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

Diagnosis: Type 2 diabetes
Treatment: Mounjaro (tirzepatide)
The insurer denied coverage for Mounjaro (tirzepatide).
The denial is overturned.
 
This is an adult diagnosed with type 2 diabetes mellitus (T2DM). This request is for Mounjaro 7.5 milligrams (mg). As per letter patient tried Mounjaro with excellent results and lowered her glycated hemoglobin (A1C). She tried and failed Trulicity due to nausea, vomiting, and abdominal pain. She tried and failed Ozempic due to vomiting, rash and abdominal pain. She tried and failed Victoza due to nausea and irritable bowel syndrome (IBS) symptoms. She tried and failed metformin due to pain and IBS (irritable bowel syndrome) flare up.

The formulary drug(s) is likely to cause the patient an adverse reaction. The patient has tried and failed Trulicity, Ozempic, Victoza due to adverse reactions. It is likely that the remaining formulary alternative Rybelsus would cause an adverse reaction due to similarities to failed formulary drugs.      

The formulary drug(s) has been ineffective based on the patient's clinical history. Trulicity, Ozempic, Victoza have been ineffective because of adverse reactions.     

The requested drug would be more effective than the formulary drug. The requested medication, Mounjaro, is expected to be more effective because it is of a different class and may not have the same adverse effects as the formulary alternatives to this patient. Furthermore, per appeal note the requested medication has shown to be effective as it lowered the patient's A1C (glycated hemoglobin).  

The formulary drugs are expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Mounjaro (tirzepatide) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This patient was a woman who presented with the complaint of abdominal pain of 1-day duration. She was approximately 3-weeks post-partum. Vital signs at the time of presentation were normal. She had epigastric tenderness on examination. Lab data identified elevated liver enzymes and bilirubin with normal amylase and lipase. The white blood cell count (WBC) was normal at 8.9. A gastroenterology consultation was obtained. An abdominal ultrasound showed small gallstones/sludge. The surgery notes states that amylase and lipase were elevated and the patient was transferred to the surgery service.

The Inpatient hospital admission was not medically necessary for this patient. This patient presented with abdominal pain. She was 3-weeks post-partum and was clinically and hemodynamically stable. Her evaluation identified gallstone pancreatitis. Her evaluation identified no common bile duct stones and her pain level subsided during the period of monitoring. Although the records and diagnostic test results establish the indication for cholecystectomy, the records do not indicate that cholecystectomy was performed during this admission. Nor is there definitive documentation of the plan for cholecystectomy in the outpatient setting.
The patient was provided IV fluid and follow up lab and imaging assessment. She remained clinically stable during the period of monitoring. This patient's clinical needs could have been satisfied with a lower level of care. This level of care would have provided for the clinical assessment and monitoring that was performed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism.
Treatment: Applied Behavioral Analysis (ABA) Behavior Assessment (97151 12 units).
The insurer denied Applied Behavioral Analysis (ABA) Behavior Assessment (97151 12 units).
The health plan's determination is upheld.

The patient is a male, who has autism spectrum disorder (ASD). This diagnosis appears to have been made on the basis of the Autism Diagnostic Interview Revised, with his mother as informant.

The patient was described as having deficits across multiple domains, including socialization and communication, with maladaptive and stereotypical behaviors.  He was described as having inconsistent responses to nonverbal cues.  He displayed inadequate listening skills, frequently interrupting a speaker. He had difficulty losing a game and compromising with peers. He was noted to have deficits in pragmatic, receptive and nonverbal communication. He did not use complex sentences. 

Applied Behavioral Analysis (ABA) Assessment Services Behavior Assessment (97151 12 units) is not medically necessary for this patient.

The vast majority of studies on behavioral and psychosocial interventions on individuals with autism spectrum disorder have been conducted on young children. Bishop-Fitzpatrick et al. performed a systematic review of all peer-review studies evaluating psychosocial interventions for older adolescents and adults with autism spectrum disorder.  A total of 1,217 studies were reviewed, only 13 met inclusion criteria.  The majority of studies were single case studies or non-randomized controlled trials, and most focused on applied behavior analysis or social cognition training.  Effects of psychosocial treatment in older adolescents and adults with autism spectrum disorder were largely positive ranging from d = 0.14 to 3.59, although the authors found that the quantity and quality of studies was limited.

Davis et al. reviewed the empirical evidence supporting the effectiveness of psychoeducational interventions in adults with Level 3 (the most severe level) of autism spectrum disorder.  The authors reviewed 56 peer-reviewed studies of psychoeducational interventions for adults, written in English and since 1968, that met their criteria.  The authors found that "The available literature was limited, and most, if not all, of the studies presented some significant methodological limitations.  When using Cochrane's criteria to assess seven key outcome domains-activities of daily living, aggressive/destructive behaviors, emotional functioning, language/communication skills, self-injurious behaviors, stereotypy/mannerisms, and vocational skills-we found only moderately reliable evidence to support the effectiveness of interventions designed to improve emotional functioning in adults with ASD-3. The reliability of evidence relevant to the six other outcome domains was rated as low or very low."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder
Treatment: Applied behavioral analysis (ABA) behavior assessment - 12 units.
The insurer denied Applied behavioral analysis (ABA) behavior assessment - 12 units.
The determination is overturned.

The patient is a female with a history of autism spectrum disorder. She has had an autism evaluation. Her physician's previous request for applied behavioral analysis therapy was denied for not having a valid diagnosis of autism spectrum disorder. Included for review was a comprehensive clinical interview, objective measures of intelligence, behavioral checklists, autism diagnostic inventory, and results from adaptive testing.
The following review is evaluating the medical necessity of applied behavioral analysis (ABA) behavior assessment - 12 units.

Yes, ABA therapy, 12 units is medically necessary for the patient. The patient has diagnosed and confirmed autism spectrum disorder. The patient has diagnosed autism spectrum disorder with deficits in maladaptive behaviors, stereotyped behaviors, communication impairments and significant aggression. Applied behavioral analysis is the gold standard treatment for autism spectrum disorder (1,2).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit x 12,

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12,

The denial is overturned
 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crossbite among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 16 points by internal reviewers when 26 points are required for approval. 

Upon review of the submitted documentation it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 
In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

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 D8080 braces and D8670 monthly visit x 12 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intractable pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned
 
This is the case of a patient with a history of diabetes mellitus, hypertension, anxiety, and morbid obesity. The patient presented to the Emergency Department (ED) due to left leg and knee pain. Due to failed pain control the patient was admitted for intractable pain and a need for further pain management. The patient received intravenous (IV) diuretics and Oxycodone for pain. Imaging reveals multilevel degenerative disease with bulging disks and stenosis as well as a lumbar (L) 4 compression fracture. The patient had an orthopedic surgery consultation. Shingles was noted on the lateral aspect of the left thigh and the patient started Acyclovir. The patient's condition improved, and he was discharged home to follow up with the primary care provider.

The medical record included documentation of multiple visits to the Emergency Department (ED) with pain medication provided. The medications were not sufficient. His physician reported the need for multiple doses of intravenous (IV) narcotics each day of hospitalization. His pain scores on the Visual Analog Scale (VAS) were elevated despite attempts to provide oral medications. 

His medical condition was significant for major comorbidities. His body mass index (BMI) approached 50. He had an ostomy bag that required care. His blood sugar was 436 showing uncontrolled diabetes. His glycated Hemoglobin (HbA1c) was 13. He required several special imaging studies (cardiac studies). 

Based upon his level of pain unresponsive to standard treatment, uncontrolled diabetes, and significant underlying medical conditions admission and length of stay were warranted. He could not have been treated at a lower level of care. 

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Full Hospital Admission. 
The insurer denied the Full Hospital Admission. 
The denial is Upheld. 

The patient is a female who presented with complaint of abdominal pain of 1-day duration. She was admitted to the hospital. Vital signs were normal at the time of presentation. He was tender in the right upper quadrant. The white blood cell (WBC) count was normal. Liver enzymes were elevated with normal bilirubin. Ultrasound showed no gallstones but a contracted gallbladder and pericholecystic fluid. Computed tomography (CT) scan showed a contracted gallbladder without stones and a normal appendix. Hepatobiliary iminodiacetic acid (HIDA) scan was obtained that showed a low gallbladder ejection fraction of 20% (percent) consistent with biliary dyskinesia. The surgical history and physical (H&P) states that the patient had cholecystitis for which laparoscopic cholecystectomy was planned. Surgery was performed. The operative notes describes robotic cholecystectomy. Laparoscopic cholecystectomy was performed without complication. 

The diet was advanced and pain was controlled with oral medications. Vital signs were normal. The patient remained clinically stable and was discharged from the inpatient setting. 
The subject under review is the medical necessity for a full hospital admission. 
A full hospital admission was not medically necessary in this case. This patient presented to the hospital with complaint of abdominal pain. Imaging and surgical consultation was performed and established the diagnosis of cholelithiasis/cholecystitis. At the time of presentation on and at the time of surgical assessment the patient had normal vital signs and was without fever. Ultrasound, CT scan and HIDA scan were completed. Lab data identified elevated serum transaminases. Surgery (cholecystectomy) was performed. The perioperative and early post-surgical recovery were uncomplicated and the patient had normal vital signs and tolerated a diet on the first post-surgical day. She was ultimately discharged from the inpatient setting. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of intravenous (IV) fluid, surgical consultation, performance of cholecystectomy, and overnight care. There were no peri-procedure complications or other clinical issues.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative colitis
Treatment: Humira 40mg (milligrams) once weekly
The insurer denied coverage for Humira 40mg once weekly.
The denial is upheld.
 
The patient has ulcerative colitis. He was previously on steroids and then adalimumab (Humira) every 2 weeks. Recently he has developed increased symptoms of his ulcerative colitis. He has low levels of adalimumab but moderate levels of antibodies. His physician is now asking for dose escalation to weekly Humira. 

The American Journal of Gastroenterology May 2010 105(5):1133-1139 has an article titled "Clinical Utility of Measuring Infliximab and Human Anti-Chimeric Antibody Concentrations in Patients with Inflammatory Bowel Disease." The authors' conclusion is that measuring drug and antibody levels is useful for management of the disease. However, increasing the dose of infliximab in patients who have antibodies is ineffective. If the dose is subtherapeutic then increasing the dose would be useful if antibodies are not present. 

The physician has referenced scientific studies that have shown that dose escalation is beneficial for patients who lose their initial response to a biologic agent. This is a well-established principle in treating irritable bowel disease (IBD). However, it does not address the problem that this patient has already developed antibodies. When anti-drug antibodies are present it is not likely that the patient will get a good response to dose escalation. Giving Humira weekly is 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 coverage for Humira 40 milligrams (mg) once weekly is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infection
Treatment: Inpatient Hospital Admission
The health plan denied: Inpatient Hospital Admission
The determination is: Upheld

The patient is a female with past medical history of hyperlipidemia (HLD), coronary artery disease (CAD), cerebrovascular accident (CVA), and traumatic brain injury (TBI) after fall from bike status/post (s/p) hemicraniectomy with functional decline, sacral decubitus ulcer with osteomyelitis s/p debridement, communicating hydrocephalus s/p ventriculoperitoneal (VP) shunt, multiple explorations of right cranioplasty due to cerebrospinal fluid (CSF) leak and infection most recently with long hospital course for wound dehiscence and infection, s/p tracheostomy, percutaneous endoscopic gastrostomy (PEG) and diversion colostomy. She presented to the emergency department (ED) with purulent drainage from site from previous scalp flap for cranial coverage. Her husband noticed a thick white discharge from her right scalp flap site.
She was empirically started on vancomycin and meropenem per infectious disease (ID). She was treated with scalp flap revision with plastics and recovered well with no further drainage. Deep operating room (OR) cultures grew staphylococci (staph) epidermidis, enterococcus faecalis, and coagulase-negative staph. She was transitioned from intravenous (IV) vancomycin and meropenem to oral linezolid.
At issue is the medical necessity of the full hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of full hospital admission was not medically necessary for this patient. The patient presented to the hospital with an infected scalp flap. She had a work-up in the ED with scans, laboratory studies, and plastic and neurosurgery consultations. She was clinically stable and was not septic. She was treated with IV antibiotics until scalp flap revision surgery was performed. There is no clear rationale for why surgery was delayed for this patient with an infection. Regardless, the surgery was straightforward, and recovery could have been accomplished at an alternate level of care. She could have then received IV and oral antibiotics and physical therapy at an alternate level of care. She did not have any acute issues (sepsis, hemodynamic, central nervous system [CNS] or respiratory failure) that required inpatient care and monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female (body mass index [BMI] 35 kilograms per meter squared [kg/m2]) who presented to the Montefiore University Hospital emergency department with new onset upper abdominal pain of four-hours duration. At the time of 
presentation, the patient was without fever and vital signs were normal. She was tender in the right upper quadrant. The white blood cell (WBC) count was normal at 8.3 thousand. The complete metabolic panel identified normal liver enzymes and bilirubin. Abdominal ultrasound showed gallstones within the gallbladder and mild wall thickening. The patient was admitted to the hospital. The patient was evaluated with surgery consultation. The patient underwent laparoscopic cholecystectomy. The operation was performed without complication. The diet was advanced following surgery and pain was controlled with oral medications. The patient remained clinically stable and was discharged from the inpatient setting on the same day with planned short term follow up.

The proposed inpatient hospital admission was not medically necessary.

An inpatient level of care was not medically necessary in this case. This patient is an adult female who presented to the hospital with abdominal pain. She was determined to have cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. The indication for cholecystectomy was established. The patient admitted to the hospital. She underwent surgery to remove the gallbladder. The patient 
responded favorably to treatment and was stable for discharge from the hospital on the same day with planned follow up. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for emergency department assessment, surgical assessment and monitoring, laparoscopic cholecystectomy as performed, provision of intravenous antibiotics and fluid, and monitoring.