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

Diagnosis: Lip swelling; hives
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female. She presented to the ED (emergency department) with symptoms of new lip swelling and hives. She had started on Macrobid for 3 days prior to developing urticaria. She was seen in Urgent Care and given Benadryl, pepcid, and prednisone for treatment of the reaction. She was given epinephrine with improvement of symptoms.

In the ED (emergency department), the patient was given IV (intravenous) solumedrol, IV (intravenous) pepcid, IV (intravenous) fluid bolus, IV (intravenous) benadryl, and IV (intravenous) epinephrine. Her symptoms persisted, however, and she was admitted with a diagnosis of anaphylaxis. Her facial swelling worsened and hives increased. She was given IV (intravenous) solumedrol every 8 hours and continued to receive IV (intravenous) solumedrol and IV (intravenous) hydration on hospital day #3.

The health plan denied coverage of the inpatient hospitalization, as they deemed it not medically necessary. This denial is being appealed.

Yes, the Inpatient admission was medically necessary.
The patient failed outpatient treatment and symptoms persisted. She required IV (intravenous) medications and IV (intravenous) fluids. Inpatient hospitalization was appropriate.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient failed outpatient treatment and the symptoms persisted. She required IV (intravenous) medications and IV (intravenous) fluids. Inpatient hospitalization was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke

Treatment: hospital admission

The insurer denied coverage for hospital admission

The denial is overturned.

This case involves a female diagnosed with stage IV breast cancer and deep vein thrombosis.

The patient was seen in the emergency department regarding dizziness, unsteadiness, and numbness and tingling.  Symptoms were present since the day prior.  There were reports of jaw pain that worsened with opening of the mouth.  There were episodes of vasovagal.  Speech is clear and there was no facial droop.  The patient was status post radiation therapy.  On examination, the patient was pale and ill appearing.  Tenderness to palpation was present in the left jaw and there was CT (computed tomography) neuro perfusion that noted low volume perfusion mismatch in the left temporal lobe.  The patient was admitted to rule out stroke.

Although the term "TIA (transient ischemic attack)" was used to describe the event, the patient's symptoms started almost 24 hours prior to coming to the ER (emergency room).  This duration of symptoms would escalate the condition from "TIA" to "cerebral ischemia".  Therefore, the request is supported, and the prior determination is overturned. 

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

Diagnosis: Abdominal pain; emesis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female. She presented with abdominal pain and emesis x 15.

The patient was hemodynamically stable, with a Hgb (hemoglobin) of 11.3, K (potassium) 3.2 and Mg (magnesium) 0.9. CT (computed tomography) scan revealed thickening in the esophagus, stomach and colon.

The patient was hydrated and K (potassium) and Mg (magnesium) were supplemented. IV (intravenous) protonix was started. On day two, GI (gastroenterology) consult saw patient and noted no further vomiting. Diet was advanced and EGD (esophagogastroduodenoscopy) was scheduled for day four. No labs were done on day two.

On day three, there was no further vomiting. The patient's Hgb (hemoglobin) was stable at 10.3 and K (potassium) was 3.3. She tolerated diet. EGD (esophagogastroduodenoscopy) revealed gastritis, duodenitis and no bleeding.

The patient's diet was advanced, and she was discharged.

No, the Inpatient admission was not medically necessary.
The patient presented to the ER (emergency room) with abdominal pain and vomiting. She had a normal CBC (complete blood count), low Mg (magnesium) (0.9) and K (potassium) (3.2), and CT (computed tomography) without obstruction, but with gastritis and esophagitis and despite no diarrhea, possible colitis. As she was hemodynamically stable, with K (potassium) over 3, and no evidence of anemia, obstruction or need for surgical intervention, a lower level of care was appropriate. On day two, there was no further vomiting, no labs repeated, her diet was advanced, and she was seen by GI (gastroenterology), who recommended an EGD (esophagogastroduodenoscopy) in another 48 hours. As there was no intractable vomiting, dehydration, ongoing electrolyte abnormalities, GI (gastrointestinal) bleeding, or obstruction, she was medically stable for discharge on day two on oral medications and a liquid diet, to advance as tolerated. In summary, a lower level of care was appropriate, and she was medically stable for discharge on day two. Acute inpatient hospital stay was not medically necessary.

Yes, as acute inpatient hospital stay was not medically necessary,  the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachypnea with a viral illness

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is a female with a history of autism spectrum disorder and speech delay. She had a history of a previous respiratory illness one month prior to this admission. She has been prescribed an albuterol metered dose inhaler in the past. She was sick for 2 days with a dry cough and nasal congestion. There were other siblings at home with similar symptoms. When she was noted to have labored breathing, she was brought to the ER (emergency room) for medical evaluation.

In the ER she was noted to have mild abdominal retractions and occasional suprasternal retractions. The mother indicated that she was acting like her chest was sore. She was afebrile with mild degree of tachycardia. The pulse oximeter reading in the ER was documented to be   96% (percent) with occasional drops to 93% on room air. She did not require oxygen supplementation. On physical exam she was not in distress and there was no audible wheezing upon chest examination. A respiratory viral panel was positive for rhino/enterovirus. She was treated with 2 back-to-back albuterol treatments and decadron. Since the mother did not have a nebulizer in the home and the child had been prescribed albuterol with a metered dose inhaler in the past and the mother indicated that she had difficulty administering this medication to her child, the decision was made to admit her with a diagnosis of Tachypnea with a viral illness for ongoing treatment with albuterol, every 3 hours and monitoring of her oxygen saturation.  

An inpatient admission is not considered medically necessary for this patient.

This child was treated appropriately in the ER for a cough, and tachypnea. She was not in acute respiratory distress; she was drinking adequately and there was no ongoing need for oxygen supplementation. She could have been discharged home with an aerochamber and education in the appropriate treatment with albuterol with the metered dose inhaler she had previously been prescribed. There was also the option to prescribe a nebulizer for use in the home to permit the administration of albuterol. The medical record does not indicate that the possibility of the child having asthma was discussed with the mother. The decision to admit to the hospital was not consistent with the standard of care for a mild case of asthma related to a viral illness. The mother could have been instructed on how to administer the appropriate treatments to be continued at home and the recommendation for a follow up visit with the pediatrician in 24 to 48 hours. This child could have been safely discharged home with appropriate medication for treatment at home.

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

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

Diagnosis: Paroxysmal atrial fibrillation. 
Treatment: Eliquis. 

The insurer denied the Eliquis. 
The determination is overturned. 

The patient has a history of paroxysmal atrial fibrillation, obstructive sleep apnea (OSA), bilateral carotid atherosclerosis and left carotid dissection who has been anticoagulated with apixaban for the prevention of stroke. He has tolerated apixaban well without side effects including bleeding. The patient's health plan has denied prescription benefit exception request for apixaban as that the patient does not meet the health plan criteria for prescription benefit exception. The patient's treating physician is appealing this denial. 
At issue is whether the formulary drugs (warfarin, Xarelto) will be or have been ineffective, would not be as effective as the non-formulary drug Eliquis, or would have adverse effects. 

Based on the patient's records provided for review of this case, the formulary anticoagulants warfarin and Xarelto will be less effective and more likely to cause adverse effects than the non-formulary medication apixaban for the following reasons. While the formulary anticoagulants are indicated for patients with atrial fibrillation to prevent stroke and systemic embolization, expert consensus guideline statements on the management of patients with atrial fibrillation recommend direct-acting oral anticoagulants (DOACs), including apixaban, over warfarin to prevent stroke given their believed superior efficacy and safety profile (1). In addition, peer reviewed medical literature has demonstrated that, in patients over the age of 65 years old, apixaban is superior to Xarelto in reducing the risk of stroke and is associated with lower risk of significant bleeding events (2). This is particularly relevant in this case given the patient's history of left carotid dissection with the possibility of increased bleeding risk. For these reasons, continued treatment with apixaban is the most effective and safest anticoagulant for the prevention of stroke for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems- Teeth Spacing Problem/severe crowding.
Treatment: Dental/Orthodontic Procedure- Comprehensive orthodontic treatment and periodic orthodontic treatment visits.
The health plan denied the comprehensive orthodontic treatment and visits as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient in question has a Class II malocclusion with severe crowding. Tooth 10 is in anterior crossbite. Tooth 8 is protrusive and has a history of trauma. He is treatment planned for 30-36 months of orthodontics with extraction of maxillary first premolars and mandibular second premolars to correct the crowding and crossbite. 

Yes, the requested treatment of comprehensive orthodontic treatment and periodic orthodontic treatment visits is medically necessary. Tooth 10 is at great risk of wear and damage, and if left untreated the maxillary central incisors are at risk for further trauma. Tooth 10 is in crossbite with teeth 22 and 23. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. [1,2,3] These problems are much more time consuming and costly to correct than the patient's current orthodontic problem. There is also strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. [1] Orthodontic treatment will make the teeth significantly less protrusive, reducing the risk of trauma.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stage IV (4) endometrial cancer

Treatment medication Keytruda 100 milligrams per 4 milliliter vial

The insurer denied coverage for medication Keytruda 100 milligrams per 4 milliliter vial

The denial is upheld

The patient has a history of metastatic uterine cancer. The treating provider has proposed first line therapy with lenvatinib plus Keytruda. She is stated to be Microsatellite instability-high (MSI-H).

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medication Keytruda 100 milligrams per 4 milliliter vial is not considered medically necessary for this patient. 

The regimen of Keytruda plus lenvatinib is only supported to treat microsatellite stable (MSS) uterine cancer in patients who have metastatic inoperable disease and have failed standard chemotherapy. While this therapy can be given in a second line setting it is not supported to be used as first line therapy as requested for this case. Keytruda as a single agent can be used to treat MSI-H uterine cancer following failure of standard first line therapy. Keytruda is not approved for use with MSI-H uterine cancer. As this patient is eligible for standard therapy, but declines it, there is no role for Keytruda at this time. (NCCN [National Comprehensive Cancer Network]) Note that the submitted article by Makker et al NEJM (New England Journal of Medicine) also involved "patients with advanced endometrial cancer who had previously received at least one platinum-based chemotherapy regimen" prior to being enrolled in the study. 

Marabelle, A., et al. (2020), "Among 233 enrolled patients, 27 tumor types were represented, with endometrial, gastric, cholangiocarcinoma, and pancreatic cancers being the most common. Median follow up was 13.4 months. Objective response rate was 34.3% (percent) ...Median progression-free survival was 4.1 months (95% CI (confidence interval), 2.4 to 4.9 months) and median overall survival was 23.5 months (95% CI, 13.5 months to not reached). Treatment-related adverse events occurred in 151 patients (64.8%). Thirty-four patients (14.6%) had grade 3 to 5 treatment-related adverse events. Grade 5 pneumonia occurred in one patient; there were no other treatment-related fatal adverse events."

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

The insurer's denial of coverage for the medication Keytruda 100 milligrams per 4 milliliter vial is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy who presented to the emergency department with decreased oral intake, abdominal pain, and decreased urine output. He was well until 2 weeks prior to admission when he developed abdominal pain. He continued to have intermittent pain, and also had emesis and nausea. He was initially seen by his primary doctor who diagnosed him with a stomach bug. His pain was initially in the middle of his abdomen and then migrated to the right side. He was drinking but was voiding less than usual. He continued to have nausea and his pain worsened, so he was brought to the emergency department for evaluation.

The inpatient hospital admission was medically necessary for this patient. He required ongoing intravenous fluid hydration to correct his dehydration and electrolyte imbalance, and required close monitoring of his abnormal laboratory values and his clinical status.
This is a young boy who presented with abdominal pain, dehydration, and metabolic acidosis. He was found to have a very low bicarbonate level as well as hypoglycemia and ketosis. He was also undergoing evaluation for possible appendicitis, due to persistent abdominal pain that had migrated down to the right lower quadrant. He continued to have electrolyte abnormalities despite emergency department treatment. He required inpatient admission for continued intravenous hydration, assessment of his intake and output, and close monitoring of his electrolytes.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atrial Fibrillation.
Treatment:  Formulary exception for Eliquis.
The insurer denied the  Formulary exception for Eliquis.
The denial is overturned.

The patient is an overweight female with history of atrial fibrillation and cerebellar infarct. Her co-morbidities include hypertension, vertebral artery dissection and migraines. The request is for Eliquis for anti-coagulation for atrial fibrillation.

Eliquis is off formulary, and there is no evidence that Xarelto or Coumadin have been tried.

The reason noted for choice of Eliquis, "Eliquis is the right drug for this patient."

Yes, the health plan should cover the Formulary exception for Eliquis.
Eliquis has established itself in several studies as both safer and more effective in preventing complications than either Xarelto or Warfarin. Studies find apixaban (Eliquis) is preferable to rivaroxaban (Xarelto) for stroke prevention, reduced bleeding complications. Eliquis was found to be more effective than warfarin in lowering the risk of stroke and systemic embolism. People who took Eliquis also had significantly fewer bleeding episodes than those who took warfarin.

In this patient with a previous cerebellar infarct, it is even more important that subsequent events are prevented.

Regarding the denial, it is not reasonable or appropriate to do a trial of either formulary alternative.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Premature Ventricular Contractions. 
Treatment: Implantable Ambulatory Event Monitor. 

The insurer denied an Implantable Ambulatory Event Monitor. The health plan's determination is upheld. 

This woman underwent implantation of an implantable loop recorder (ILR). Her medical history was remarkable for symptomatic premature ventricular complexes (PVCs) originating in the right ventricular outflow tract, treated with multiple catheter ablation procedures. The patient's heart was structurally normal by echocardiogram and cardiac catheterization. She was evaluated after an episode of severe, debilitating chest pain the night prior that was associated with PVCs. She was then scheduled for ILR implantation the next day. 

Implantable Ambulatory Event Monitor was not medically necessary for this patient. Per the medical record, the purpose of cardiac monitoring in this instance was to determine the frequency of this woman's ventricular ectopy. This could best be accomplished by a continuous monitoring device for a brief period of time, such as 24 to 48 hours. With such a device, the total number of heart beats during the monitoring period as well as the total number of premature ventricular complexes (PVCs) could be determined and, with that information, the PVC burden (percentage of total beats) could be calculated. This information could not be determined from an implantable loop recorder. Moreover, as previously mentioned, the ILR is most appropriate for detecting very infrequent arrhythmic events. The medical record does not reflect that it was used for this purpose in this instance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic Renal Cell Carcinoma. 
Treatment: Avastin Injections. 

The insurer denied the Avastin Injections. 
The denial is upheld. 

The patient is a male. The patient in this case was initially diagnosed with clear cell carcinoma of the kidney.  Right radical nephrectomy was performed at that time and he did well until he was diagnosed with metastatic disease earlier in the year.  He was recommended to proceed with clinical trial treatment and the study in question was examining the use of pazopanib alternating with bevacizumab.   At issue is use of Avastin (bevacizumab) in this case. 

No, the requested Avastin is not medically necessary. 

The treatment in this case, a combination of Avastin (bevacizumab) and pazopanib in which the treatments are being given in alternating fashion, is not a standard treatment for the patient's disease. This treatment is unproven. While both agents are standard drugs used in the treatment of kidney cancer, this specific treatment with the agents being given in alternating fashion remains under active investigation as the treatment is being given on a clinical trial. Given that this treatment is currently under study in an open clinical trial it should be considered unproven and therefore not medically necessary. 

Lack of NCCN (National Comprehensive Cancer Network) endorsement and lack of evidence that this specific treatment can improve health outcomes also support the conclusion that this treatment is not medically necessary. 

In addition, use of brand-name Avastin rather than the plan preferred agent of Zirabev would also not be considered medically necessary, as there is no evidence showing that brand-name Avastin is safer or more effective than the biosimilar equivalent, which carries all of the same FDA (United States Food and Drug Administration)-labeled indications as the brand-name product. 

Therefore, given the above, the requested Avastin is not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Bipolar Disorder. 
Treatment: Vraylar. 

The insurer denied coverage for Vraylar. 

The denial is upheld. 

This patient has a diagnosis of Bipolar Disorder and had reports of manic and depressive symptoms. She had a period of racing thoughts, decreased need for sleep, referential and circumstantial thinking, paranoia, and talkativeness. She reportedly started Olanzapine and had some reported improvement but had weight gain, sedation, and dullness cognitively. She also reportedly was taking Klonopin. She had no past reported psychiatric hospitalization or suicide attempts. She reportedly was in the PHP (partial hospitalization Program) and the treatment provider requested Vraylar (Cariprazine) 1.5 mg (milligrams) to start to target bipolar disorder symptoms and wanted to cross taper Olanzapine. 

I agree with the decision to deny coverage for Vraylar (Cariprazine) for the treatment of this patient's bipolar disorder based on the insurance plans formulary exception criteria as this patient reportedly tried Olanzapine but not the other formulary medications such as Aripiprazole, Risperidone, Paliperidone, Asenapine, Clozapine, or Ziprasidone. 

The APA (American Psychiatric Association) Practice Guidelines for the Treatment of Patients with Bipolar Disorder reports that standard pharmacotherapy includes Lithium, anticonvulsants such as Depakote and Carbamazepine, and antipsychotic medications. The above-mentioned FDA (Food and Drug Administration) approved formulary medications were considered standard treatment for bipolar disorder. It was not reported that he tried and failed the above formulary medications such as Aripiprazole, Risperidone, Paliperidone, Asenapine, Clozapine, or Ziprasidone, or that there was a contraindication to them. Aripiprazole which is a dopamine partial agonist and also an antagonist with a unique mechanism of action. These FDA approved formulary medications for the treatment of Bipolar 1 disorder were not tried and failed, and there was no documented contraindication or reports that she had adverse effects from these or the other formulary medication. Each medication has a unique receptor mechanism of action although they are dopamine and serotonin antagonists so there was no specific evidence to support that these medications could not treat her symptoms and diagnosis. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for Formulary Exception for Vraylar is upheld.