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

Diagnosis:  Diabetes.
Issue under review:  Formulary exception for Janumet.

The health plan denied Formulary exception for Janumet.  The health plan's denial is overturned.

This is an adult male diagnosed with type II diabetes mellitus (T2DM) with hyperglycemia.  This request is for Janumet.  As reported; the patient has tried and failed more than three other oral diabetic agents over the past three years including Glipizide (gastrointestinal [GI] problems), metformin, Glimepiride and Amaryl (nausea/vomiting), Tradjenta (allergic reaction), Jardiance, Onglyza, and Farxiga.  His glycated hemoglobin (A1C) was 11.6%; and four months prior, it was 10.6%.  Formulary alternatives include Jentadueto and Jentadueto XR.

The dipeptidyl peptidase IV (DPP-IV) Inhibitors have similar efficacy.  There are no trials showing superiority of one DPP-IV inhibitor over another including linagliptin (Tradjenta), saxagliptin (Onglyza), vildagliptin (Galvus), alogliptin (Nesina) or sitagliptin (Januvia) [1-4].  The American Association of Clinical Endocrinologists consensus statement regarding treatment of patients with type two diabetes is as follows [5, 6]:  It recommends the use of metformin followed by the use of a DPP-IV inhibitor or a glucagon-like peptide (GLP-1) agonist.  

The formulary alternatives that are proposed by the health plan are Jentadueto and Jentadueto XR.  Jentadueto has Tradjenta in it.  Given the fact that the patient has already failed Tradjenta due to an allergic reaction, Jentadueto or Jentadueto XR are contraindicated.

Therefore, the health plan should cover the proposed treatment because it is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  History of stroke, lung cancer, bladder cancer,
gait imbalance/drop foot, COPD.
Treatment:  Personal Care Aide Level II: 12 hours per day - seven days per week - 12 hours per day - seven days per week for a total of 168 hours per week.

The insurer denied the Personal Care Aide Level II: 12 hours per day - seven days per week - 12 hours per day - seven days per week for a total of 168 hours per week.  The denial is overturned.

This is a female with a history of stroke, lung cancer, bladder cancer, gait imbalance/drop foot, COPD and multiple falls.  Due to restrictions/limitations related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  The medical records include recent documentation from the patient's physician.  In this documentation, the physician reports that the patient has demonstrated progressive functional decline with worsening gait ataxia/falls.  Specifically, the physician reports that the patient has sustained 11 major fall events in four months, which required medical intervention including inpatient hospitalizations and Adult Protective Services intervention.  For these reasons, the currently approved plan of Personal Care Aide Level II: nine hours per day - seven days a week - for a total of 63 hours per week is insufficient to meet the patient's current needs.  Hence, the proposed treatment of an increase in Personal Care Aide Level II: 12 hours per day - seven days per week - 12 hours per day - seven days per week for a total of 168 hours per week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath 
Treatment: Inpatient Hospital Stay 

The insurer denied an inpatient hospital stay. The determination is overturned. 

The patient with a past medical history (PMH) of asthma who was admitted with complaints of (c/o) a two-week history of shortness of breath (SOB). Vital signs were remarkable for a pulse of 120, peripheral capillary oxygen saturation (SpO2) of 95% on room air (RA). The patient received duonebs times (x) 5 and continued to have dyspnea and bilateral wheezing on exam. The physical exam was notable for no accessory muscle use, positive (+) wheezing, minimal air movement. Lab work was unremarkable. A computed tomography (CT) scan of the chest was negative for a pulmonary embolism (PE). An electrocardiogram (EKG) showed right atrial enlargement and tachycardia. The patient was diagnosed with an asthma exacerbation and treated with fluids, intravenous (IV) steroids, magnesium and bronchodilators. Her peak flow was 70, with a baseline of 200. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay. 

The hospital stay was medically necessary at an acute inpatient level of care. Overall, this patient suffered a severe exacerbation of asthma and could not have been safely treated at a lower level of care. 

The patient presented with a two-week history of worsening SOB associated with a cough and wheezing. The patient was evaluated and found to have bilateral wheezing with minimal air movement on initial examination. The patient was treated aggressively in the ED with five treatments of duonebs, magnesium and IV steroids, but was still found to be weak and wheezing after these treatments. In addition, the patient's peak flow was 70, which was significantly lower than the patient's baseline of 200, which is less than 40% of patient's baseline. This was compounded by the patient's tachycardia, tachypnea, symptoms for more than one week and lack of significant response in the ED.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal 
Inpatient Hospital 

Diagnosis: Abdominal pain/vomiting
Treatment: Inpatient hospital stay 

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

This is the case of a female with past medical history of diabetes mellitus and difficulties with compliance with insulin, multiple episodes of deep vein thrombosis, and inferior vena cava (IVC) filter placement, who presented to the emergency department with epigastric pain, vomiting, and inability to take food for the past few days. 

The inpatient hospital admission was medically necessary. This is a patient with past medical history of diabetes and non-compliance who presented to the emergency department with nausea, vomiting, and abdominal pain. She notably had bicarbonate as low as 13 on presentation then decreasing to 9 with anion gap of 21, and large acetones noted, with inability to take oral intake, and wildly brittle diabetes with blood glucoses varying from 50-500s. She required IV fluids, close titration of insulin, frequent Basic metabolic monitoring, and was at risk for worsening acidosis in the setting of severe uncontrolled hyperglycemia as well as severe hypoglycemia, particularly in the setting of gastroparesis with nausea and vomiting and inability to take good oral intake. She was not started on an insulin drip, but this was in the setting of having dropped her blood glucose precipitously in the emergency department. The intensity of service required for this patient presenting with an initial bicarbonate of 13 and anion gap of 21 with bicarbonate that actually worsened on the second day to 9 including IV fluid administration, very frequent blood glucose monitoring and monitoring of her basic metabolic panel, and her wildly fluctuant blood glucoses placing her at risk of significant complications from severe hyperglycemia or hypoglycemia including acidosis, arrhythmia, neuroglycopenia, or seizure, was appropriate for inpatient care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Pneumonia, Asthma Exacerbation.

Treatment: Inpatient Admission.

The insurer denied the inpatient admission.

The denial was modified.

This is a male patient with medical history of asthma, pneumonia, hypertension and smoking cigarettes. He presented to the hospital with complaints of chest pain, weakness, and productive cough with yellow brown sputum, shortness of breath, and vomiting. His vital signs at presentation were: temperature 98.6 F, heart rate 84, respiratory rate 18, blood pressure 131/84, and oxygen (O2) saturations 97 %. The patient's lung exam revealed decreased breath sound and some wheezing; the patient's cardiac exam was within normal limits (WNL). The patient had a white blood cell (WBC) count as high18K during his hospitalization. The patient's chest x-ray and computed tomography (CT) scan revealed bilateral patchy, multilobar infiltrates; negative for a pulmonary embolism (PE). The patient was admitted to the hospital for treatment of multilobar pneumonia, asthma exacerbation, and acute kidney injury (AKI). He received intravenous (IV) fluids, (IV) steroids, and IV antibiotics; Vancomycin, Aztreonam and Doxycycline. 

A few days into the patient's admission, the patient had started feeling better. The patient was afebrile and hemodynamically (HD) stable. The patient's oxygen saturation was 98 % on nasal cannula, and the patient's lungs were clear to exam; the patient's wheezing had improved. The patient's culture and sensitivity were negative. The differential diagnosis of myocardial infarction was ruled out. The patient was tolerating oral intake, and his cough had improved. The patient could have been switched to oral steroids and antibiotics, and the patient could have been continued treatment regimen at home with close follow-up as outpatient. Thus, while admission for the first few days was medically necessary, continued inpatient stay for the last several days was not medically necessary for this patient.

The health plan acted reasonably with sound judgment to deny coverage for continued inpatient stay for the first several, but did not act in the best interest of the patient to deny coverage for inpatient admission for the last few days. 

Based on the above, the medical necessity for the inpatient admission from is partially substantiated.  The insurer's denial should be modified.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered mental status
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the inpatient admission is not medically necessary. 

The patient is a female with a history of ADHD and seizure disorder who presented to the ER with altered mental status. Intake vitals were afebrile, hemodynamically stable and non-hypoxemic on room air. Examination was notable for patient being lethargic and confused but was otherwise non focal. Laboratory testing, EKG and Head CT was within normal limits with no significant abnormalities noted. The medical records indicate that the patient was admitted to the inpatient medical unit in stable condition where she underwent further diagnostic evaluation including transvaginal ultrasound and liver MRI. She also continued treatment with meclizine, anti-emetics and IV seizure medication, Levetiracetam that was started in the ER. The patient improved with the prescribed therapies and was subsequently discharged in stable condition. 

The patient improved with the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic migraines.
Treatment: Botox.
The insurer denied the Botox.
The denial is overturned. 

Yes, the treatment with Botox is medically necessary.

The patient is a female with a cardiac history (congenital aortic valve stenosis) as well as chronic migraine headaches that are refractory to multiple medications.  She had headaches as a younger child, but they worsened after a cardiac procedure. It was noted the patient could not use beta blockers, or calcium channel blockers could not be used due to her cardiac condition.  

As of a follow-up with neurology nurse practitioner, the patient was weaned off flunarizine, which was minimally effective, and was on gabapentin. However, she was still having headaches three to four times per week. The patient reported the frequency of her headaches had possibly decreased and they did not last as long, but they were more severe in pain intensity, which she rated as 10/10. She was not taking any abortive medications when she had a headache; Fioricet was tried but caused lethargy and vision issues.  In the past the patient had also been tried on and failed amitriptyline and Topamax.  

On exam, the patient had pressure point tenderness at the temples and mandible. Nurse Practitioner recommended increasing the patient's gabapentin dosage and noted the patient was a good candidate for Botox injections due to the pressure point tenderness on exam and the failure of three classes of medication.  Headache lifestyle changes were discussed. The patient was to return to the office once Botox injection therapy was approved.
 
The patient saw neurologist and reported having four migraines per week, which usually started in the afternoon. The patient described them as constant and bifrontal with an occasional pounding sensation.  Her headaches were associated with light and sound sensitivity as well as an aura of bright spots in her vision. The patient had titrated her gabapentin up to 400 mg twice a day, which she felt made her tired and was not very effective.  The patient was interested in trying Botox injections.  Exam was notable left occipital, right masseter, left frontal and temporal pressure point tenderness.  Assessment was listed as intractable migraine with aura. The provider reviewed various medications with the patient but felt the best option for her was Botox injections and the provider was going to work on another appeal for Botox injections.  In meantime, the patient was to continue on gabapentin at her current dosage.  

The patient has chronic migraine, with failure of gabapentin, Topamax, amitriptyline and flunarizine. She has a cardiac condition, so beta blockers are contraindicated. She is overweight (BMI at 70 percentile) so Depakote and cyproheptadine are contraindicated. According to medical literature, Botox has good efficacy and safety record in adolescents with chronic migraine. Considering the absence of any additional treatment options, the proposed treatment is medically necessary. 

The patient has no other treatment options. Therefore, Botox is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Heart disease, atrial fibrillation, hypertension.
Treatment: Pradaxa.
The insurer denied the formulary exception for Pradaxa (dabigatran).
The denial is upheld. 

No, the health plan should not cover the Formulary exception for Pradaxa (dabigatran).

The patient is a male. He has a history of ischemic heart disease, coronary artery bypass surgery, Maze procedure, paroxysmal atrial fibrillation and hypertension.  The request is for Pradaxa.

Xarelto (rivaroxaban) is a viable alternative that is on the plan formulary. This patient suffers from paroxysmal atrial fibrillation. He has risk factors for stroke (CHADSVASC [congestive heart failure, hypertension, age >= 75, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age 65-74, sex category] 3) that include age, coronary disease and hypertension.  The patient should be treated on an oral anticoagulant regimen . 

Warfarin, apixaban, rivaroxaban and dabigatran have all been shown to reduce the risk of stroke in patients with atrial fibrillation.  This patient was prescribed dabigatran, a medication that is not on the health plan formulary.  The paperwork submitted notes "coumadin, eliquis failure to treatment" on question #4 of the prior authorization form. The patient can be treated with Xarelto/rivaroxaban therapy, as this is an oral anticoagulant medication that is on the health plan formulary. 

In conclusion, the health plan should not cover the formulary exception for Pradaxa/dabigatran, as there is a viable alternative available on formulary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptoms of sudden heart problems.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a male. He presented for evaluation of left-sided chest pain, non-exertional, with no radiation. His past medical history was significant for a venous malformation in the cerebellum, diagnosed three years prior, which did not require an intervention. 

The patient was hemodynamically stable. His BP (blood pressure) was elevated, but the treating physicians felt there was no indication to start antihypertensive therapy, and the BP was monitored. Cardiac troponins were negative. BNP (brain natriuretic peptide) was low. ECG (electrocardiogram) revealed normal sinus rhythm with no ST segment change, but T-wave inversion in the inferior leads. 

The patient was admitted to telemetry. Repeat troponin levels were also negative. A 2D echo was obtained, which was unremarkable. No inpatient stress test was planned, and the patient was discharged home with a plan for outpatient follow-up.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. Echocardiogram revealed normal LV (left ventricle) wall motion. No stress testing or other inpatient ischemic work-up was planned by the treating physicians. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overdose of medication(s)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

No, the Inpatient admission was not medically necessary. 

The patient is a woman with a past medical history of schizophrenia. She presented to the ED. The patient had been discharged from the hospital's psychiatric ward two days earlier. She stated that she had accidentally ingested extra doses of her psychiatric medication, including Risperdal and Depakote. The patient denied that this was a suicide attempt. 

In the ED, the patient was complaining of dizziness and nausea. Her vital signs were normal. Her physical examination was normal. During her ED evaluation, the patient was kept under constant observation. Lab tests were normal. An ECG (electrocardiogram) showed a minimal increase in the QTc interval. Following her ED evaluation, the patient was admitted to a monitored bed within the hospital. Her admission note states that she would be kept on a cardiac monitor. She would have a repeat ECG and a repeat Depakote level. A psychiatry consultation was planned. No other tests or consultations were expected for the patient as written in her admission note. 
 
Following this patient's ED evaluation, she was clinically stable. She had ingested extra doses of her psychiatric medications. It was unclear if this was done intentionally. Despite this, the patient had normal vital signs and normal mental status. Her ECG was only slightly abnormal. She complained only of dizziness and nausea. The admission note for this patient states she would have constant cardiac monitoring. She would be maintained under constant observation. A psychiatry consultation was planned. Repeat blood tests as well as a repeat ECG were planned. No other testing or consultations were anticipated for this patient. At the time this patient was kept in the hospital, it would have been reasonable to believe that this limited plan of care could be accomplished for a stable patient with only a short stay in the hospital. For that reason, an inpatient level of care was not medically necessary. The patient could have safely and effectively been managed at an observation level of care. 

The patient did not have a severity of illness to justify an inpatient admission. She had normal vital signs and normal mental status. There was no intensity of required services to justify an inpatient admission. The patient was kept on a cardiac monitor. Constant observation was ordered. Repeat blood tests and a repeat ECG would be done.

In conclusion, an inpatient level of care was not medically necessary for this patient. She was clinically stable. A limited plan of care was anticipated for her. The patient could have been safely managed at an observation level of care. The Health Plan did act reasonably in denying coverage for this inpatient admission
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Treatment: DME/Motorized wheelchair
The insurer denied the approval of the DME
The health plan's determination is upheld in whole

The motorized wheelchair is not medically necessary for this patient. Patient  has a diagnosis of facet arthritis, facet joint pain and central stenosis. The patient was prescribed a motorized wheelchair secondary to poor balance and history of falls. Documentation noted, "Patient is currently using walker and cane." Per records, an approval and reference  was obtained, and on a later date the motorized wheelchair was delivered. It was later learned that the authorization was void. 
The patient has back pain. A magnetic resonance imaging (MRI) Lumbar Spine noted "Moderate central canal stenosis and mild-to-moderate bilateral foraminal narrowing at Lumbar (L)3/L4 secondary to mild degenerative anterolisthesis of L3 on L4, uncovering of the posterior disc with small disc bulge, and severe bilateral facet arthrosis." While these MRI changes support the cause of pain, the findings do not explain an inability to walk or loss of balance. The patient is currently ambulating with a walker and cane. In addition, despite the patient's reports of falls the physical exam by the PA did not include gait analysis or even muscle strength testing but it did state "DTRs - Normal" which this reviewer would expect to be abnormal if the MRI findings were significant. Additionally, while it was noted  that physical therapy improved pain there was no included physical therapy documentation to support that the patient's functional impairments were of the severity to require a motorized wheelchair. For all of these reasons, a motorized wheelchair is not supported at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's disease
Issue under review:  Increase in Personal Care Aide Services

The health plan denied Increase in Personal Care Aide Services.  The health plan's denial is overturned.

The patient is an elderly female with a history of Parkinson's disease.  Due to impairments related to this progressive neurologic condition, she requires assistance for the completion of the majority of her activities of daily living (ADLs).  Recent documentation from one of the patient's providers reports that the patient has demonstrated significant functional decline with repeated falls, increasing visual hallucinations and more frequent sundowning behavioral disturbance.  For these reasons, the currently approved plan is insufficient to meet the patient's current needs.  Hence, the proposed treatment of an increase in Personal Care Aide Level is deemed medically necessary to offer increased ADL assistance.