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

Diagnosis: Chest pain.
Treatment: Inpatient Admission.
The insurer denied: Inpatient Admission.
The denial is upheld.

This elderly male was hospitalized for chest pain. His past medical history is pertinent for known coronary artery disease (CAD) and an abnormal stress test. He was sent to 
the hospital emergency department (ED) for evaluation of worsening angina for planned left heart catheterization which was done the next day and showed non-obstructive coronary artery disease (CAD) and no intervention required. The patient's vitals were stable. There were no acute electrocardiogram (EKG) changes, elevated troponin or significant cardiac arrhythmia documented. There were no procedure-related complications, and the patient was deemed medically stable and discharged to home later the same day. This is an appeal of the denied inpatient admission.

The proposed treatment was not medically necessary.

In review of this case and based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the Milliman Care Guidelines (MCG) for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic 
instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome (ACS), chest pain that is indicative of a serious cardiac condition like pulmonary embolism, aortic dissection or acute myocardial infarction, or pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and 
observation care has failed or are not considered inpatient admission would be appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period at the acute inpatient level of care. The care the patient received, including urgent cardiac catheterization like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left midfoot pain.
Treatment: Magnetic resonance image (MRI) left foot.
The insurer denied: Magnetic resonance image (MRI) left foot.
The denial is overturned.

The patient is an adult female who presented with severe left midfoot pain. She was examined and found to have mid foot pain and x-rays of the foot were taken. These were negative for fracture. The patient had a corticosteroid injection which did not 
improve her condition. A magnetic resonance image (MRI) was ordered.

The proposed magnetic resonance image is medically necessary.

The patient had severe midfoot pain and did not respond to a corticosteroid injection. X-rays were negative for fracture. Given the location of her symptoms, the patient is at risk for a Lisfranc fracture dislocation or a Lisfranc ligament sprain/tear. These injuries can only be ascertained on a magnetic resonance image (MRI). Delay in treating these injuries or failure to properly treat them can lead to permanent disability. Therefore, a magnetic resonance image is medically necessary to rule out this diagnosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment: home health care. 
The insurer denied Personal Care Services: 24 Hours per Day, 7 Days per Week (Split Shift/Live-In) - Total of 91-168 Hours. The health plan's determination is overturned. 

The patient is a female with past medical history of hearing loss, depression, gastroesophageal reflux disease (GERD), osteoarthritis, hypertension, dementia and urinary incontinence who had been hospitalized with acute hypoxic respiratory failure secondary to Covid-19 pneumonia. The discharge summary noted hospital diagnoses of acute kidney injury, chronic kidney disease, hypocalcemia, metabolic acidosis, anemia, lymphopenia, and hyperphosphatemia and the patient was discharged to home without oxygen. There was a request to increase PCA (personal care aide) services.

Personal Care Services: 24 Hours per Day, 7 Days per Week (Split Shift/Live-In) - Total of 91-168 Hours are medically necessary for this patient.
There is documentation of worsening cognitive and physical functioning following hospitalization. There is documentation from the patient's PCP (primary care provider) of medical necessity of increased PCA services. There is also documentation from the patient's PCP of overnight care needs every 1-2 hours. The patient requires at least extensive assistance with walking, locomotion, transfer toilet, toilet use, and dressing lower body. The patient 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 patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 assistance with ADLs in the overnight hours would not allow a PCA 5 hours of uninterrupted sleep. 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, Personal Care Services: 24 Hours per Day, 7 Days per Week (Split Shift/Live-In) - Total of 91-168 Hours are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID-19 (coronavirus disease)
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This patient had a past medical history significant for a COVID infection, hyperlipidemia, pulmonary embolism, and a deep vein thrombosis who presented to the emergency department with complaints of fever, body aches, and dyspnea on exertion.  

Vitals on presentation included: Temperature 102.7degrees Fahrenheit, Blood Pressure 148/84, Pulse 93, Respiratory Rate 20, and oxygen (O2) saturation 96 percent (%) on Room Air. Laboratory results included the following: white blood cell count (WBC) 7.3, Hemoglobin (HGB) 13.3, Hematocrit (HCT) 38.5, creatinine 1.12, glucose 92, and a procalcitonin of 0.14. A chest x-ray (CXR) was negative.

The patient was admitted for symptoms related to a COVID infection. Infectious Diseases were consulted and they recommended monoclonal antibodies. A doppler of the bilateral lower extremities re-identified a right popliteal and posterior tibial deep venous thrombosis. A computed tomography (CT) angiogram of the chest was negative for a pulmonary embolism. The patient improved clinically, remained afebrile and hemodynamically stable. She was discharged to continue outpatient management.  

According to documentation, the patient presented with symptoms related to a COVID infection. She had fever but was otherwise hemodynamically stable with unremarkable laboratory values. A doppler and CT angiogram did not reveal any acute findings. The decision to hospitalize patients with a COVID infection is typically based on presence of severe dyspnea (dyspnea at rest and interfering with the ability to speak in complete sentences), oxygen saturation on room air less than 90% (regardless of severity of dyspnea), alterations in mentation (i.e., confusion, change in behavior), and other signs of hypoperfusion or hypoxia. Similarly, the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel suggests hospitalization for patients with any of the following: an oxygen saturation of less than (<) 94 percent on room air, respiratory rate of greater than (>)30 breaths/minute, or lung infiltrates >50 percent. Based on medical record findings, the patient did not fulfill criteria for acute hospitalization; the patient met the criteria for observation 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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


This is a patient with diabetes mellitus type 2 (DM II), bladder cancer status/post (s/p) urostomy with frequent urinary tract infections on prophylactic Bactrim, liver cancer s/p transplant on tacrolimus who presented to the emergency room (ER) with altered mental status and agitation for the prior 2 days. The patient started vomiting in triage. His wife had was concerned he had a urinary tract infection. His vital signs were within normal limits. Lab results showed a creatinine of 1.4 (baseline unknown), total bilirubin (T bili) 2.0, positive (+) urinalysis (UA). The patient was admitted for further work-up to obtain a urine culture, tacrolimus level (4.7), and other causes of altered mentation. The patient was started on Levaquin for a urinary tract infection and continued to vomit, but with improved mental status. An echocardiogram was obtained with an ejection fraction (EF) of 61-65%. A chest x-ray showed nonspecific bilateral findings possibly consistent with a viral etiology. A computed tomography (CT) scan of the head showed generalized atrophy but no acute changes. He was started on lactulose and Rifaximin. His mental status improved and he was discharged to home.
At issue is the medical necessity of an inpatient stay.

The inpatient level of care was medically necessary/appropriate for this patient. The patient is a recipient of a liver transplant and altered mental status is not uncommon following solid organ transplant and can manifest at any point as encephalopathy (Zivkovic 2010). Given that the patient is immunosuppressed, there is an urgency to establish a diagnostic cause to his altered mentation (i.e. infection, metabolic abnormalities, drug toxicity, stroke, hypertension) (Alissa et al 2014). This involved a complex work-up that also required discussing the case at his transplant center. The work-up for a medically complex patient with a liver transplant would not be expected to occur in less than 2 midnights. Thus, the patient meets Centers for Medicare and Medicaid Services (CMS) criteria for the inpatient level of care (CMS guidelines).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-ST (interval on EKG) elevation myocardial infarction

Treatment: Full Hospital Admission

The insurer denied coverage for full hospital admission

The denial is upheld

This is an adult that presented to the hospital after waking up from sleep with dyspnea followed by chest pain and nausea. She had a history of using nocturnal Continuous Positive Airway Pressure (CPAP). Past medical history was significant for hypertension. On arrival to the hospital, she was hypertensive ([blood pressure] BP 210/100 mmHg [millimeters of mercury]). Physical examination revealed bilateral wheezing on lung examination. A 12-lead electrocardiogram (ECG) revealed sinus tachycardia with no evidence of ischemic ST (interval on EKG) or T (interval on EKG) wave abnormalities. Serial serum troponin levels were elevated (758ng/L (nanogram per liter) and 1245ng/L). In addition, she was noted to have an elevated hemoglobin A1c (glycated hemoglobin) levels consistent with newly diagnosed diabetes mellitus. Computerized tomography (CT) chest revealed bibasilar haziness consistent with atelectasis versus bibasilar pneumonia. Echocardiogram demonstrated an inferior wall motion abnormality with a left ventricular ejection fraction (LVEF) of 55% (percent). The patient was diagnosed with non-ST elevation myocardial infarction.

She was transferred to another hospital for cardiac catheterization. Admitting note indicates on arrival she was ambulating in the room, no complaints, examination noted some wheezing especially on the right side. White blood cell (WBC) was 17.1, 14.2 and 13.2.  Cardiac catheterization revealed normal coronary arteries and an elevated left ventricular end diastolic pressure.  No complications were noted. She was treated with diuretics and discharged.

At the time, the patient was transferred she was clinically stable and underwent cardiac catheterization with no complications. Post catheterization, no complications are noted. The pre catheterization evaluation while contradictory regarding her lung exam, mostly is noted as clear lungs and clinically stable. There was no active acute process that required acute inpatient admission. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Acne vulgaris.
Treatment: Winlevi.
The insurer denied: Winlevi.
The denial is upheld.

The patient is a female with acne vulgaris who has previously tried therapy with topical benzoyl peroxide, clindamycin, adapalene, and tretinoin 0.025%, as well as oral spironolactone and oral doxycycline. The subject under review is whether the requested non-formulary drug Winlevi will be more effective than the formulary alternatives.

The health plan's determination is upheld.

The prescriber is requesting for coverage of topical Winlevi for the treatment of acne vulgaris. The patient has not yet tried all of the topical formulary drugs for the treatment of acne vulgaris including topical erythromycin, topical Epiduo, topical Onexton, and topical combination erythromycin-benzoyl peroxide. These topical therapies are indicated for the treatment of acne vulgaris and can be used for the treatment of this patient's acne. Furthermore, there is no evidence in the published medical literature supporting any superiority of Winlevi over these other topical formulary drugs. For this reason, there is no indication that the remaining formulary drugs would not be as effective as Winlevi or would have adverse effects for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure, diabetes, anemia, percutaneous coronary intervention, hyperlipidemia, implantable cardioverter defibrillator, chronic renal failure, and hemodialysis
Treatment: Verquvo 5 mg (milligrams) Tab
The insurer denied the Verquvo 5 mg Tab.
The denial is upheld.

The patient is an adult female with a history of congestive heart failure, diabetes, anemia, percutaneous coronary intervention, hyperlipidemia, implantable cardioverter defibrillator, chronic renal failure, and hemodialysis. The patient's congestive heart failure was due to diagnosis of myocardial ischemia with an ejection fraction of 20% (percent). The patient developed dyspnea that she felt was possibly related to her coronavirus disease (COVID) vaccine. The emergency room evaluation showed the patient to be comfortable. Her exam showed no rales or rhonchi. There was no gallop. The patient was admitted with "mild respiratory distress." Medications are listed. The attending physician did not state why Verquvo was medically necessary for treatment of congestive heart failure.

The proposed Verquvo is not medically necessary.

The patient has not been treated with maximum doses of standard guided therapy. The attending physician did not provide any explanation of why this drug, which is not standard in the treatment of congestive heart failure, was needed, nor did he explain why maximum doses and all standard guided medical therapy were not used. The recommendation from Up to Date suggests that the medication may be considered for additional therapy in patients who are persistently symptomatic despite an optimal medical regimen for heart failure with reduced ejection fraction. In the clinical trial, patients who were concurrently using or anticipated to use long-acting nitrates or a phosphodiesterase type five (PDE-5) inhibitor (e.g. [for example], sildenafil) were excluded due to potential for additive hypotensive effects. This criterion is not satisfied in this patient's care. There are concerns regarding the use of this drug. An important concern of combining Verquvo (vericiguat) and sacubitril-valsartan (soluble guanylyl cyclase and particulate guanylyl cyclase) would have a synergistic effect, and the effect on adverse effect of hypotension or syncope is unanswered. There is an ongoing study. There are medications in the formulary that are effective in treating heart failure with reduced ejection fraction (HFrEF) whose use is not documented nor any allergies or intolerance to those medications on formulary. There was not an explanation or rationale in the records to justify the use of Verquvo (vericiguat).
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity
Treatment: Mounjaro
The insurer denied Mounjaro.
The health plan's determination is upheld.

This is a male diagnosed with obesity. This request is for Mounjaro. As reported, he has metabolic syndrome, pre-diabetes, obstructive sleep apnea (OSA), hyperlipidemia, and hypertension (HTN). He has failed to achieve weight loss with lifestyle modifications alone. He was previously on Ozempic and stopped due to lack of efficacy and side effect of gastroesophageal reflux disease (GERD). His weight is 265 lbs (pounds) and body mass index (BMI) is 35.94.

A formulary exception is not indicated in this case. Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a GLP-1 (glucagon like peptide 1) and GIP (gastric inhibitory polypeptide) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1C as well as weight loss. However, Mounjaro is not FDA approved for obesity in patients who do not have diabetes.

There is no superiority of the requested medication over the formulary alternatives. The patient has not tried any FDA approved medications for obesity. The patient can try FDA approved medications for obesity.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: diabetes.
Treatment: Mounjaro.
The insurer denied Mounjaro. 
The health plan's determination is upheld. 

This is a female diagnosed with T2DM (type II diabetes mellitus). This request is for Mounjaro. As reported; she is currently taking Ozempic 0.5 milligrams (mg) weekly.

A formulary exception is not indicated. The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a GLP-1 (glucagon-like peptide 1) and GIP (gastric inhibitory polypeptide) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss.
However, there are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The patient can try the formulary alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic ampullary cancer
Treatment: Kanjinti
The insurer denied Kanjinti. 
The health plan's determination is upheld. 

The patient is a female with recurrent, metastatic ampullary cancer. The patient has previously undergone resection and adjuvant gemcitabine followed by trastuzumab+gemcitabine at recurrence. The tumor is HER2 (human epidermal growth factor receptor 2) 3+(plus). Kanjinti is under review.

Kanjinti is not medically necessary for this patient. 
There is a paucity of data demonstrating a benefit to Kanjinti in this clinical scenario. Neither the National Comprehensive Cancer Network (NCCN) nor the authors of Up-To-Date recommend the use of this agent in this clinical scenario. Clinical trials are ongoing for HER2-directed therapy (NCT04579380) in this setting but this approach is not considered a standard of care at this time. For these reasons, medical necessity is not established.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #3:

Diagnosis: Lung cancer

Treatment: CPT (Current procedural terminology) code 0242U

The insurer denied coverage for CPT (Current procedural terminology) code 0242U

The denial is upheld

The patient has a diagnosis of non-small cell lung cancer (NSCLC). She has brain metastasis. The treating provider performed guardant 360 testing.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

There is insufficient evidence in the literature that guardant 360 specifically improves health outcomes. While molecular testing is supported in NSCLC, this particular testing has not been shown to improve outcomes over other testing.      

Current procedural terminology (CPT) code 0242U (Targeted genomic sequence analysis panel, solid organ neoplasm, cellfree circulating DNA analysis of 55-74 genes, interrogation for sequence variants gene copy number amplification and gene rearrangements) does have final approval from the appropriate regulatory bodies for this diagnosis. This testing has Food and Drug Administration as a companion diagnostic for NSCLC.     

This patient is a good candidate for the procedure. However, the requested service was not aappropriate.     

CPT code 0242U (Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants gene copy number amplification and gene rearrangements) is not the best available treatment for this patient at this time.

Tissue based testing is universally preferred for molecular testing over blood based testing. The use of blood based testing is reserved for patients who have insufficient tissue for testing or can not undergo repeat biopsy.     

The adverse risks are not increased over standard treatment/services.     

In summary, the denial of CPT code 0242U (Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants gene copy number amplification and gene rearrangements) and coverage for the requested service should be upheld.  

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.