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

Diagnosis: Seizures, Alcohol Withdrawal. 
Treatment: Inpatient Hospital Stay. 

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

The patient has a past medical history (PMH) of alcohol withdrawal seizures, asthma, cerebrovascular accident (CVA), and polysubstance abuse who was admitted with complaints of (c/o) a seizure while at a detoxification center. Her vital signs were unremarkable. The physical exam was notable for no acute distress, the Clinical Institute Withdrawal Assessment (CIWA) on the admission history and physical (H&P) was documented to be 2. Lab work was unremarkable. Imaging studies included a chest x-ray (CXR) which showed no acute process, a computed tomography (CT) scan of the head which showed no acute intracranial pathology, a recently performed electroencephalogram (EEG) which showed no seizure activity. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with seizures secondary to non-compliance versus pseudo-seizures and were treated with benzodiazepines (BZDs) and anti-epileptics. The patient was discharged against medical advice (AMA). 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 c/o seizures. The patient's mental status was documented to recover on the admission documentation. The patient was hemodynamically stable, there was no hypoxia, respiratory failure or distress, apnea, intentional overdose/exposure, disruptive/uncooperative behavior, other acute co-existing illness, fever, significant trauma, focal deficits or unstable vital signs. In addition, there was no status epilepticus, poorly controlled repetitive seizures, delirium tremens, need for immediate surgical intervention, acute/subacute stroke, intracranial bleed, encephalitis, eclampsia, or alcohol withdrawal seizures. The patient received clinical monitoring, Keppra, BZDs, and imaging work-up without significant findings. In addition, a recent electroencephalogram (EEG) showed no seizure activity, and the leading differentials were seizures secondary to medication non-compliance versus pseudo-seizure, while the patient's CIWA on admission the H&P was documented to be 2, which his not consistent with a severe withdrawal. Overall, this stable patient could have received these interventions safely at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who initially presented to the emergency department with concerns for fever, neck stiffness, and altered mental status. Initial vital signs revealed a temperature of 100.8oF, heart rate (HR) 86, blood pressure (BP) 138/74, respiratory rate (RR) 18, and peripheral capillary oxygen saturation (SpO2) 98% on room air. Initial examination documented the patient as alert and oriented with a negative Kernig's and Brudzinski sign. The patient was placed in the hospital thereafter with an impression of aseptic meningitis. Treatment plan included continued empiric antibiotics and acyclovir, intravenous fluids, and consultations. 

The inpatient hospital admission was not medically necessary. The patient presented with concerns of fever, neck stiffness, headache, and confusion. Initial examination documented a negative Kernig and Brudzinski sign. Head imaging was unremarkable. A lumbar puncture was performed and cerebrospinal fluid (CSF) analysis was essentially normal. Following emergency department care, the patient was afebrile, hemodynamically stable, and at mental baseline. Treatment plan included acyclovir and empiric antibiotics even though the lumbar puncture essentially ruled out a bacterial meningitis. Following observation care, the patient felt much better and denied any new issues. The hospital course appeared to be prolonged to receive CSF Lyme antibody results. No other issues or complications were documented.

Moreover, clinical indications for admission to inpatient care were not met. The patient did not have bacterial meningitis, encephalitis, hemodynamic instability, severe or persistent altered mental status, severe neurologic findings, severe or persistent vomiting, severe or persistent dehydration, severe pain, cerebral bleeding, or increased intracranial pressure.
Appeal type: Medical necessity
Decision: Upheld

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

The patient presented to the emergency department with concerns of back pain, abdominal pain, fever, and chills. The pertinent history included an umbilical hernia repair, diabetes mellitus, and hypertension. 
A computed tomography (CT) scan of the abdomen/pelvis revealed bilateral multifocal striated nephrograms consistent with pyelonephritis. No abscess, hydronephrosis, or obstructing stones were noted. Empiric ceftriaxone and intravenous fluids were administered. The patient was admitted to the hospital with an impression of pyelonephritis, diabetes mellitus with hyperglycemia as she had not been taking prescribed medications, and hypertension. The treatment plan included continued empiric ceftriaxone, intravenous fluids, and subcutaneous insulin. The patient remained afebrile and hemodynamically stable. The hemoglobin A1C returned at 14 percent (%). A urine culture grew group B Streptococcus (Strep). Insulin adjustments were continued. The fingerstick glucose was brought down to 97. The serum glucose returned at 148. The treatment plan was continued. The patient was discharged. At issue is the medical necessity of an inpatient admission.

Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.

Colgan et al. note that urinary tract infections are the most common bacterial infections in women. Most urinary tract infections are acute uncomplicated cystitis identified by increased urinary frequency and dysuria in an immunocompetent woman who has no comorbidities or urologic abnormalities.[1]

The patient had a history of diabetes mellitus and no urinary tract abnormalities who presented with abdominal pain, fever, and chills. Initial evaluation found the patient to be afebrile with a normal WBC and serum glucose of 491. Computed tomography (CT) imaging revealed findings suggestive of bilateral pyelonephritis without abscess, hydronephrosis, or obstructing stones. The treatment plan included empiric ceftriaxone, intravenous fluids, and subcutaneous insulin. The urine culture grew group B strep. Following observation, the patient was afebrile, hemodynamically stable, and with adequately controlled blood sugar. No other issues or complications were documented.
The clinical indications for admission to inpatient care were not met.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Totalis
Treatment: Olumiant 2 mg (milligrams) tablet
The insurer denied coverage for Olumiant 2 mg tablet.
The denial is overturned.

The patient is an adult female with a diagnosis of alopecia totalis. The patient has failed therapy with Intralesional Kenalog and bimatoprost. The requested medication is Olumiant tablet.

Based on the submitted documentation, Olumiant is medically necessary. Olumiant is the only currently available Food and Drug Administration (FDA) approved therapy for alopecia areata. The patient has failed topical and intralesional therapy and requires systemic therapy based on the extent of hair loss involvement of 100% (percent) as measured by Severity of Alopecia Tool (SALT). The health plan criteria for approval of Olumiant is at least 50% hair loss by SALT with diffuse pattern alopecia. Based on the clinical documentation, the patient appears to meet the health plan criteria given documentation of 100% hair loss with diffuse pattern alopecia. The decision is overturned based on the current standard of care for the treatment of alopecia areata and its variants.

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

The insurer's denial of coverage for Olumiant 2 mg (milligrams) tablet is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic migraine without aura, not intractable
Treatment: Formulary exception for Ubrelvy 100mg tablets
The insurer denied: Formulary exception for Ubrelvy 100mg tablets
The denial is upheld

The patient is an adult female with migraine headache disorder. She has tried and failed sumatriptan and eletriptan for abortive therapy. The provider is requesting Ubrelvy. The requested medication was denied coverage by the health plan, as she has not tried and failed three formulary medications for her condition, and she does not have a contraindication to using the preferred agents. The denial is being appealed.

The health plan should not cover the Formulary exception for Ubrelvy 100mg tablets.

There is no documented reason the patient cannot be treated with the preferred agents. Previous side effects from other medications do not preclude the use of the preferred agents. She does not have a contraindication to using any of the preferred agents. The preferred medications are FDA (United States Food and Drug Administration)-approved for the acute treatment of migraine headaches and are considered first-line, standard-of-care, abortive agents (Tepper, 2019). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Ubrelvy relative to the preferred medications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Skyrizi Pen.
The insurer denied: Skyrizi Pen.
The denial is: Upheld.

The patient is a male with psoriasis. He has failed clobetasol, halobetasol, and betamethasone. The prescriber is a dermatologist. The medication under review is Skyrizi pen.

The requested health service/treatment of Skyrizi Pen is not medically necessary for this patient. There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the preferred treatments Enbrel, Siliq, and Cosentyx 2 Pack, which have been shown to be effective for psoriasis.
According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines Cosentyx and Enbrel are effective treatments for the management of psoriasis (1, 2). Within the peer-reviewed literature, Garnock-Jones writes "Subcutaneous secukinumab is an effective and generally well tolerated first-line treatment for moderate to severe plaque psoriasis" (3). Moreover, Kivelevitch writes "Anti-tumor necrosis factor (TNF)- agents are currently considered as first line biological therapies for the treatment of moderate to severe psoriasis and psoriatic arthritis" (4).

The evidence-based literature is consistent and in line with the plan's preferred medications. The preferred agents are appropriate agents for the treatment of the patient's psoriasis. These agents should be tried and failed. It is noted that the patient has tried and failed topical therapy. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Skyrizi prior to the plan preferred alternatives such as Cosentyx and Enbrel.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Fall, Rib Fractures.
Treatment: Inpatient Hospital Stay.

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

This is a female patient, who presented to the emergency department after a mechanical fall. She was found to have left 3-9 displaced rib fractures with a small left pneumothorax. She was admitted for pain control and respiratory hygiene. She was evaluated by rehabilitation medicine, and acute inpatient rehabilitation was recommended. Her follow up chest x-ray showed stability of the pneumothorax. She was discharged to home. At issue is the medical necessity of an inpatient stay.

This is a medically necessary inpatient admission. This is an older patient with 7 displaced rib fractures and a pneumothorax. She required inpatient care, which is standard of care for rib fractures this numerous.

Many hospital protocols for inpatient admission are to admit patients with 3 or more rib fractures. It is standard of care. This is because pain control can be difficult and often involve trial and error, aggressive pulmonary hygiene is critical, pulmonary contusions take time to worsen and cause patient deterioration, and the morbidity and mortality associated with so many rib fractures is very high. Interventional pain approaches may be required, such as epidural analgesia. The discretion of the treating physician is important for disposition, as some younger patients with minimal pain and good results on incentive spirometry can be treated at a lower level of care. However, this patient was nowhere near that. In an article on the management of rib fractures in UptoDate, the authors state "A patient with severe rib fractures (eg, greater than (>) 5 ribs involved, multiple displaced fractures, flail chest) or signs of significant respiratory compromise, or in whom there is concern for developing respiratory compromise, should be admitted to the intensive care unit (ICU)." The morbidity and mortality of 7 rib fractures is quite high, and even higher in this patient, as she is of advanced age. The effects of pulmonary contusion are often not at their maximum until 72 hours from injury. Thus, a several day hospital stay would be expected. This was a very appropriate and medically necessary inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Subdural hematoma
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

This patient is a man who presented as a transfer patient from an outside hospital following a fall 4-days prior. The records indicate that there was a transient loss of consciousness at the time of the fall. Past medical history is notable for asthma, depression, and polysubstance abuse. There was a 4-millimeter (mm) subdural hematoma of the left cerebral convexity with 1-mm midline shift to the right. At the time of presentation, he was awake and alert and complained of severe persistent headache. Vitals signs included a heart rate of 51/minute and blood pressure of 135/77. Oxygen saturation was 98% (percent).

The inpatient hospital admission was not medically necessary for this patient. A lower level of care would have satisfied the clinical needs of this patient. This patient had a small left subdural hematoma based on computed tomography (CT) imaging. He was determined by the neurosurgery services to be neurologically and hemodynamically stable and nonoperative. There was no infection, no vertebral fracture, no compartment syndrome, no anticipated surgical intervention, no evidence for limb threatening injury, no suspicion of abuse or neglect, and no ongoing severe pain that required inpatient hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Home care/personal care HHC- level 2 personal care services per 15 minutes increase to 24 hours per day (split shift).
The insurer denied home care/personal care HHC- level 2 personal care services per 15 minutes increase to 24 hours per day (split shift).
The determination is overturned.

The patient has a medical history notable for dementia, history of cerebrovascular accident with resulting hemiplegia and aphasia, dysphagia with gastrostomy tube in place, and urinary incontinence. The patient is approved for 24-hour live-in personal care 7 days per week. The patient and his care team requested an increase to 24-hour split-shift (12-2 hour shifts), 7 days per week of personal care services. 
The patient's physician's assistant provided a letter of medical necessity that states that the patient requires a change in position every 2 hours overnight and has been requiring up to six diaper changes overnight. Because of this, he requires continuous 24 hour split-shift personal care.
A letter of support was also provided by a patient advocate. The letter states that the patient does not receive any income and cannot afford additional help. He requires continuous 24-hour care, but his personal care aide is unable to get the required sleep overnight due to his personal care needs.
A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was moderately impaired; he was oriented to person only. He requires total dependence for all instrumental activities of daily living (IADLs). He requires total dependence for nearly all activities of daily living (ADLs), including bathing, hygiene, dressing, toilet use, and eating. He requires extensive assistance for bed mobility. He is unable to walk even with assistance. He is incontinent of stool and urine with no control present. Compared with a prior assessment, no significant change was noted. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services per 15 minutes increase to 24 hours per day (split shift).

The requested health service/treatment of home care/personal care HHC- level 2 personal care services per 15 minutes increase to 24 hours per day (split shift) is medically necessary for this patient.
The patient is approved for 24-hour live-in personal care. Live-in personal aides require the expectation of 5 hours per night or more of uninterrupted sleep. If this cannot occur due to the patient's functional needs, then split shift care should be authorized. The documentation states that it is not possible for the patient to go without personal care for five or more hours. He is dependent on others for all ADLs. He is completely incontinent with no control of stool or urine. He has required up to six diaper changes per night and requires turning and positioning every 2 hours to prevent pressure ulcers. His care aide has been unable to get 5 hours of uninterrupted sleep. It is therefore medically necessary to provide the patient with split-shift services to meet his functional needs.
Appeal type: Medical necessity
Decision: Overturned

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


The patient has no past medical history (PMH) who was admitted with complaints of (c/o) left arm pain associated with blistering, erythema, fever, and streaking after a tattoo. The vital signs were notable for tachycardia. The physical exam was notable for left arm erythema, blistering, tenderness to palpation (TTP), and streaking. Lab work was significant for leukocytosis. The patient was diagnosed with cellulitis and was treated with intravenous (IV) antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o left arm pain associated with blistering, erythema, fever, and streaking after a tattoo. Given the patient's presentation, this patient met sepsis criteria, met the Infectious Diseases Society of America (IDSA) definition of severe cellulitis due to presence of leukocytosis and tachycardia, and the expected length of stay was greater than 48 hours. In addition, given the patient's presentation, close clinical monitoring was required to ensure there was no associated complications such as abscess, necrotizing fasciitis, or bacteremia, which are known complications of tattoo-related cellulitis. Overall, this patient presented with systemic signs and symptoms of infection suggesting that the patient required immediate treatment for cellulitis with intravenous antibiotics and that an inpatient level of care was required for safe medical evaluation and treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Ulcerative colitis and severe dermatitis.
Treatment:  Rinvoq 45MG (milligrams) ER (extended release) Tablet.

The insurer denied Rinvoq 45MG (milligrams) ER (extended release) Tablet.  The denial is upheld.

The patient is an adolescent female. She has been diagnosed with ulcerative colitis and severe dermatitis. She failed steroids and Stelara. Her doctor requested Rinvoq 45 mg (milligrams) daily. The health plan denied coverage of the request because the patient is under the plan approved age for Rinvoq. The denial is being appealed.

The requested Rinvoq is not medically necessary.

Upadactinib (Rinvoq) was recently studied in a phase 3, multicentre, randomised, double-blind, placebo-controlled clinical programme (1). This study found that "Upadacitinib demonstrated a positive efficacy and safety profile and could be an effective treatment option for patients with moderately to severely active ulcerative colitis." Another recently published systematic review and network meta-analysis showed that "upadacitinib 45 mg [milligrams] once daily ranked first for clinical remission in all patients, patients naive to anti-TNF [tumor necrosis factor] drugs and patients previously exposed." (2)
In the appeal letter, Crohn's disease was mentioned. Published clinical studies showed the safety and effectiveness of upadacitinib in adult patients with Crohn's disease (3-4).
This patient also has severe dermatitis. The appeal letter mentioned about a phase 3 randomized, multicenter, double-blind study to evaluate the safety of upadacitinib in combination with topical corticosteroids in adolescent and adult patients with moderate-to-severe atopic dermatitis. This study included 272 patients with only 29 children (9 placebo, 10 in low dose and 10 in high dose group). This study reported the safety data and did not report its effectiveness. The pediatric patient number is very small. There has been no large pediatric study yet.

In summary, all published clinical studies were performed in adult patients with ulcerative colitis or Crohn's disease. There have been no clinical studies of upadacitinib in children with ulcerative colitis or Crohn's disease. There have been no adequate clinical studies of upadacitinib in children with atopic dermatitis. This patient is an adolescent. Thus, there has been no medical literature or SOC (standard of care) to support the safety and effectiveness of upadacitinib in children with ulcerative 
colitis, Crohn's disease or atopic dermatitis. Therefore, given the above, the requested Rinvoq is not medically necessary.