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

Diagnosis: Gunshot wound
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient was an adult male who presented to the emergency department (ED). He had previously been treated at another facility for gunshot wounds to the abdomen and left arm. He left that hospital against medical advice (AMA) claiming poor treatment and lack of air conditioning. His past medical history is significant for bipolar disorder, post-traumatic stress disorder (PTSD), opioid use, and generalized anxiety.

At the time of presentation to the ED, the patient was awake and alert with normal vital signs. His Glasgow coma score was 15/15 at the time of presentation. He had abdominal tenderness and a drain in place without sign of infection. Lab data identified a white blood cell (WBC) count of 6.3 thousand (K) and hemoglobin of 9.2 grams per deciliter (g/dl). A computed tomography scan identified recent post-operative changes of bowel resection in the setting of an abdominal gunshot injury. The patient was admitted to the hospital. He was started on a diet. On the next day, the patient was able to walk in his room and was receiving oral pain medications. Follow up lab data documents stable hemoglobin values. A psychiatric assessment was completed yielding the recommendation for anxiety and mood stabilization. Inpatient psychiatric admission was not needed per this evaluation. Nursing records document stable vital signs throughout this hospitalization. The patient was considered to be stable for discharge from the hospital on the following day.

The records reference Milliman Care Guidelines (MCG) - Multiple Trauma. 

The proposed inpatient hospital admission was not medically necessary.

Inpatient admission was not medically necessary for this patient based on the submitted clinical documentation and the standards of medical care. A lower level of care would have been clinically appropriate in this case and would have been consistent with 
medical standards.

In this case there is no documentation of an adverse change in clinical status, intensity of services, or new condition supporting need of an inpatient level of care. In this case the patient was clinically stable at the time of presentation to the ED. He was able to resume a diet and tolerate oral medications. He did not require acute surgical intervention. A lower level of care would have permitted the short-term monitoring that would not have been expected to be longer than 48 hours and would have permitted acute treatment and reassessment, monitoring of his response to therapy, and diagnostic evaluation to establish a treatment plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Back Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female with a history of diabetes mellitus (DM), osteoarthritis, chronic kidney disease (CKD) stage 3, bipolar disorder, history of opioid use and gastroesophageal reflux disease (GERD) who presented with lower back pain. She reports that she fell down some stairs 3 months prior to presentation and has had worsening back pain since that time. The pain is exacerbated by any movement of the lumbar spine, relieved with Tylenol/codeine tabs, is rated 10/10 in severity. She denied recent trauma. She denied fevers, headaches, dizziness, changes in vision or hearing, shortness of breath, chest pain or any changes in bowel movements or urination. She was admitted for further management of her pain with a plan to continue Tylenol as needed every 6 hours with transition to morphine intravenous (IV) or Percocet for moderate to severe pain. Physical therapy (PT) evaluated the patient and recommended sub-acute rehabilitation. The patient's pain improved, and she requested to be discharged to home with outpatient follow up. She was considered stable for discharge home. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

The inpatient hospital admission was not medically necessary based on the documentation provided. The patient presented with worsening subacute back pain. She was hemodynamically stable. She did not have any evidence of a severe or progressive neurologic defect. She did not have evidence of acute spine fracture with damage or threat of damage to vertebral column or spinal cord. She did not have a suspected spinal infection. She did not have another suspected cause of back pain that would require admission such as an aortic dissection. She did not have severe pain requiring inpatient management. She did not require immediate surgery. She did not have acute kidney injury that required inpatient hospital admission. She did not have any other documented condition that required inpatient monitoring or management. The patient could have been managed at a lower level of care status.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sarcoidosis
Treatment: Xeljanz
The insurer denied Xeljanz
The denial is: Overturned

The patient is a female with sarcoidosis, gastroesophageal reflux disease (GERD), and anxiety first diagnosed that initially improved on prednisone but flared with tapering. She was started on methotrexate but could not tolerate it (chest pain and worsening dyspnea). Azathioprine was tried, but she had progression of lung disease despite this medication, and she also developed gastrointestinal (GI) intolerance. She had persistent dyspnea, hypoxemia, and recurrent hospital admissions. She was next tried on leflunomide but still had to be hospitalized for respiratory failure. Infliximab was not tolerated. Adalimumab was working but she unfortunately developed neutralizing antibodies, so it was lost as option along with other tumor necrosis factor (TNF) inhibitors. She was started on tofacitinib with an excellent response, came off of supplemental oxygen and prednisone, pulmonary function tests (PFTs) improved.

The patient has life threatening sarcoidosis and has already tried and failed (either due to intolerance or lack of effectiveness) nearly all other standard treatments. Xeljanz has data supporting its effectiveness and was clearly effective in this patient's case. There are no other valid options, and that Xeljanz is required for the patient's condition. Even if she had not been through nearly all other available options, there is good data that for severe sarcoidosis, Xeljanz may be one of the most effective options in looking at its effectiveness outcomes in literature cited below.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sarcoidosis
Treatment: Xeljanz
The insurer denied Xeljanz
The denial is: Overturned

The patient is a female with a history of sarcoidosis first diagnosed by bronchoscopy biopsy. She has pulmonary and musculoskeletal involvement. Over the ten years that she has been living with sarcoidosis she has tried a multitude of therapies. She was started on prednisone, but her symptoms did not improve. This was followed by methotrexate, but she developed chest pain and dyspnea. This was followed by azathioprine, but she developed gastrointestinal side effects. This was followed by leflunomide, but inflammatory symptoms continued to progress, and infliximab was started. Tofacitinib (Xeljanz) was attempted but denied by insurance; she was instead started on adalimumab, but she developed neutralizing antibodies and progressive worsening of pulmonary function tests. Tofacitinib was then started, and the patient demonstrated improvement in symptoms and in pulmonary function testing with a rise in forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and diffusing capacity for carbon monoxide (DLCO) after starting tofacitinib. She was also able to completely wean off of prednisone. The plan was made to reassess her clinical condition 4 months later and consider stopping tofacitinib if improvement continued.

The patient presents with difficult-to-control sarcoidosis, which is extensively documented by her longitudinal pulmonologist of the last 10 years. Six different therapies are documented as attempted and failed throughout the patient's disease course, including the core therapy for sarcoidosis (corticosteroids) and all of the first line steroid sparing therapies that were appropriate (methotrexate, azathioprine). After starting tofacitinib, the patient demonstrated a clear improvement in symptoms, objective tests, and was able to wean off of a more dangerous and side effect-laden therapy (corticosteroids). Thus, Xeljanz (tofacitinib) is likely to be more beneficial than any standard treatments for the insured's life threatening and disabling disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sarcoidosis
Treatment: Xeljanz
The insurer denied Xeljanz
The denial is: Upheld


This is the case of a female patient who suffers from sarcoidosis. The treating provider is requesting the coverage of Xeljanz. The patient tried and failed or has been intolerant to prednisone, leflunomide, infliximab, adalimumab, azathioprine and methotrexate. The patient was started on Xeljanz with improvement in symptoms.

The proposed health service or treatment Xeljanz is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient suffers from sarcoidosis. The patient tried and failed prednisone, leflunomide, infliximab, adalimumab, azathioprine and methotrexate. The request is for the Xeljanz. However, there are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long-term efficacy and safety of Xeljanz for the treatment of this patient medical condition. There is no high-quality literature showing an improvement in health outcomes with the use of Xeljanz for this patient condition. There are no national guidelines that support the routine use of Xeljanz for the treatment of sarcoidosis as in this patient case. The available evidence regarding the role of the Xeljanz in the management of sarcoidosis is limited to either small, uncontrolled, short-term and / or retrospective studies.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Migraines.
Treatment:  Formulary Exception for Emgality 120 milligrams (mg)/milliliter (ml) to treat chronic migraines.

The insurer denied coverage for Formulary Exception for Emgality 120 mg/ml to treat chronic migraines.  The denial is overturned.

This case involves a patient with a Formulary Exception Request for Emgality 20 milligrams mg/ml. A progress note reported the patient has a history of chronic migraines. Prior treatment included Topamax, Nortriptyline, Gabapentin, Venlafaxine, and Aimovig. The patient had continued Botox injections. The patient reported having 15-30 migraine days a month that were less severe and disabling with Botox. It was reported that the patient was inconsistently taking Emgality through insurance and availability. The patient was also taking Sumatriptan almost every day. The Botox injection was performed. 

A Final Adverse Determination letter reported the request for Emgality was denied due to lack of documentation of formulary alternatives being tried. The exception form reported the patient tried and failed Topamax, Botox, Venlafaxine, Amitriptyline and was unable to take beta-blockers due to low blood pressure. 

The documentation indicates the formulary alternative was Aimovig. Documentation indicates that the patient has already utilized Aimovig. Therefore, the requested drug would be more effective than the formulary alternative.

Emgality is a calcitonin-gene related peptide antagonist that is Food and Drug Administration approved for the preventive treatment of migraines in adults. In this case, the patient had a history of chronic migraines. Prior treatment included Topamax, Nortriptyline, Gabapentin, Venlafaxine, and Aimovig. The patient reported having 15-30 migraine days a month. A Botox injection was performed. It was noted that the patient was unable to take beta-blockers due to low blood pressure. Given failure of a formulary alternative, the request for Emgality is approved. 

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective. 

The not formulary drug is expected to be more effective that the formulary alternatives.

Based on the above findings, the Formulary Exception Emgality 120 milligrams mg/ml is expected to be more effective for chronic migraines. The health plan did not act reasonably, with sound medical judgement and in the best interest of the patient. 

The carrier's denial of Formulary Exception for Emgality 120 mg/ml to treat chronic migraines is overturned.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a girl with autism who presented with decreased oral intake, fever, and cough. She was well until 2 days prior to presentation when she developed fever and a barky cough. Her temperature was up to 104 at home. She also had decreased oral intake and had not voided in 24 hours. She typically does not drink when she gets sick, and she had been hospitalized previously for bronchiolitis and dehydration.
In the emergency department, she was described as irritable with dry and cracked lips. Her temperature was 101.8, her heart rate was 158 beats per minute (bpm), and her oxygen saturation was 94% on room air. A chest x-ray revealed mild peribronchial thickening. 

The Inpatient Hospital Admission was medically necessary for this patient.
This is a young girl who required ongoing intravenous fluids to maintain her hydration status due to decreased oral intake with increased insensible fluid loss from fever and respiratory illness. Indications for hospitalization for intravenous rehydration therapy include an inability of the child to take oral rehydration therapy sufficient to maintain hydration status. This patient continued to refuse oral intake despite a fluid bolus in the emergency department, was felt to be dehydrated, and had increased fluid needs due to her viral illness. Therefore, inpatient hospitalization for intravenous fluid hydration was indicated along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Sugar Levels, Nausea and Vomiting.
Treatment: Inpatient Hospital Admission.

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

The patient is an adult female with type 1 diabetes. She presented with hyperglycemia, abdominal cramping, and nausea and vomiting. She had taken off her insulin pump due to malfunction. The patient's glucose was 547 mg/dL (milligrams per deciliter), anion gap 200, CO2 (carbon dioxide) 20, sodium 133, and urine positive for ketones. She was treated with intravenous fluids, insulin, Protonix, Reglan, and Benadryl. She was admitted to the intensive care unit. She was transitioned to long-acting insulin, and insulin drip was continued. Inpatient stay for 2 days is under review.

The Inpatient Hospital Admission was not medically necessary.

This patient presented with known type 1 diabetes with mild diabetic ketoacidosis due to an insulin pump malfunction. Her hyperglycemia and ketoacidosis responded quickly to insulin therapy.  Patients with diabetic ketoacidosis can be safely managed in observation units, unless they present with severe alteration of mental status or with critical illness such as sepsis, which is not documented in this case. This patient did not have alteration in her mental status. She was hemodynamically stable. Her nausea and vomiting resolved. The documentation does not support a trial and failure of a lower level of stay. Therefore, no, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD)
Treatment: Breztri Aerosphere 160 micrograms (mcg)-9mcg-4.8mcg/actuation Hydrofluoroalkane (HFA) aerosol inhaler (budesonide-glycopyr-formoterol)
The health plan denied the requested medication Breztri Aerosphere 160mcg-9mcg-4.8mcg/actuation HFA aerosol inhaler (budesonide-glycopyr-formoterol) as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with occupational asthma/reactive airways disease with significant sensitivity to environmental conditions and frequent coughing. She had been on Dulera and Montelukast but had insurance coverage issues. She had tried and failed Breo (did not tolerate). There was also a plan for evaluation in allergy clinic and with speech therapy.

At issue is the medical necessity for the requested health service/treatment of Breztri Aerosphere 160 micrograms (mcg)-9mcg-4.8mcg/actuation Hydrofluoroalkane (HFA) aerosol inhaler (budesonide-glycopyr-formoterol).

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

There are formulary approved equivalents that have not been tried.

It does not seem like the provider or patient tried the available formulary options to achieve this combination of medications. As there are formulary approved options to achieve this drug combination that have not been tried yet, I do not think a non-formulary exception is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is an adult female. She presented to the hospital after having experienced a syncopal episode. She had complained of dizziness, blurry vision, excessive sweating and unexplained weight gain. 

The patient's neurological examination was significant for imbalance and difficulty walking. Electrocardiogram showed left atrial enlargement. She also had MRI (magnetic resonance imaging) of the brain, echocardiogram and further evaluation for prolactin number.

The inpatient hospitalization was denied coverage by the health plan as not medically necessary. The denial is being appealed. 

The Inpatient Admission was medically necessary. 

Inpatient hospitalization was necessary due to a need for continuous telemetry and neurological monitoring given that the patient had a witnessed syncopal episode, and due to the fact that she had an abnormal neurological exam and EKG (electrocardiogram). 

Syncope can have both neurological and cardiac causes, and workup to rule out both was medically indicated in this patient's case. According to MCG (Milliman Care Guidelines) guidelines on neurology, if there is a deficit in the neurological examination, inpatient hospitalization is warranted for neurological checks. From a cardiac perspective, continuous telemetry was warranted, and that could not be provided in the outpatient setting. 

Therefore, given the above, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Uterine Fibroids
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient had a history of symptomatic uterine fibroids. They presented to the hospital and underwent an open abdominal myomectomy, dilation and curettage (D&C), and chromopertubation. The hospital course was uneventful. The patient was discharged after a period of medical stability. This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in the hospital for 48 hours. 

On postoperative day 1, the Foley catheter was removed, the patient was encouraged to get out of bed and ambulate, clear liquids were started. On postoperative day 2, if the patient is passing flatus and tolerating regular diet, they are discharged home. This patient was actually discharged home a day earlier than standard (on postop day 1).

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

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

Diagnosis: Back Pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is upheld.

The patient has a history of low back pain. Prior treatments have included lumbar epidural injections, physical therapy, as well as medication. The pain impacts her daily activities. The pain is ranging from 4-9 out of 10. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated multilevel degenerative changes. There is a request for Intracept Procedure. At issue is whether the Intracept Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The patient has complaints of low back pain. The requested procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is a lack of substantial support for this procedure, and it is currently not considered standard of care.

Given the above, the proposed health service or treatment, the Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.