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

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The health plan's determination is upheld.

The patient is a male who presented to the emergency department complaining of chest pain. He had recently been hospitalized at a different facility for the same complaint and had been discharged after a negative workup, including cardiac stress testing with myocardial perfusion imaging. His medical history was remarkable for coronary artery disease, percutaneous coronary intervention, polysubstance abuse, hypertension, anxiety, depression, and hyperlipidemia. His blood pressure was 118/74 millimeters of mercury (mmHg) with a heart rate of 82 beats/minute. An electrocardiogram showed sinus rhythm with nonspecific repolarization changes. The patient's serum troponin levels were normal. His serum creatinine level was 1.6 milligrams per deciliter (mg/dl) (baseline .9 mg/dl) He was admitted to the hospital. He was treated with intravenous fluid for his elevated creatine level and his previously prescribed diuretic and angiotensin converting enzyme (ACE) inhibitor were held. His home medication regimen, including aspirin, a statin, and a beta-blocker, were continued. The patient remained stable and he was transferred to another institution for cardiac catheterization. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

Based on the documentation provided an inpatient stay was not medically necessary. This patient, with known coronary artery disease, presented with chest pain that was thought to possibly represent acute coronary syndrome. Accordingly, monitoring until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/The American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment inpatient emergency admission

The insurer denied coverage for inpatient emergency admission

The denial is upheld

The patient presented to the hospital complaining of chest pain and shortness of breath.  The only information submitted for review was a summary from the Northwell appeals specialist.  A 12 lead electrocardiogram (ECG) was performed, and that patient was admitted to the hospital for planned cardiac catheterization. No information is provided regarding findings on electrocardiogram or serum troponin levels. No information is provided regarding results from cardiac catheterization. The patient was discharged the day after presentation following a "successful" cardiac catheterization. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with chest pain. Her pretest probability of coronary artery disease was low (Reference 1). Utilizing the HEART [history, ECG abnormalities, age, risk factors] score she was considered low risk (Reference 2). Utilizing the TIMI [thrombolysis in myocardial infarction] risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.

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

The insurer's denial of coverage for the inpatient emergency admission is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Blood Disorder/Other/Thalassemia Major. 
Treatment: Pharmacy/Prescription Drugs. 

The health plan denied the requested medication Deferasirox as not medically necessary. 

The health plan's determination is overturned. 

This patient is a male with beta thalassemia major, receiving regular transfusion therapy - typically twice monthly. The patient has iron overload. Deferasirox has been recommended but declined due to the patient's ferritin stores being below 500 mcg/L (micrograms/liter). 

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. 

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

The service was declined due to the patient's ferritin however, available evidence would indicate that as the underlying disorder is genetic and the patient's transfusion requirements have not resolved, ongoing therapy is indicated. This approach is supported by the authors of UpToDate and by the peer-reviewed literature. This is reflective of the long-term consequences of iron deposition in tissues, thereby resulting in end-organ dysfunction, mainly due to liver damage. In this clinical scenario, the only indication for discontinuing therapy would be toxicity, which this patient has not experienced. Not treating the patient would not be considered effective and would likely lead to increased morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Posterior Shoulder Dislocation. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient sustained a locked right posterior shoulder dislocation. She was admitted for shoulder surgery. An open reduction of the posterior shoulder dislocation was performed along with biceps tenodesis and a lesser tuberosity transfer. The patient was admitted to the hospital overnight and was deemed stable for discharge to home the following day. The patient's health plan denied the inpatient hospital admission as not medically necessary. At issue in this case is the medical necessity of the inpatient hospital stay. 

The requested health service/treatment of inpatient hospital stay is not medically necessary for this patient. This patient sustained a fixed posterior shoulder dislocation associated with a glenoid rim fracture. Open reduction of this dislocation was performed along with biceps tenodesis and lesser tuberosity transfer. The surgery was done with regional anesthetic and sedation through a deltopectoral surgical approach - the same surgical approach often utilized for shoulder replacement surgery. The records further document that this surgery was successful with no complications. Her post-operative lab values and vital signs were within normal limits. A brief neurology note of a telephone consult only (the attending neurologist did not examine the patient) notes that the patient had 2 breakthrough seizures last night.  The note also documented that the patient often has breakthrough seizures as the norm for her condition and that she is back to baseline currently.  The neurologist advised Clonazepam .5 milligrams (mg) for one dose and continuation of her routine anti-seizure medications.  There was no documentation in the note advising against her discharge home. The care rendered in this case was consistent with the recommendations of the current, peer-reviewed orthopedic literature as documented by Khira and colleagues in Orthopedics in 2017. Furthermore, Charles and associates documented that "Outpatient shoulder arthroplasty is a safe option for appropriately selected patients. No difference in complications and outcomes occurs regardless of outpatient setting." This patient's surgery was completed throughout a similar surgical approach but was performed without prosthetic implants. Thus, the care rendered could have been completed at a lower level of care and the inpatient stay was not medically necessary based on the provided records and the recommendations of the peer-reviewed literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 
The denial is overturned. 

The patient was admitted to this inpatient hospital for suspected acute coronary syndrome due to cocaine use or alcohol pancreatitis as he had reports of severe and worsened abdominal pain of maximal intensity, chest pain, nausea and vomiting, and inability to tolerate oral intake while using cocaine. He had a positive toxicology for cocaine. It was reported that he used cocaine 2 days prior to admission and also was binge drinking including the night prior to admission. His troponin was elevated at 96.6 and lipase was elevated at 239. He had severe concentric left ventricular hypertrophy. He was given intravenous (IV) hydration, pain management, aspirin 324 mg (milligrams), and had cardiology and gastrointestinal consultations. When cardiology and gastrointestinal consultants deemed him ready for discharge, the patient was discharged. 
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification and patients with acute medical conditions related to alcohol or substance use are candidates for inpatient hospital treatment. This patient reportedly had both alcohol and cocaine use, and it was reported that his admission and medical symptoms including severe and worsened abdominal pain of maximal intensity, chest pain, nausea and vomiting, and inability to tolerate oral intake were likely due to acute coronary syndrome due to cocaine use or from alcohol pancreatitis as he had elevated lipase of 239 with severe and maximal abdominal pain and also had elevated troponin levels with chest and abdominal pain. He was treated with IV hydration, IV pain medications, and aspirin and had cardiology and gastrointestinal consultations. He was not deemed ready for discharge outside of this hospital setting when both cardiology and GI (gastroenterology) consultants deemed him safe for discharge. Untreated acute alcohol pancreatitis or untreated acute coronary syndrome due to cocaine use would have put this patient at high medical risk and possibly could have been life threatening so he required 24-hour hospital treatment. 

According to the American Heart Association (AHA) the management of patients with suspected acute coronary syndrome requires inpatient hospital treatment. It was reported that his cocaine use was the likely etiology or alcohol pancreatitis, and this required hospital medical treatment and work up. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male for which an inpatient level hospitalization is under review. He presented with sudden onset of left side chest pain after eating. The pain was constant and was worse with palpation and body movement. He had a past medical history of atrial fibrillation, hypertension, and hyperlipidemia. He was in no apparent distress. The creatinine electrolytes were normal. Troponins were negative. The electrocardiogram (ECG) was non-acute. Vital signs and the oxygen saturation were normal. He remained stable. He underwent an exercise test which was normal. Echocardiography demonstrated mild concentric left ventricular hypertrophy (LVH) and was otherwise normal. 

The inpatient hospital admission was not medically necessary.
This individual presented with chest pain and remained stable. There were elevated troponins reflective of a Type II non-ST elevation myocardial infarction (NSTEMI) secondary to methamphetamine use. There was no deep vein thrombosis (DVT), congestive heart failure (CHF), pulmonary embolism, recurrent syncope, or ongoing medically refractory chest pain. There was no evidence of pericardial effusion, ST segment elevation, need for acute anticoagulation, need for continuous cardiac monitoring, or unstable arrhythmia. The patient did not have a high degree of heart block, refractory hypertension, hemodynamic instability, need for invasive hemodynamic monitoring, or need for vasopressor or mechanical cardiac support. In this patient's case, an inpatient level hospitalization was not medically necessary. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves woman with a history of substance abuse, anxiety, and depression, with previous admissions for overdose, who was brought into the hospital with an overdose and mental status changes. The patient's husband noted the patient is altered, and the patient is presumed to have taken multiple tablets of gabapentin clonidine and Flexeril. The patient reportedly has no prescriptions for Klonopin. The morning of the presentation, the patient complained of right lower extremity pain. On arrival in the emergency department (ED), she was lethargic but oriented times place and only endorsed cough and foot pain.

The inpatient hospital admission is not medically necessary for this patient. The patient presented to the hospital with encephalopathy related to taking to many sedating medications. Vital signs were stable. The patient has no true hypoxemia, with O2(Oxygen)saturations of 91% on room air. The oxygen supplementation is typically placed in the emergency department when patients are monitored for mental status change. Twenty-four hours later, the patient showed significant clinical improvement from admission until discharge, with stable vital signs and stable repeat labs. There is no evidence of QT prolongation on EKG(electrocardiogram). There is no evidence of arrhythmias, hemodynamic instability, or seizures. The patient was cleared by psychiatry for discharge home within 24 hours of admission.
Based on nationally accepted guidelines, the typical standard of care for these types of presentations is management at a lower level of care. There is no clinical documentation that the patient failed clinical observation. There is no evidence of significant organ dysfunction caused by the polysubstance ingestion. The encephalopathy resolved.
In summary, an inpatient hospital admission is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Pharmacy/Prescription Drugs (Edarbi) 
The insurer denied Edarbi. 
The denial is overturned. 

The patient is a female with a past medical history significant for essential hypertension, breast cancer, and deep vein thrombosis (DVT). She has experienced significant intolerances and failed treatment with multiple anti-hypertensives from the angiotensin II receptor blockers (ARB) class including Losartan, Losartan-hydrochlorothiazide (HCTZ), Olmesartan, and valsartan. The patient currently is being treated with Edarbi (azilsartan) 40 milligrams (mg) daily with adequate control of her blood pressure. The patient's treating provider is appealing the health plan's denial of prescription benefit exception for Edarbi 40 mg.

The health plan's determination is overturned.

Based on the patient's documented intolerances and treatment failures associated with four of the listed formulary ARB medications, the patient does meet the health plan's prescription criteria for coverage of the non-formulary drug, Edarbi. In this case, ongoing treatment with Edarbi is preferable, medically appropriate, and necessary to achieve adequate blood pressure control for this patient with essential hypertension which is supported by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. (1)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Severe major depressive disorder.
Treatment:  Additional 15 Sessions of Transcranial Magnetic Stimulation (TMS), Pre-service.

The insurer denied the  Additional 15 Sessions of Transcranial Magnetic Stimulation (TMS), Pre-service.  The denial is upheld.

The patient is a adult female with a diagnosis of severe major depressive disorder without psychotic features. The patient has a history of treatment refractory depression. She was subsequently referred for repetitive transcranial magnetic stimulation (rTMS) therapy to include up to thirty-six treatment sessions per protocol. Progress notes indicate a patient health questionnaire (PHQ)-9 scale score of 24 at the time of starting transcranial magnetic stimulation (TMS) therapy sessions, and a decline to 11 or 12 with a score of 12 at the time of her 35th therapy session, reflecting at least 50 percent improvement in the patient health questionnaire (PHQ)-9 score and indicating a clinical response to the transcranial magnetic stimulation (TMS) therapy. The treating clinician has recommended continuation therapy with transcranial magnetic stimulation (TMS) with up to 15 additional transcranial magnetic stimulation (TMS) therapy sessions in order to achieve a remission and additional benefit from transcranial magnetic stimulation (TMS) treatment.

No, the proposed treatment, an additional 15 sessions of transcranial magnetic stimulation, is not medically necessary for this patient.

In this case, the patient reached a plateau scoring an 11 or 12 on the patient health questionnaire (PHQ)-9 scale following a 50 percent reduction in scoring. Continued treatment did not produce additional benefit with regard to patient health questionnaire (PHQ)-9 scoring. Thus, the proposed continuation of treatment with repetitive transcranial magnetic stimulation (TMS) therapy is not likely to be more beneficial for the patient than any other available standard therapy, and medical necessity is not met in keeping with the plan denial determination. This answer is consistent with practice guidelines concerning major depressive disorder and the scientific literature pertaining to transcranial magnetic stimulation (TMS) therapy for major depressive disorder, and this answer is consistent with New York State instruction for this review.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.

The requested benefit of transcranial magnetic stimulation (TMS) with 15 additional sessions for the treatment of major depressive disorder is considered not medically necessary in this case scenario, as the request for transcranial magnetic stimulation (TMS) with 15 additional sessions for the treatment of recurrent and severe major depressive disorder is not clinically appropriate or reasonable as noted in the answer to question #2 above. 

Transcranial magnetic stimulation (TMS) with 15 additional sessions for the treatment of recurrent and severe major depressive disorder is not likely to benefit the patient based upon the submitted documentation.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Januvia. The denial is upheld. 

This is a female diagnosed with type two diabetes mellitus (T2DM) with hyperglycemia. This request is for Januvia. As reported; she has been on Januvia which her blood glucose (BG) levels were stable and glycated hemoglobin (A1C) improved. On visit note she was on Januvia, metformin hydrochloride (HCL) 500 mg, Lantus. Her A1C levels were 6 %, 5.9 %, 6.1 % (percent). 

The health plan's determination is upheld. 

The requested medication is Food and Drug Administration (FDA) approved for type II diabetes. The dipeptidyl peptidase four (DPPIV) inhibitors have similar efficacy. There are no trials showing superiority of one DPPIV inhibitor over another including linagliptin (tradjenta), saxagliptin (onglyza), vidagliptin (galvus), alogliptin (Nesina) or sitagliptin (Januvia). (1-4) The American Association of Clinical Endocrinologists consensus statement regarding treatment of patients with type two diabetes is as follows; it recommends the use of metformin followed by the use of a DPP4 inhibitor or a glucagon like peptide one (GLP 1) agonist. (5, 6) 

There are no studies showing superiority of Januvia over Tradjenta. These medications are in the same class. They are expected to be equally effective. There are no studies showing more adverse effects with the formulary alternative Tradjenta over the requested medication Januvia. The patient has no documentation of trial or failure of Tradjenta. The patient can try Tradjenta.