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

Diagnosis: Crohn's Disease.
Treatment: Formulary exception for Stelara IV plus Stelara SQ 90MG.
The insurer denied the Formulary exception for Stelara IV plus Stelara SQ 90MG.
The denial is overturned.

The patient is a male with moderate to severe Crohn's. He has failed mesalamine, Prednisone, budesonide and Humira. His provider is requesting treatment with Stelara.

Yes, the health plan should cover the formulary exception for Stelara.
The patient has moderate to severe Crohn's. He is noted to have failed the preferred formulary alternative, Humira. Therefore, the requested formulary exception for Stelara is clinically appropriate, accepted standard of medical care and is medically necessary, and should be covered.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, chronic hepatitis C, right knee osteoarthritis status post left total knee replacement.
Treatment: Custodial (long term) care.
The insurer denied the Custodial (long term) care.
The denial is overturned.

The patient is a male with history of general debility due to multiple medical issues and admitted to skilled nursing facility (SNF) at which point he was totally dependent for all activities of daily living (ADLs).  The patient's relevant past medical history includes diabetes mellitus, chronic hepatitis C, liver cirrhosis, hypertension, hyperlipidemia, alcohol abuse, chronic obstructive pulmonary disease (COPD), right knee osteoarthritis status post left total knee replacement (TKR), liver failure, kidney failure, pressure ulcer, lumbar and cervical spondylosis, COVID positive, etc.

The patient has been undergoing physical therapy (PT) and occupational therapy (OT).  The patient was able to ambulate 100 feet with supervision and no device, contact guard for hygiene/grooming, self-feeding, upper body dressing and toilet, required supervision for bed mobility, transfers, required maximum assistance for toileting.  The plan was to discharge the patient home to live in his home with support from others.

Yes, the proposed custodial (long term) care was medically necessary.
The continued stay in a long-term custodial care facility was medically necessary because the patient came in with general debility due to multiple medical issues, each that can be extremely debilitating and worse when combined, and was totally dependent. The patient was only able to ambulate 30 feet with moderate assistance, required minimum assistance for bed transfers, bed mobility, moderate assistance for transfers and most other activities of daily living (ADLs). The patient began showing improvement, and was able to ambulate 100 feet with supervision and no device, contact guard for hygiene/grooming, self-feeding, upper body dressing and toilet, bed mobility, toilet transfers/commode, hygiene, and required maximum assistance for toileting. The plan was to discharge the patient home to live in his home with support from others. 

The patient needed to be in long-term custodial care because he had a severe level of debility with multiple medical issues that can benefit from occupational therapy (OT) and physical therapy (PT), and he was able to show progress.

No, the health plan has not acted reasonably in this instance, and its decision was without sound medical judgment which was not in the best interest of the patient because the transfer to a long-term custodial care was medically necessary with clinical evidence as stated above of general debility and decreased activities of daily living (ADLs) associated with initial confusion in the midst of multiple medical issues.
The patient would not be able to achieve any tangible improvement in a lower level of care such as outpatient rehabilitation or home rehabilitation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Areata

Treatment: Xeljanz 5 mg (milligrams)

The insurer denied coverage for Xeljanz 5 mg

The denial is overturned.

The patient has a diagnosis of alopecia areata.  The patient has been successfully treated with oral Xeljanz without complication and with improvement.  The patient briefly discontinued Xeljanz during her pregnancy and now wishes to resume xeljanz following a miscarriage. The requested medication is continuation of Xeljanz.  

The patient would currently be stable with her prescribed regimen had she not discontinued it due to her pregnancy.  The patient was successfully treated without any adverse effects noted with oral Xeljanz.  As a result, the denial is overturned and the use of Xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment. 

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 Xeljanz 5 milligrams (mg) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient hospital stay. 

The health plan denied the inpatient stay as not medically necessary. 

The reviewer has upheld in whole the health plan's determination. 

The patient is a previously healthy female who presented to the hospital emergency department (ED) with a history of progressively worsening abdominal pain. Her evaluation included physical exam, computed tomography (CT) scan, and labs. She was afebrile at the time of presentation. The heart rate was normal at 87/minute at presentation. The abdomen was tender in the right lower quadrant. Lab data identified a normal white blood cell count (WBC) of 10.6 thousand (K). CT scan showed a dilated appendix consistent with appendicitis. Her evaluation yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested. She was admitted to the hospital. 
The patient was provided IV fluid and antibiotics. She underwent laparoscopic appendectomy with findings of appendicitis. Surgery was performed without complication. The diet was advanced and pain management was converted to oral medications. She was discharged home later in the day. 

Inpatient care was not medically necessary. A lower level of care would have satisfied the clinical needs of this patient. She presented to the ED and underwent an uncomplicated appendectomy. The post-surgical course was without adverse incident. The patient responded favorably to this treatment and the hospitalization was uncomplicated. The patient was previously healthy, and the vital signs were consistently normal. The progress notes document clinical stability without complication during this period of monitoring. The submitted clinical documentation does not support the need for inpatient admission for this patient. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. Generally accepted medical standards indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the treatment of appendicitis can be provided without an inpatient level of care. In this case the patient tolerated oral hydration, diet/medication, and surgical treatment. A lower level of care would have appropriately provided for surgical treatment and monitoring. Inpatient care was not required or medically necessary in this case per generally accepted medical standards.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a male whose inpatient admission is under review. The patient started developing symptoms of erythema and pain in the left thigh several days before admission. He was seen in urgent care, given antibiotics, but he did not take any of the medications as he did not fill the prescription. He noted a progressive increase in size of the erythema and presented to the ER (emergency room).

In the ER (emergency room), the patient's vitals were as follows: T (temperature) - 97.4, BP (blood pressure) - 128/78, P (pulse)  76, RR (respiration rate)  14. On general examination, the patient was noted to be NAD (no acute distress). Examinations of the chest, CVS (cardiovascular system) and abdomen were normal. Examination of the extremities revealed left thigh erythema.

The patient's labs were as follows: WBC (white blood count) - 12.4 (high), Hg (hemoglobin) - 14.9, Hct (hematocrit) - 43.9, Plt (platelets) - 169, Na (sodium) - 138,
K (potassium) - 3.7, Cl (chloride) - 107, CO2 (carbon dioxide) - 25, BUN (blood urea nitrogen) - 20, and Cr (creatinine) - 1.13.

In the ER (emergency room), the patient was thought to have cellulitis that failed outpatient management. The patient was started on IV (intravenous) vancomycin and defepime and admitted. After several days in the hospital, an abscess developed, which was drained (10cc [cubic centimeters] pus). The patient thereafter improved and was discharged home on PO (oral) antibiotics.

U/S (ultrasound) of the thigh revealed no fluid collection.

Yes, the Inpatient admission was medically necessary.
According to the Infectious Diseases Society of America, systemic signs of infection (including elevated WBC [white blood cell] count) are indications for admission and IV (intravenous) therapy (1). In addition, the patient had demonstrated not being compliant with outpatient therapy. Standard of care would require inpatient treatment of such a patient. Failure to treat such a patient, could lead to loss of function, sepsis, or death.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Pulmonary Embolism.
Treatment: Formulary exception for Eliquis.
The insurer denied the Formulary exception for Eliquis.
The denial is upheld.

The patient in this case was diagnosed with pulmonary embolism.  Eliquis was prescribed.  There is a hand-written note saying that this patient had an allergic reaction to Xarelto and also to Coumadin.  Also provided is a phone note stating that this patient was changed to Xarelto and that it caused gum bleeding when brushing her teeth.  This happened once and she held the medication for two nights and tried taking it again and she had the bleeding again.  She was instructed to stop Xarelto based on that.

No, the Health plan should not cover the proposed formulary exception for Eliquis.
The formulary alternatives are Xarelto and Coumadin.  Both are standard drugs for treatment of venous thrombosis.  As both are Food and Drug Administration (FDA) approved for this purpose and as there are only minimal differences in efficacy and safety between these agents, there is no compelling reason to find Eliquis medically necessary in this case.  It is noted that this patient had prior reactions to Xarelto and Coumadin.  The reaction to Xarelto is documented as above.  However, there is no documentation showing that this patient tried and failed Coumadin or that she had a bad reaction to this medication.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Paroxysmal Atrial Fibrillation
Treatment: Eliquis, Pre-service

The insurer denied the Eliquis, Pre-service.
The denial is upheld.

The patient is a male with a past medical history of paroxysmal atrial fibrillation, status post ablation, TIA (transient ischemic attack), CHADS-VASC (congestive heart failure, hypertension, age >= {greater than/equal to} 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category) score of 2, who has been maintained on chronic anticoagulation with Eliquis with no side effects. Xarelto became a preferred alternative and further coverage for Eliquis was denied, as there is no history of therapeutic failure or adverse side effects with a plan preferred alternative, such as Xarelto. Continuation of Eliquis is being requested by the treating physician and the patient.
As per attached plan policy, the requested drug will be covered if the following criteria are met:
1. The patient cannot be switched to a formulary drug.
2. The patient is unable to take formulary alternatives for the given diagnosis due to trial and inadequate treatment response or intolerance or a contraindication.
3. The requested drug is being used for an FDA (United States Food and Drug Administration) approved indication.
4. The prescribed dose and quantity fall within the FDA (United States Food and Drug Administration) approved labeling.

No, the health plan should not cover the proposed treatment.
Although the drug requested - Eliquis, is being prescribed for an FDA-approved (United States Food and Drug Administration) indication at an approved dose, the first two criteria are not met, as the patient has no history of trial and failure or adverse reaction to a formulary alternative, such as Xarelto.
There are no randomized trials with direct comparison of Xarelto and Eliquis and thus there is no reliable data to suggest that one of these agents is clinically superior to the other. 
As a formulary alternative has not been tried, there is no indication that a formulary drug would be ineffective for this patient, less effective for this patient or have adverse effects for this patient.
Therefore the plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

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

The patient has a medical history of diverticulosis complicated by prior diverticulitis. He presented to the emergency department with abdominal pain since the prior day, and chills. Vital signs were notable for an elevated blood pressure of 200/124 millimeters of mercury (mmHg). The physical examination was notable for left lower quadrant abdominal tenderness with guarding. Lab results showed an elevated white blood cell count of 15.7 thousand per microliter (K/uL), low sodium of 134 millimoles per liter (mmol/L), elevated C-reactive protein of 17.0 milligrams per deciliter (mg/dL), and elevated bilirubin of 1.4 mg/dL. An ultrasound of the abdomen showed small bilateral hydroceles, but was otherwise unremarkable. A computed tomography scan of the abdomen and pelvis showed severe diverticulitis of the sigmoid colon with a small amount of adjacent fluid but no abscess, perforation, or obstruction, and a small fat-containing periumbilical hernia. He was treated with intravenous fluids, Zosyn, ondansetron, and hydromorphone. A surgery consultation concluded that he had a second episode of acute diverticulitis; the recommendation was elective colon resection. He was feeling well and had no real abdominal pain. Lab results showed an elevated white blood cell count of 11.6 K/uL, and elevated bilirubin of 1.2 mg/dL. He was discharged on Augmentin for 10 days, with a plan for Primary Care and Surgery follow-up.
At issue is the medical necessity for the inpatient level of care.

The inpatient stay was not medically necessary.
In patients with uncomplicated diverticulitis (without complications such as an abscess or perforation), outpatient management or observation is the standard of care [1]. The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated [2]. A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the emergency department and then discharged with oral antibiotics [3]. A systematic review of the literature underscored this [4]. Observation level of care can be appropriate when there are significant symptoms and leukocytosis, as in this case [5]. However, there was no protracted fever or hypotension to suggest that intravenous antibiotics in the hospital were ineffective. There had been no definitive evidence of abscess on imaging [4-6]. The patient improved on intravenous antibiotic therapy, and was appropriately discharged on intravenous antibiotic therapy [7,8]. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication was documented. For these reasons, the inpatient level of care is not supported in this case, and the care provided could have been provided at a lower level of care. Per the Milliman Care Guidelines for Diverticulitis, Acute, the inpatient level of care is not supported.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Ilumya
The insurer denied the Ilumya
The denial is overturned.

The patient is a female with a medical history of plaque psoriasis. The clinical chart notes and appeal letter endorses cognitive delays, needle phobia, and inability to self-administer injections at home. She has tried and failed Humira and topical steroids. The provider is appealing the denial of Ilumya, stating that the patient was started on in-office injections and she is 90% [percent] clear on this medication.

Yes, the requested Ilumya is medically necessary.
According to the clinical chart notes and appeal letter, this patient has cognitive delays, needle phobia, and inability to self-administer injections at home. Additionally, the family has been unsuccessful at attempting to help with these injections. Given that she has improved dramatically since initiation of in office Ilumya injections, there is no clinically valid reason to switch her off of Ilumya to try one of the plan's preferred biologics. Changing biologics at this time would most certainly cause skin flaring. Therefore, this request is medically necessary continuation of therapy. It is recommended to be approved for a duration of 12 months.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision problems and decreased hearing
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP): 8 Hours per day - 5 days a week for a total of 40 hours per week

The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP): 8 Hours per day - 5 days a week for a total of 40 hours per week.
The denial is overturned.

The patient is a female. She reportedly has vision problems and decreased hearing. The patient is legally blind in both eyes. The patient also has decreased mental capacity.

The patient needs assistance with hygiene, dressing and eating.

The denial of an increase in her CDPAP (consumer directed personal assistance program) hours from 20 hours/week to 40 hours/week is being appealed. The appeal position is that the patient needs services of an aide for extended hours.

Yes, the requested Increase Consumer Directed Personal Assistance Program (CDPAP) to 8 Hours per day - 5 days a week for a total of 40 hours per week is medically necessary.
The patient is legally blind in both eyes. The patient also has decreased mental capacity. The patient needs assistance with hygiene, dressing and eating. The patient will need extended hours and services of an aide.

Therefore, given the above, the requested health service is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient needs extended hours of services and will need an aide for 40 hours per week. The functional capacity of the patient and the presence of visual and hearing impairments warrants extended aide services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine Fibroids.
Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.  The denial is overturned.

The patient has a history of uterine fibroids. She presented to the hospital and underwent an abdominal myomectomy. Twenty fibroids were removed. The blood loss was 300 cc (cubic centimeters).  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 hospital for 48 hours. 

On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, clear liquids are started. 

On postoperative day 2, if the patient is passing flatus and tolerating regular diet, she is discharged home.

This patient was managed according to the guidelines and the standard of care. 

The admission should be approved based on MCG (Milliman Care Guidelines) Laparotomy.

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

The full hospital admission is considered medically necessary for this patient. 

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 full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angioedema.
Treatment: Inpatient admission.

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

The patient had a history of anaphylactic type reaction to Lisinopril and presented to the emergency department (ED) with complaints of shortness of breath (SOB), wheezing and lip swelling after eating cherries.  The patient has past medical history (PMH) of gastric adenocarcinoma, hypertension (HTN), hyperlipidemia (HLD), transient ischemic attack (TIA), ETOH (ethanol alcohol) abuse, and asthma. The patient reported allergy to penicillin (PCN) and shellfish.  The patient called emergency medical services (EMS) and was given Duonebs by EMS.  Vital signs at presentation to the emergency department (ED) were: Temperature 98.1, Heart Rate 117, Respiratory Rate 30, Blood Pressure 141/90, and oxygen (O2) saturations were 99% (percent). The patient was in mild distress, alert, and oriented X 3 (person, place, and time). Swelling of face and Lips noted lung exam revealed bilateral (B/L) wheezing. The patient was given 0.5 mg (milligrams) Epinephrine intramuscular (IM). The patient was also given Dexamethasone and Benadryl. The patient did report symptomatic improvement after same.  Labs white blood cell count (WBC) 11 K (thousand), hematocrit (Hct) 40, Electrolytes revealed mild hyponatremia, and blood urea nitrogen (BUN). Creatinine 25/1.0. Chest x-rays revealed (CXR) minimal perihilar opacities. Electrocardiogram (EKG) revealed sinus tachycardia there was no acute ischemic changes. Troponin was negative and NT-proB-type Natriuretic Peptide (BNP) was within normal limits (WNL). 

The patient was admitted to the hospital for Angioedema rule out (R/O) anaphylaxis.
Continued on Steroids, Benadryl and other medications. He remained stable after admission. Steroids were tapered off and patient discharged home.  The patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient started improving after treatment in the emergency department (ED) with Epinephrine, Dexamethasone and Benadryl.  The patient had remained afebrile and hemodynamically (HD) stable, was tolerating oral intake (PO). The patient was stable for discharge after improvement and observation in the hospital. The patient did not exhibit any stridor, airway obstruction or hypoxia. Cardiac enzymes were negative. He had some evidence of fatty liver on sonogram secondary to his ETOH abuse. The patient could have been discharged home after a period under observation of tapering steroids and Benadryl with close follow up in outpatient setting.

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 admission is upheld. Medical necessity  is not substantiated.