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

Diagnosis: Duchenne muscular dystrophy (DMD) 
Treatment: Emflaza SGM
The insurer denied the Emflaza SGM.
The denial is upheld. 

The patient is a male with Duchenne muscular dystrophy (DMD) diagnosed at age nine.  According to neurologist, genetic testing revealed a pathologic variant in the DMD gene. The patient has been non-ambulatory and requires assistance for all his activities of daily living.  He has severe muscle wasting and low tone. 

The patient was on prednisone in the past, but this was discontinued by his prior neuromuscular team. The patient has mild cardiomyopathy. Due to progressive decline in muscle strength as well as scoliosis, the patient had restrictive lung disease, which was expected to progress without treatment. 

The patient was on a ventilator and had a tracheostomy placed.  The patient could not restart prednisone therapy reportedly due to side effects, and initiation of therapy with Emflaza was recommended. Office note indicates that the patient previously has been on prednisone but he did not know why or when he was taken off. 

No, the treatment with Emflaza is not medically necessary.

The records do not provide any evidence that in the patient's case, Emflaza is more efficacious or safer than prednisone. The appeal letter indicates that "the expected and proven side effects of Prednisone treatment would preclude reintroduction of this therapy." However, the medical records clearly state that the patient does not know why the prednisone was discontinued by the prior neurologist, and there is no documentation of any side effects documented in the records. There is no evidence that, in the patient's case, prednisone was not effective or was causing any side effects in the past. Therefore, there is no evidence that Emflaza is expected to be safer or more efficacious than prednisone. Emflaza is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Helicobacter Pylori
Treatment: Talicia 10mg-250mg cap 
The insurer denied the Talicia 10mg-250mg cap.
The denial is upheld. 

The patient is a female with persistent Helicobacter pylori (H. pylori), having failed multiple regimens. She has taken amongst others, Prevpac and Pylera. Recent esophagogastroduodenoscopy (EGD) revealed H. pylori gastritis. The attending physician is requesting treatment with Talicia.

No, the proposed Talicia is not medically necessary.

The patient has H. pylori gastritis and needs treatment. Talicia was denied as there was no documentation that the patient had failed the components of Talicia (amoxicillin, rifabutin and omeprazole) prescribed as separate agents, used concurrently. Therefore, as the patient has not tried and failed amoxicillin, rifabutin and omeprazole for the treatment of H. pylori gastritis and there is no medical reason why those three agents taken together would not be as effective as Talicia (as they are the components of Talicia), the proposed treatment with Talicia is not medically necessary. The health plan did act reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Ears/Nose/Throat
Treatment: Pharmacy/Prescription drugs

Diagnosis:Ears/Nose/Throat-Rhinitis
Treatment: Pharmacy/Prescription drug- QNasl
The health plan denied the prescription as not medically necessary. The health plan determination is upheld in whole.

This is a patient with a history of allergic rhinitis, with headaches, postnasal discharge, and facial pressure. The patient has been allergy tested and a computed tomography (CT)scan revealed narrowing of the left ostiomeatal unit with mild sites of mucosal thickening. The patient reportedly failed trials of Claritin D, Flonase nasal spray and triamcinolone. There is no documentation why the patient is unable to use Rhinocort over the counter. QNasl nasal steroid spray was recommended.
Qnasl 80MCG/ACT Na AERS is not medically necessary for this patient. There is no documentation as to why the patient was unable to use Rhinocort over-the-counter (OTC). The patient has failed Claritin D, Flonase nasal spray and triamcinolone. In addition, per Up To date , it was concluded that comparative studies among different nasal steroid sprays have not demonstrated significant differences in efficacy and in a 2016 review of the literature by Chong, there was insufficient evidence found to suggest that one type of intranasal steroid is more effective than another in patients with chronic rhinosinusitis. Based the peer reviewed medical literature, at this time, Qnasl is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer
Treatment: Radiology
The insurer denied the PET CT Imaging.
The health plan's determination is upheld in whole.

This is a patient with metastatic breast cancer. The patient has been treated with Faslodex for metastatic disease and has been in her usual state of health. The patient had a positron emission tomography (PET) / computed tomography (CT)  that appears to have been for routine restaging.

The requested service of Positron Emission Tomography and Computed Tomography imaging is not medically necessary for this patient.

The routine use of PET/CT for the routine restaging of patients with metastatic breast cancer has not been demonstrated to improve outcomes. The authors of UpToDate state "...There are no studies to demonstrate whether it is preferable to monitor patients with either PET/CT or scintigraphic bone scanning and dedicated CT or magnetic resonance imaging (MRI)...". This approach is not recommended by the National Comprehensive Cancer Network (NCCN), either, who state "...(fludeoxyglucose) FDG PET/CT is most helpful in situations where standard staging studies are equivocal or suspicious...". Lacking data demonstrating a benefit to this modality, medical necessity for this service cannot be established.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hyperlipidemia

Treatment: Colesevelam Hydrochloride 625 milligrams OR tablets.

The insurer denied Colesevelam Hydrochloride 625 milligrams OR tablets. 

The denial was upheld.   

This is a male patient with a history of hyperlipidemia.  He had intolerance to colestipol.  It was reported that the patient had been compliant with Welchol (colesevelam) for several years prior, and his insurance changed.  He was switched to colestipol, which, after a few months of therapy, resulted in the patient's low-density lipoprotein (LDL) and total cholesterol no longer being controlled.  In early 2020 his LDL was 123, HDL 49, TG 112.  On the last visit, LDL was 171, HDL 59, TG 87. 

All the noted agents are bile acid sequestrants, the lipid levels at the time the patient switched to colestipol were clearly better than after 3 months of colestipol.  The most recent note states, "feels well on medication, no longer constipated; needs levels checked."  The patient was prescribed 1GM tabs take 2 daily.  The recommended dosing is "Tablets: Initial: 2g once or twice daily; increase by 2g once or twice daily at 1- to 2-month intervals.  Maintenance: 2 to 16 g/day administered once daily or in divided doses."  Thus, the patient was on the minimal dose of colestipol.

In view of the above, the trial of the formulary medication, colestipol, was inadequate to determine its efficacy. 

Based on the above, Formulary Exception for Colesevelam Hydrochloride 625 milligrams OR tablets is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.  

This is a male patient with a history of heroin abuse on methadone. He presented to the Emergency Department (ED) with complaints of right lower quadrant abdominal pain.  The patient was sent to the ED by his primary care doctor for suspicion of acute appendicitis. In the ED, the patient's temperature was 99.9. On exam, the patient's abdomen was soft, tender to palpation in the right lower quadrant (RLQ). The plan was to receive intravenous (IV) antibiotics and IV fluids. Surgery was consulted. The patient's white blood cell (WBC) count was 6.96 and his computed tomography (CT) scan of the abdomen that was obtained outside of the facility showed acute appendicitis with no evidence of appendiceal rupture. The patient was admitted to the hospital and underwent an uneventful laparoscopic appendectomy.The pathology report revealed acute appendicitis. The patient's pain was tolerating diet, voiding and ambulating without difficulty. The patient was discharged home. 

According to MCG Health Inpatient and Surgical Care 24th Edition Appendectomy, without Abscess or Peritonitis, by Laparoscopy ORG: S-175 (ISC) optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; successfully uncomplicated lap appendectomy; no evidence of postop or surgical site infection; diet tolerated; pain absent or managed; no evidence of ileus or bowel obstruction; oral medications and oral diet.  In this case, the patient reached these milestones, and was discharged following observation. The patient did not have factors, such as ileus, postoperative bleeding, signs of peritonitis, and/or wound infection that required prolonged hospitalization. 

Based on the review of the medical record, acute inpatient admission was not medically necessary as this patient could have been cared for based upon an observational level of care.  The patient presented to the hospital with the diagnosis of acute appendicitis and underwent lap appendectomy and was discharged after an uneventful lap appendectomy.  The patient did well postoperatively with stable vital signs. The patient was discharged home following observation.  The patient did not require an acute inpatient admission but rather observation status as he did not have any complications from the surgery that warranted inpatient level of care.  The patient's lap appendectomy was uneventful and there was no perforation.  There was no evidence of a complicated postoperative course requiring hospitalization.  Thus, the patient should have had the appendectomy performed under an observation status without an inpatient admission. 

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

The carrier's denial of coverage for inpatient admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain, gait ataxia, chronic dizziness, falls 
Treatment: PCA 63 hours per week 

The insurer denied the PCA 63 hours per week. The denial is overturned. 

The patient is a female with a history of low back pain, gait ataxia, chronic dizziness and frequent falls. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of an increase in Personal Assistance Services from 42 to 63 hours per week to offer increased ADL support. 

Yes, the proposed treatment of an increase in Personal Assistance Services from 42 to 63 hours per week is deemed medically necessary. 

Recent documentation from the patient's Primary Care Provider indicates that the patient has demonstrated progressive functional decline with increased low back pain, worsening gait ataxia and frequent falls. Hence, the currently approved plan of 42 hours per week in Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of an increase in Personal Assistance Services from 42 to 63 hours per week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Asthma.
Treatment:  Inpatient admission.
The insurer denied Inpatient admission.  The denial is upheld.

The patient is an adult gentleman.  He was admitted to the hospital for acute asthma exacerbation.  His past medical history is significant for anxiety disorder, bipolar disorder.

The patient presented to the emergency room with complains of shortness of breath and feeling anxious since the night before.  The patient stated that he was unsure the way his medications make him feel, such as anxiety.  He did not complain of any fever, wheezing, chest pain, trauma or recent travels.  The patient was speaking in full sentences, and mild wheezing was audible.  

The patient's blood pressure 138/93, pulse 103 and regular respiration 18, temperature 97.6 degrees, and the oxygen saturation on room air at rest was 96%.  He received a nebulizer treatment in the emergency room, and he voiced that he felt better.  The patient's laboratory data during the ER evaluation, such as labs, chest x-ray, EKG (electrocardiogram) were unremarkable.  A psychiatry evaluation was requested, though patient had no suicidal ideation.

Based on the clinical information provided, the patient's clinical history when evaluated in the emergency room did not suggest that patient was in any acute respiratory distress or cardiopulmonary distress.  Clinical examination, including the hemodynamics, was unremarkable.  Even though the patient had a complaint of feeling shortness of breath the night before, there was no evidence of hypoxia, respiratory distress, cardiac issues, asthma exacerbation.  The clinical evaluation, including laboratory data, was unremarkable.  There was an element of concern of anxiety.  Psychiatric evaluation was requested.  

Therefore, based on the clinical documentation provided, the acute inpatient hospital stay for the dates requested was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes mellitus 
Treatment: Januvia (Sitagliptin) 

The insurer denied coverage for Januvia (Sitagliptin). The denial is upheld. 

This patient is a male with a history of diabetes mellitus and seizure disorder. The patient used Januvia (sitagliptin) and his treating provider did not want him to switch this current medication to the formulary alternative linagliptin (tradjenta) due to concerns of lowering this patient's seizure threshold with linagliptin compared with sitagliptin. 

According to LeRoith, et al. (2019), "The DPP-4 inhibitors sitagliptin, saxagliptin, and alogliptin undergo some renal clearance and require dosage adjustment in patients with reduced eGFR (420) (see Table 7). Only a small amount of linagliptin is cleared renally, and no dosage adjustment is indicated with a reduced GFR (420). In general, these drugs are very well tolerated." 

As per Thomas, et al. (2016), "These results suggest that DPP-4 inhibitors have the potential to improve glycemic control in patients with [renal impairment] without increasing the risk of [hypoglycemic episodes] or overall [adverse events]." 
And as per McGuire, et al. (2019), "In a large, international cardiovascular outcome trial in participants with type 2 diabetes mellitus and concomitant atherosclerotic cardiovascular disease and/or kidney disease, linagliptin did not affect the risk of [hospitalization for heart failure] or other selected [heart failure]-related outcomes, including among participants with and without a history of [heart failure], across the spectrum of kidney disease, and independent of previous left ventricular ejection fraction." 
                                            
Based on the review of the medical record provided, it is unclear what medications the patient takes for seizure prophylaxis and why specifically the treating provider has concerns about using linagliptin. Furthermore, based on the review of the literature, neither drug (linagliptin and sitagliptin) has any impact on seizure threshold. Without knowing the specifics of why the treating provider has this concern for this patient, it is hard to say that these two medications with similar blood glucose lowering effects would be of varying safety to this patient. Therefore, the formulary drug, linagliptin (tradjenta) is not likely to cause the patient an adverse reaction; the formulary drug has not been ineffective based on the patient's clinical history, and the requested drug, Januvia would not be more effective than the formulary drug. 

The insurer's denial of formulary exception for Januvia (Sitagliptin) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back pain.
Treatment:  Inpatient admission.
The insurer denied Inpatient admission.  The denial is upheld.

The patient is an adult female with history of back pain.  She went to the ED. 

The patient's MRI showed moderate disc degeneration with endplate edema.  Exam revealed no focal deficit.  The patient was admitted to the hospital for possible osteomyelitis diagnosis. 

Neurosurgery evaluation deemed the imaging findings to be likely degenerative in nature.  The patient was discharged the following day to home with oral pain medications

The patient did not require acute inpatient level of care.  The imaging suggested discitis, but all labs did not support the diagnosis.  The patient did not require any acute inpatient level of care, as the IV antibiotics were not necessary, and the records do not support that the patient was under severe pain that could only be controlled with IV pain medications.  There were no vital sign issues, pain issues, neurological deficits, or any other finding that would support acute inpatient level of care, instead of monitoring as observation status or lower level of care.

The denial of acute inpatient level of care is appropriate, as the patient did not require any acute interventions, have any diagnosis or medical condition that requires acute inpatient level of care, and no unstable vital signs or other findings that would support acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p Eye injury
Treatment: Air ambulance
The insurer denied Air ambulance.
The denial is overturned.

The patient is a teen-aged. She presented to the ED after having been hit in the left eye at close range by a kicked soccer ball. She had no loss of consciousness, vomiting, or headache, but she had blurry vision and left periorbital pain rated 5/10. She was initially taken by private auto to another ED and found to have irregular pupil with grade 1 hyphema. 

An orbital CT scan was negative. Visual acuity tested 20/25 in the right eye and 20/40 in the left eye. Although the blurriness was improving, eyelid swelling was getting worse. She was transferred to another ED via air transport for higher level of care. 

The patient's vital signs included temperature 36.8, heart rate 63, respiratory rate 18, and blood pressure 116/71. Examination was significant for no distress, left periorbital swelling with tenderness to palpation, conjunctival redness with tiny hyphema, extraocular movements intact, left pupil ovoid/irregular, and non-focal neurologic exam. She was diagnosed with tiny hyphema, likely traumatic iritis. Pediatric Ophthalmology was consulted, diagnosing traumatic hyphema and retinal commotion. She was prescribed Pred Forte drops, cyclopentolate drops, recommendations to sleep upright, and recommendations to follow-up in three days. 

This teenage female presented to the ED after a traumatic injury to her left eye. She initially was driven to the ED where she was evaluated and noted to have left hyphema with irregularly shaped pupil. After completing a physical examination and obtaining a CT scan, the decision was made to transfer her to higher level of care. One of the concerns with anterior chamber bleeding with hyphema formation is increased intra-ocular pressure. Without the proper tools, the first ED was not able to fully evaluate her. She would undergo further evaluation in the Pediatric ED by both the ED team and Pediatric Ophthalmology. 

The acute development of increased intra-ocular pressure presents an urgent/emergent situation. In the absence of proper tools and consultants at the first ED, with intact vision at risk, unnecessarily wasted time serves only to exacerbate the situation. The distance between the first hospital and the destination hospital based on a standard map site is about 30 miles, representing three quarters of an hour transport time without any traffic or detours by land. With a potential ocular emergency, ground transportation represented an unnecessary and unacceptable waste of time. Air transport was medically necessary and appropriate in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central nervous system /neuromuscular disorder   
Treatment: Inpatient hospital 
The insurer denied the entire hospital stay
The denial is upheld in whole 

This case involves male patient, with history of hyperlipidemia, who presented to the emergency department  with complaints of bilateral facial numbness, right arm numbness and tingling, which started approximately 6 hours before this presentation. The patient was at work, changing a car battery, and began to experience confusion, apraxia, and the symptoms resolved after a few minutes.

No, the requested health service/treatment of inpatient stay is not medically necessary for this patient. This is a patient , with hyperlipidemia, as  only risk factor, presents to the emergency department, with paresthesias to the face and arm, without focal neurologic deficits on the examination. The patient's head CT was normal. It was reasonable to admit this patient at a lower level of care, for the TIA work-up. The Brain MRI did not show any abnormal findings the following day. With this testing, the work-up was completed, and the patient did not require additional evaluation and treatment in the hospital. The consulting neurologist, findings that this is a complex migraine headache, which was treated with caffeine and resolved the symptoms.

In conclusion, there is no medical complexity or necessity to indicate the need for inpatient hospitalization of this patient. This type of presentation is generally managed in a lower level of care. Therefore, the inpatient stay was not medically necessary in this case.