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

Diagnosis: Shortness of breath. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

Patient is an adult male with history of morbid obesity and Asthma who presented to the emergency department (ED) with complaints of shortness of breath and respiratory distress. Vital signs at presentation were Temperature 98.6 degrees Fahrenheit, Heart Rate 120 beats per minute, Respiratory Rate 30 breaths per minute, Blood Pressure 140/95 mm Hg (millimeters of mercury), oxygen saturation at 90 percent on room air. The patient was unable to speak sentences due to dyspnea and was using accessory muscles of respiration. Lung exam revealed decreased air movement and bilateral wheezes. Patient was treated with intravenous (IV) steroids and bronchodilators via nebulizer. 

White blood cells were elevated at 14.9. Electrolytes were within normal limits. The viral panel was negative. Venous blood gas 7.32/60/30.  Chest X-ray showed no acute infiltrates, however computed tomography (CT) of the chest revealed right upper lobe and bilateral lower lobe infiltrates. 

The patient was treated with Azithromycin for atypical pneumonia. The patient was admitted to the hospital for Asthma Exacerbation, Hypoxic and Hypercarbic Respiratory Failure, Atypical pneumonia. 

The patient remained hypoxic after admission to the hospital and required supplemental oxygen. 
He subsequently improved after treatment with oxygen saturations of 90-92 percent but kept desaturating with exercise. 

He was discharged home on tapering steroids and supplemental home oxygen on exertion. 

This patient with Morbid Obesity, Hypercapnic and Hypoxic Respiratory Failure and Atypical Pneumonia was not stable enough to be treated without inpatient admission. He needed supplemental oxygen, steroids, bronchodilators and antibiotics and close monitoring. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ventral hernia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.

 
Umbilical and ventral hernias are common surgical complaints. These hernias can become symptomatic and therefore are at an increased risk of incarceration and subsequent strangulation. Therefore, surgical repair is indicated. Emergency repair has been associated with an increased risk of mortality, reoperation, and readmission. Bowel compromise can occur regardless of the hernia size, and the belief that larger hernias do not incarcerate is inaccurate.

Per clinical documentation, the patient presented for an elective hernia repair. The patient underwent a robotic-assisted laparoscopic incisional hernia repair with mesh and component separation. There were no reported surgical complications postoperatively. Their pain was controlled. The patient was noted to have bilious vomiting postoperatively that resolved with medical management. The patient was discharged home. Peer-reviewed literature indicates that the greatest variable associated with hospital admission is totally dependent upon baseline functional status. The patient was not noted to have any functional impairments. Per Milliman Care Guidelines (MCG) Guidelines, there were no indications of ileus/obstruction, hemodynamic instability, or surgical site infection that would warrant inpatient admission. The patient was tolerating a diet. Therefore, the requested hospital stay should be observation status. Inpatient admission was not medically necessary. The health plan acted reasonably. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is an adult with a past medical history of hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, and myocardial infarction (MI) status post stent who presented to the Emergency Room (ER) with complaints of left sided chest pain which radiated to the back along with some shortness of breath. The patient initially said the pain was 10 out of 10 (on a scale of 0 to 10). The patient was given aspirin in the ED. Repeat pain was 4 out of 10. The pain appeared to be of pleuritic type and not like the pain the patient had during the prior MI.

Vital signs on presentation included Temperature (T) 99.5 degrees Fahrenheit, heart rate (HR) 92, respiratory rate (RR) 18, blood pressure (BP) 151/78. The patient was in no acute distress. The lungs had some coarse breath sounds. The abdomen was soft, the patient was alert and oriented to person, place and time, with non-focal neurological exam. Pertinent labs included White Blood Cell Count (WBC) of 14, Sodium 134, Blood Urea Nitrogen/Creatinine (BUN/Cr) within normal limits (WNL). Chest x-ray (CXR) showed airspace disease to the left lung with a small effusion and possible pneumonia (PNA). Electrocardiogram (EKG) did not demonstrate acute ischemic changes. The troponin was negative X2. The plan was to place the patient in Observation status. The patient was given pain medications and received 1 dose of Azithromycin and Rocephin. The patient remained stable after admission. Repeat vital signs were T 98.4, HR 88, RR 18, BP 144/56, Oxygen Saturation 98 % on room air.

The patient eloped the following morning. This patient did not need acute inpatient hospitalization. The patient was afebrile and hemodynamically stable. The patient did not have an MI, cardiac enzymes were normal, EKG with no ischemic changes, pain had improved after the patient came to the ER. The patient may have had a small pneumonia as per the CXR, but the patient remained afebrile, hemodynamically stable, and was not hypoxic (low oxygen saturations). The Patient's pneumonia was mild with CURB 65 (confusion, uremia, respiratory rate, BP, age > 65 years) score of zero. The patient was non-toxic, was tolerating food and drinks, BUN/ Cr were normal. 

This patient could have been kept in observation, switched to oral antibiotics, and discharged home. There was no suggestion of pulmonary embolism. MI was ruled out with Troponins being negative X2 and EKG with no acute changes. The patient left the hospital in less than a day. The patient did not need acute inpatient stay and could have been managed in Observation. The patient was stable to be discharged on oral medications with outpatient follow up after a few hours of observation.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a geriatric patient with chronic medical problems including diabetes, kidney stones and hypertension. The patient lives with the daughter. The insurer approved 10.5 hours per week, and the patient is requesting 36 hours per week, Consumer Direct, 1 Client.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Modified independent." The patient is alert and oriented. The patient is able to walk with an assistive device without help or supervision. The patient has all the equipment at home needed for safety. In case of an emergency, the patient can call 911. The patient reportedly requires maximal to total dependence for completing much of the Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is independent with Activities of Daily Living (ADL) tasks including personal hygiene, dressing, mobility (bed mobility, locomotion and ambulation) as well as toilet transfer/use, however the patient is frequently incontinent of bladder and continent of bowel. There have been no reported falls over the prior 90 days. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested CDPAS 36 hours/week; particularly since the patient is independent with ADL tasks and many of the IADL tasks are shared responsibilities with the daughter. In addition, CDPAS for companion care or safety supervision without the direct provision of ADL tasks is not a covered service. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved 10.5 hours/week.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, the requested 36 hours per week, Consumer Direct, 1 Client are not medically necessary.   

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 36 hours per week, Consumer Direct, 1 Client is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, kidney stones and hypertension
Treatment: Personal care aide 36 hours per week, Consumer Direct, 1 Client
The insurer denied coverage for personal care aide 36 hours per week, Consumer Direct, 1 Client
The denial is upheld.

This is a geriatric patient with chronic medical problems including diabetes, kidney stones and hypertension. The patient lives with the daughter. The insurer approved 10.5 hours per week, and the patient is requesting 36 hours per week, Consumer Direct, 1 Client.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Modified independent." The patient is alert and oriented. The patient is able to walk with an assistive device without help or supervision. The patient has all the equipment at home needed for safety. In case of an emergency, the patient can call 911. The patient reportedly requires maximal to total dependence for completing much of the Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is independent with Activities of Daily Living (ADL) tasks including personal hygiene, dressing, mobility (bed mobility, locomotion and ambulation) as well as toilet transfer/use, however the patient is frequently incontinent of bladder and continent of bowel. There have been no reported falls over the prior 90 days. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested CDPAS (Consumer Directed Personal Assistance Services) 36 hours/week; particularly since the patient is independent with ADL tasks and many of the IADL tasks are shared responsibilities with the daughter. In addition, CDPAS for companion care or safety supervision without the direct provision of ADL tasks is not a covered service. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved 10.5 hours/week.  

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

From a physical medicine and rehabilitation perspective, the requested 36 hours per week, Consumer Direct, 1 Client are not medically necessary.   

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 36 hours per week, Consumer Direct, 1 Client is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

The patient is a child with a history of reactive airways disease who has previously been treated with albuterol. The child was noted to have fever and a cough for three days. When the breathing became more labored the mother administered albuterol at home the night before and the day of the admission with no improvement in the breathing, so she decided to take the child to the Emergency Room (ER) for an evaluation.

In the ER, the child was noted to be in respiratory distress with increased work of breathing, belly breathing, retractions and wheezing. On physical exam the child had diffuse wheezing upon auscultation of the chest and decreased air movement over the left lower lobe. There was also evidence of respiratory distress with retractions. The child was treated with three treatments of DuoNeb and Decadron. Following treatment, the child continued to have increased work of breathing and wheezing. The child received two additional treatments of albuterol in the ER and there was an order for the child to receive intravenous (IV) magnesium sulfate. When the wheezing and increased work of breathing did not improve following treatment in the ER the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus and a plan for treatment with albuterol every two hours.

The patient was treated appropriately in the ER for an acute episode of wheezing and difficulty breathing. The child has a history of previous treatments with albuterol for reactive airways disease. When the child did not respond to treatment in the ER and the child continued to have wheezing and retractions, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol every two hours. The child was not stable enough to be safely discharged.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hereditary angioedema
Treatment: Orladeyo capsule 150 milligrams (mg)
The insurer denied coverage for Orladeyo capsule 150 mg
The denial is upheld 

This is an adolescent patient. The patient has been diagnosed with hereditary angioedema (HAE) with normal C1 inhibitor levels. The patient has tried and failed H1 and H2 antihistamines. The treating provider is requesting therapy with Orladeyo capsule 150 mg, which is under review.

There is no gene testing or family history provided to confirm HAE with normal C1. This form as described by Magerl et al - "In patients with the new form of HAE, C1-INH (inhibitor) plasma levels and function values are normal, so it's termed HAE with normal C1-INH (HAE-nC1)."  A search of Pubmed using "Hereditary Angioedema with Normal C1 Inhibitor" and berotralstat yielded a single case report by Kelbel et al. 

"The genetic transmission of HAE as an autosomal dominant trait was first described in 1917. Discovery and subsequent sequencing of the C1-INH gene (SERPING1) confirmed that the disease occurs when one of the two alleles is mutated. Rare homozygous C1-INH deficient patients have also been described. The presence of one mutated allele affects mRNA (messenger RNA) transcription and protein secretion, which eventually leads to C1-INH plasma levels ranging from 10% to 30% of normal. The mechanisms that prevent the remaining wild-type allele from generating C1-INH plasma levels around 50% remain unknown. Patients with HAE catabolize C1-INH faster than normal subjects, but concomitant downregulation of the normal allele may also occur, at least with some mutations. Most mutations that cause HAE are point mutations resulting in single amino acid substitutions. Independent families rarely possess identical mutations. More than 200 different mutations have been associated with HAE, and only one protein polymorphism resulting in an amino acid substitution not associated with a disease state has been described to date. Moreover, no correlation between genotype and clinical phenotype has been found." (Caccia, et al., 2014)

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Orladeyo capsule 150 milligrams (mg) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This case involves an adult patient with a history of seizure disorder who presented to the emergency department after having a seizure earlier that morning.  The patient had fallen and hit his head at work whereupon he had a seizure.  Afterwards, the patient's wife stated that the patient slept for several hours and then went to the bathroom where he called out for his wife and had another witnessed seizure.  The seizure lasted for approximately one minute with generalized shaking.  The patient took around five minutes to wake up.  Because the patient's post seizure period is typically shorter, the wife called emergency medical services.  Records stated the patient had recently switched from Keppra to lacosamide as he did not like the way Keppra made him feel.  He was on lacosamide for approximately 1.5 months and missed a few recent doses.  In the emergency department, the patient had an elevated heart rate of 104 with laboratory values showing abnormalities with a white blood cell count of 14.2, potassium 5.3, creatinine 2.35, estimated glomerular filtration rate (GFR) 35. Imaging studies consisting of computed tomography (CT) of the head, abdomen/pelvis, and cervical spine returned with negative results for acute abnormalities.  A chest x-ray showed vascular crowding with low lung volumes. The patient received Sodium Chloride 0.9% 2liters (L) intravenously (IV), Lacosamide 100 milligrams (mg} by mouth (PO) and Ondansetron 4mg IV.  

Records stated that following the emergency department physician evaluation and treatment, because of the patient's medical history and significant risk factors along with presenting symptoms and sufficient objective and subjective clinical data, the patient was admitted for further evaluation, treatment, and monitoring of recurrent seizures and acute kidney injury.  After further laboratory studies showed improvement in renal function, when the lacosamide was transitioned to oral administration with toleration noted, and when no further seizure activity was noted, the patient was discharged in stable condition.  

The documentation provided for the review stated the patient presented after having a seizure at work after hitting his head and then an additional seizure in the bathroom at home witnessed by his wife.  The patient had a history of seizures and was using a new medication when he presented to the emergency department.  Imaging of the head was negative for acute findings while laboratory studies noted abnormalities which led to the diagnosis of acute kidney injury.  However, the evidence did not support that the patient could not have been treated on an observational or outpatient basis for both conditions.  He responded to treatment and had no additional seizure activity.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Asthma.
Treatment:  Ventolin HFA (hydrofluoroalkanes).
The insurer denied coverage for Ventolin HFA.  
The denial is upheld.
 
The patient is an adult who has a history of asthma/allergies. She was being treated with Breo Ellipta 110/25, Theophylline, Singulair and Albuterol for rescue. The patient was also on Xolair. The patient was being followed by her allergist as per the medical records provided. She had returned to be started on "allergy shots".

Oxygen saturations on room air were 97% (percent). Lungs were clear. Spirometry results were as follows:  Forced Vital Capacity (FVC) 2.84, 82 % (percent), Forced Expiratory Volume 1 (FEV1) 1.96, 72 %, and FEV1/FVC 69 %.

This was indicative of a mild obstructive pattern.

Review of the records shows the patient was previously on Albuterol HFA. The medication list lists albuterol sulfate, levalbuterol tartrate and Ventolin HFA. The use of Ventolin appears to have been continued based on subsequent notes. Ventolin was not on the most current med list, - on this list levalalbuterol (Xopenex) is noted. There was no clear documentation in the medical records to show that the patient had tried and failed the preferred Beta agonists on the insurance formulary. These medications are Albuterol Sulphate (generic Pro Air HFA), Proair HPA and Proair Respiclick. All of these drugs are bioequivalent.

The formulary drugs are not likely to cause the patient an adverse reaction.

Based on the record provided the formulary drugs have not been ineffective.

The requested drug would not be more effective than the formulary drug.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The Request for Formulary Exception for Ventolin HFA cannot be approved.