobin 11.8, and white blood cells 3.57. Computed tomographic angiography (CTA) was suboptimal. Head computed tomography (CT) showed no acute disease. The patient was admitted with likely vasovagal syncope from prolonged standing. Plan of care included ventilation/perfusion (V/Q) scan and echocardiogram. There is no progress note for the date of admission. The patient was discharged the next day.

The inpatient admission was not medically necessary. 

Most causes of syncope are benign. There are no standard criteria for diagnosing undifferentiated syncope. Inpatient admission should be reserved for patients identified to be at immediate risk, i.e., structural heart disease or history of ventricular arrhythmia. Outpatient management can be used for patients who are at low risk for a cardiac etiology. Evaluation showed the patient to be hemodynamically stable. The patient did not have fever or leukocytosis. Electrocardiogram (EKG) was unremarkable for arrhythmia. The MCG (Milliman Care Guidelines) Guideline for Syncope is not met. The patient was hemodynamically stable. She did not have altered mental status and did not have cardiac disease of findings that indicate necessity for immediate intervention. The inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a toddler male child born prematurely with medical history significant for asthma, eczema, and seasonal allergies. He presented to the emergency department with worsening allergies over the previous week with runny nose, congestion, trouble sleeping, two-day history of worsening cough, and one-day history of increasing wheezing poorly responsive to albuterol treatments. The patient's vital signs included temperature 37.8, heart rate 159, and respiratory rate 44 with 93 percent saturation in room air. His examination was significant for non-toxic appearance, moist mucous membranes, tachypnea, respiratory distress with retractions, wheezing, benign abdomen, no rash, and non-focal neurologic exam. The patient was initially given three DuoNebs and Decadron for a respiratory score of six. He continued to exhibit significant distress with retractions and poor air movement. Rapid viral screen was negative. The patient was admitted for ongoing management of acute on chronic asthma exacerbation with albuterol every two hours. Admission orders included albuterol every three hours weaning as able, consider transitioning from nebulizer to metered-dose inhaler (MDI), five-day course of steroids, regular pediatric diet, consider magnesium, asthma education, and respiratory scoring per pathway. The patient did well overnight with no acute events. He remained stable in room air, tolerating wean to albuterol every four hours. His most recent respiratory score was two, and 
he was eating and drinking well. He was deemed stable for discharge later that day to complete his course of steroids and complete an albuterol taper.

The patient did not require acute inpatient admission.

This young male child born prematurely with significant atopic disease presented with acute asthma exacerbation. He was treated aggressively with bronchodilators and steroids in the 
emergency department with persistent signs of bronchospasm. While it was reasonable and medically indicated to monitor the patient in the hospital for worsening versus resolution, he was overall hemodynamically stable with no need for supplemental oxygen, no significant metabolic abnormalities or dehydration, and no evidence of impending respiratory failure. He did not 
require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gastrointestinal Bleeding. 
Treatment:  Inpatient Hospital. 
The insurer denied the Inpatient Hospital Stay.  The determination is upheld. 

This is a female patient with a past medical history (PMH) of obesity, major depressive disorder (MDD), irritable bowel syndrome (IBS), diabetes mellitus type 2 (DM2), gastroesophageal reflux disease (GERD), postural orthostatic tachycardia syndrome (POTS), and peptic ulcer disease (PUD), who was admitted with complaints of (c/o) a three-day history of abdominal pain associated with dark red stool. Her vital signs were unremarkable. The physical exam was notable for diffuse abdominal tenderness to palpation (TTP). The patient was diagnosed with a gastrointestinal (GI) bleed and treated with a proton pump inhibitor (PPI), anti-emetics, pain control, and GI consultation. GI doubted a GI bleed due to the stable hemoglobin and hematocrit (H/H) but performed a colonoscopy and found no acute bleeding cause. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care. 

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) a three-day history of abdominal pain associated with dark red stool. The patient was found to have a stable hemoglobin, GI doubted an upper GI bleed, and the colonoscopy did not demonstrate any acute evidence of bleeding. The patient did not have hemodynamic instability, persistent orthostasis, evidence of active bleeding in the ED (such as frequent episodes of hematemesis, melena, or bright red blood per rectum (BRBPR)), or known esophageal varices. This patient could have been safely observed and received diagnostic work-up, consultation, and colonoscopy at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria. 
Treatment: electrolysis epilation. 
The insurer denied coverage for electrolysis epilation. 
The denial is overturned. 
 
The patient's therapists and surgeon recommend electrolysis as a key component of treatment for gender dysphoria. 

According to the relevant surgical sections of World Professional Association for Transgender Health (WPATH) guidelines, 8th edition: 
13.6- We suggest health care professionals consider gender-affirming genital procedures for eligible transgender and gender diverse adults seeking these interventions when there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated). 
13.7- We recommend surgeons consider gender-affirming surgical interventions for eligible* transgender and gender diverse adolescents when there is evidence a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process. 

In this case, there is evidence of a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process. The patient's therapists and surgeon recommend electrolysis as a key component of treatment for gender dysphoria. In addition, there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated). The patient has lived as a female and has been on hormone therapy. This patient has anxiety, depression and dysphoria that her mental health providers attribute directly to the incongruence of her face and body hair (male pattern) with her assigned sex as female. Her condition represents a unique clinical situation in which facial feminization is indicated. A systematic literature review on facial feminization concluded that it appears that facial feminization surgery is highly efficacious and beneficial to patients. A prospective, international, multicenter, cohort study concluded that facial feminization achieved improved quality of life, feminized cephalometries, feminine gender appearance, good overall aesthetics, and high satisfaction that were present at 1 month and stable at more than 6 months. The electrolysis is necessary to treat the patient's unique clinical situation of disabling dysphoria related to the incongruence of her facial and body appearance as documented in the notes and letters from her treating mental health providers. 

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 electrolysis epilation (current procedural terminology (CPT) code 17380 services is substantiated.