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

Diagnosis: Anxiety. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient was admitted due to heart palpitations and elevated heart rate in the 150's and low hemoglobin and iron. She reportedly had headache, dizziness, brain fog, nausea, and was coughing a lot. She reportedly had multiple reported medical hospitalizations for low hemoglobin (Hb). She reportedly had elevated QTc (interval on ECG [electrocardiogram]) of 469. However, the ECG did not show any changes suggestive of acute ischemia and the troponin levels were normal. She reportedly also had a hiatal hernia. She had an intravenous (IV) fluid bolus, IV Solumedrol, Albuterol inhaler, and hematology recommended to take Venofer. She reportedly had a psychiatric consultation due to anxiety and depressive symptoms and was taking Lexapro for this. The psychiatric consultant recommended outpatient mental health treatment and stated that she was not in need of inpatient psychiatric hospital treatment. The patient reportedly was discharged. 
    
This reviewer agrees with the decision to deny coverage for inpatient hospital treatment as not medically necessary treatment due to either acute cardiac issues or psychiatric reasons as there was no specific evidence in the medical records provided supporting acute coronary syndrome (ACS) or that she required inpatient mental health treatment or hospital treatment due to substance reasons. This patient reportedly was seen by the psychiatric consultant and it was reported that the psychiatric consultant did not recommend psychiatric hospitalization and stated that she did not require inpatient psychiatric hospital treatment. The recommendation was to continue with that medication and for outpatient mental health follow up treatment. There was no reported specific evidence that she only required 24-hour acute hospital treatment for chest pain or for behavioral health reasons. 

Inpatient hospital treatment was not medically necessary. It appeared that the health care plan acted reasonably and with sound medical judgment. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty Breathing
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. Service under review is Inpatient Admission. This service was denied twice as not medically necessary.

This decision is being appealed. The patient had a recent ICU (intensive care unit) admission for acute respiratory failure due to bronchiolitis due to rhino/enterovirus, and presented to ER (emergency room) with respiratory distress, wheezing, retractions, tachypnea, tachycardia. Her VBG (venous blood gas) and CBC (complete blood count) were normal. Her CXR (chest x-ray) was unremarkable. She tested positive for rhinovirus.

The patient was given inhaled bronchodilators, systemic steroids, systemic bronchodilators, and IV (intravenous) fluids. Afterwards the patient's work of breathing decreased, lung sounds improved but wheeze not resolved, less tachypnea, still mild retractions.

The reason for admission was documented as hypoxemia, despite normal SpO2 (pulse oximetry) (note states SpO2 was 94-100% on room air). She was admitted to inpatient unit, remained on room air, given albuterol every four hours, and discharged after one night in the hospital.

No, the inpatient admission was not medically necessary.

The proposed treatment was not medically necessary, using applicable and generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations. The stated reason for the hospitalization was need for supplemental oxygen. Hypoxemia is generally defined as oxygen saturation less than 92% (percent) on room air (MCG [Milliman Care Guidelines]), which this patient did not have. There were no other reasons for the admission. The patient did not have hypotension, elevated PCO2 (partial pressure of carbon dioxide), cyanosis, apnea, tachypnea wheeze or retractions that are severe or persistent after observation care treatment, inability to maintain oral hydration, feeding difficulties, or lethargy.

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: Paroxysmal Atrial Fibrillation.
Treatment:  Eliquis, Pre-service.
The insurer denied the  Eliquis, Pre-service.
The denial is upheld.

The patient is a male with atrial fibrillation. Eliquis is under review. There was report of unspecified treatment failure to warfarin and Xarelto.

No, the health plan should not cover the proposed treatment with Eliquis.
Those with atrial fibrillation can be at elevated risk of an associated cerebral vascular accident (CVA) and in some individuals, anticoagulation is indicated. Warfarin has been proven effective for atrial fibrillation (afib) stroke prevention.  New generation of anticoagulants, including Eliquis and Xarelto, have been developed for atrial fibrillation stroke prevention. All agents have an associated increased risk of both major and minor bleeding. The newer medications have generally been demonstrated more effective than Warfarin for stroke prevention and are generally safer. However, Eliquis has not been established as standard of care, compared to Xarelto, towards improved atrial fibrillation outcomes.  Also, there is no established contraindication or treatment failure to Xarelto in this case (ie: clinically significant bleeding, cerebral vascular accident).  Therefore, Eliquis is considered not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: giant cell arthritis, weakness, arthritis and blindness
Treatment: Increase Personal Care Worker (PCW) Services to 6 Days per week, 8 Hours per Day (Monday - Saturday); 48 Hours per Week
The insurer denied the Increase Personal Care Worker (PCW) Services to 6 Days per week, 8 Hours per Day (Monday - Saturday); 48 Hours per Week.
The denial is overturned.

The patient is a female. Her conditions include giant cell arthritis, weakness, arthritis and blindness. Denial of increase personal care worker (PCW) services to 6 days per week, 8 hours per day (Monday - Saturday), 48 hours per week, is being appealed. The health plan partially approved an increase to 7 days/week, 5 hours/day, 35 hours per week. The patient's child notes that the patient has been falling more at home and needs more attendant hours.

Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation and shopping; extensive assistance with stairs, transportation, and bathing dressing; and limited assistance with managing finances and medications, phone use, personal hygiene, walking, locomotion, bed mobility, and eating. The patient has frequent bladder incontinence and infrequent bowel incontinence.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
This patient has multiple chronic medical conditions. Denial of increase in PCW (personal care worker) services to 6 days per week, 8 hours per day (Monday - Saturday), 48 hours per week, is being appealed. The health plan partially approved an increase to 7 days/week, 5 hours/day, 35 hours per week.

UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). She has frequent bladder incontinence and infrequent bowel incontinence. She has been having falls. Due to this patient's inability to perform all ADLs (activities of daily living) or personal care without assistance, including limited assistance with walking, locomotion, bed mobility, and eating, the approved PCW (personal care worker) 35 hours per weeks is inadequate to meeting the patient's needs. The proposed increased increase PCW (personal care worker) services to 6 days per week, 8 hours per day (Monday - Saturday), 48 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

In this case, the patient is a pregnant female who presented with elevated blood sugar at home but was also found to have preterm labor and was admitted to labor and delivery for management of preterm labor.
The patient was noted to have underlying chronic hypertension as well as insulin controlled gestational diabetes in the third trimester. She also had migraines and preterm contractions. She had a past medical history of aortic insufficiency and chronic hypertension that was not managed on medications. The patient had no pertinent surgical history. At presentation, her blood pressure was normal at 135/74 with a heart rate of 90 and respirations of 16/minute. Her oxygenation was 99% on room air and the patient was afebrile at 98.2F(Fahrenheit ). The patient had no complaints. She was noted to have an abdomen that was soft, nontender and gravid. 

Based upon a review of the medical records, the recommendations of the American College of Obstetrics and Gynecology (ACOG) and the Milliman Care Guidelines (MCG) entitled "Preterm Labor, Threatened, the inpatient stay was not medically necessary. In this case, the patient was noted to have a singleton gestation at 33 weeks gestation with threatened preterm labor. There was a cervical exam on admission to document the cervix by the physician at 3 cm(centimeter)/50% effaced and ballotable. Given preterm contractions, a plan was made for ultrasound, oral nifedipine and steroids. The ultrasound and monitoring were reported as initially Category II due to late decals but this reverted to Category I and normal and reassuring with a singleton gestation that was normally grown with normal fluid. The patient completed nifedipine without complications. There was completion of two doses of betamethasone for fetal lung maturity. The patient had a trial of tocolysis that was successful and without complications with the oral nifedipine. In this case, the care rendered would have been appropriate at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis.
Treatment: E0483 High Frequency Chest Wall Oscillation System.

The insurer denied the E0483 High Frequency Chest Wall Oscillation System.
The denial is overturned.

The patient is a male with history of chronic obstructive pulmonary disease (COPD), bronchiectasis, and productive cough who is prescribed High Frequency Chest Wall Oscillation System (HFCWO). The patient has tried and failed aerobike device and manual chest physical therapy (PT). However, the patient has not had any exacerbations requiring antibiotics. Thus, the High Frequency Chest Wall Oscillation System (HFCWO) is denied. This denial is being appealed.

Yes, the proposed treatment is medically necessary.
This patient has evidence of bronchiectasis with inability to clear pulmonary secretions. Although the patient has not had exacerbations requiring antibiotic therapy, the patient is at high risk to develop frequent infections if the mucus plugging due to bronchiectasis is not treated aggressively. The patient has already tried and failed manual chest physical therapy (PT). The High Frequency Chest Wall Oscillation System (HFCWO) will loosen the mucus and improve pulmonary secretion clearance. The proposed treatment is medically necessary. High-frequency chest wall oscillation (HFCWO) is a commonly prescribed airway clearance technique (ACT) for patients whose ability to expectorate sputum is compromised. Non-cystic fibrosis bronchiectasis (nCFb) is an acquired condition of variable etiology. An impaired mucociliary clearance seems to be one of the mechanisms behind nCFb (Non-cystic fibrosis bronchiectasis), and treatment involves antibiotics, mucoactive agents, and airway clearance techniques (ACTs). High frequency chest wall oscillation (HFCWO) is described as safe for individuals with stable bronchiectasis; where there may be improvements in sputum expectoration, selected measures of lung function, and health-related quality of life.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
This patient has evidence of bronchiectasis with inability to clear pulmonary secretions. Although the patient has not had exacerbations requiring antibiotic therapy, the patient is at high risk to develop frequent infections if the mucus plugging due to bronchiectasis is not treated aggressively. High frequency chest wall oscillation (HFCWO) is described as safe for individuals with stable bronchiectasis; where there may be improvements in sputum expectoration, selected measures of lung function, and health-related quality of life.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine.
Treatment: Nurtec.
The insurer denied Nurtec.
 The health plan's determination is overturned.

The patient is a woman with migraines. Nurtec ODT (oral disintegrating tablet) is being prescribed for the treatment of acute migraines. The drug was denied because the patient is also being treated with Aimovig for prevention of migraine. The provider appealed the determination because the patient cannot take alternative medications for acute migraine such as non-steroidal anti-inflammatory drugs and triptans due to medical contraindications.

Nurtec is medically necessary for this patient.
The patient is diagnosed with acute migraine headaches. The patient is unable to take first-line therapies for treatment of acute migraine, such as non-steroidal anti-inflammatory drugs and triptans. The patient has absolute medical contraindications to these drugs. The patient has also tried and failed acetaminophen and Fioricet, a combined analgesic.
Nurtec ODT, an oral CGRP (Calcitonin gene-related peptide) inhibitor, is requested. This drug is Food and Drug Administration (FDA) approved for treatment of acute migraine. As such, its use is compendia and literature supported. The patient is also using Aimovig, which is a long-acting CGRP antagonist. Aimovig is FDA approved for prevention of chronic migraine. In this clinical scenario, the drug is also being used per the compendia and FDA labeling. There are no national or published guidelines by compendia or the manufacturers that caution against the use of short-acting oral and long-acting injectable CGPR inhibitors. Furthermore, clinical studies show that the practice of using these drugs in combination is safe and effective.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Paroxysmal atrial fibrillation
Treatment: Eliquis
The insured denied the Eliquis.
The determination is overturned.

The patient has a history of chronic heart failure, paroxysmal atrial fibrillation, hypertension, hyperlipidemia, and right middle cerebral artery (MCA) stroke with residual left-sided weakness. The patient has been treated with apixaban for prevention of recurrent stroke. The patient's health plan has denied coverage for apixaban as lacking documentation of intolerance, treatment failure, or contraindication to the formulary anticoagulants warfarin and Xarelto. At issue is whether the formulary drug warfarin, Xarelto will be or has been ineffective, would not be as effective as the non-formulary drug Eliquis, or would have adverse effects.

Based on the records provided for review of this case, apixaban is the most appropriate anticoagulant for the prevention of recurrent stroke for this patient for the following reasons. The patient has been doing well while being treated with apixaban with no recurrence of stroke. A growing body of published medical literature indicates the direct oral anticoagulants including apixaban are superior to warfarin for the prevention of stroke with a more favorable safety profile with an associated lower risk of significant, potentially life-threatening, bleeding events (1, 2). Published medical literature also indicates that amongst the direct oral anticoagulants, apixaban is preferable to rivaroxaban (Xarelto) in patients with atrial fibrillation due to a reduced rate of severe bleeding complications and superior efficacy for reducing stroke occurrence (3). This is particularly important for this patient since he already has experienced a stroke and has residual neurologic deficits. For these reasons, the formulary anticoagulants warfarin and Xarelto would be less efficacious and be associated with a higher risk of adverse outcomes for this patient making apixaban the preferable anticoagulant in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental abscess
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned.

The patient is a girl who presented with swelling and pain of her chin. She was well until several days prior to presentation, when a friend at school accidentally hit her chin. She developed swelling at that time with some redness. Afterwards, the swelling progressed and the pain worsened, particularly with eating, drinking, and speaking. She took acetaminophen at home with no relief. The pain progressed to a 10 out of 10 in intensity, and therefore she was brought to the emergency department for care.

Inpatient hospital admission was medically necessary for this patient.

This is a patient who presented with a significant odontogenic infection. If unrecognized and untreated, these infections are potentially serious since they can spread contiguously into the deeper fascial spaces of the head and neck. For patients with pyogenic odontogenic infections, parenteral therapy is appropriate along with intravenous fluids to maintain hydration status and pain control. Inpatient hospitalization was necessary for these treatments, as well as expert consultation with surgical intervention.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Chronic idiopathic Constipation/recurrent small intestinal bacterial overgrowth
Treatment: Pharmacy/Prescription Drugs-Motegrity

The health plan denied the prescription medication as it does not meet their criteria. 
The reviewer has overturned in whole the health plan's determination.

This is a patient with a history of chronic idiopathic constipation, and recurrent small intestinal bacterial overgrowth who was for complaints of acute on chronic gastrointestinal (GI) symptoms (abdominal bloating, flatulence, and constipation). Per medical records, he failed Linzess, lactulose, and Miralax to manage constipation. He was initially treated with Motegrity at a low dose but developed diarrhea. The patient's physician requested Motegrity during his last Office visit after the failure of alternative treatment therapy.

The formulary drug choices include (Linzess and Amitizia). Per the submitted documentation for review, the patient failed Linzess, and there is no documentation of the trial of Amitizia. There are no direct comparison studies for the prokinetic agents (Amitizia, Linzess, and Motegrity) in managing constipation. The common side-effect of all the three prokinetic agents is diarrhea; however, Amitizia carries an additional significant adverse side-effect of nausea. Therefore, the Formulary drug alternative (Amitizia) will be as effective but does have a potential side effect risk profile of nausea for this patient with significant GI tract symptoms. Therefore, Amitizia would have adverse effects for this patient.
This patient already failed Linzess, and the second formulary alternative carries an additional adverse effect of nausea. It will be prudent to offer a trial Motegrity to treat chronic idiopathic constipation with less of a side effect profile than the formulary drug of Amitizia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder. 
Treatment: Transcranial magnetic stimulation (TMS). 

The insurer denied Transcranial magnetic stimulation (TMS). 
The denial is overturned. 

The patient is a female with a history of Major Depressive Disorder, recurrent, severe without psychotic features, anxiety disorder and bulimia nervosa. She has had several medication trials of different classes and engaged in outpatient psychotherapy that was ineffective in treating her depressive symptoms. The patient's health plan previously denied the request for transcranial magnetic stimulation (TMS) approval and an appeal has been requested. 

At issue is the medical necessity of Transcranial magnetic stimulation (TMS). 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of Transcranial magnetic stimulation (TMS) is medically necessary for this patient. 

The previous denial of care is overturned based on patient meeting plan criteria. The patient, per the documentation, meets all the plan criteria. 1. Member must be at least 18 years old; this is met. 2. Documentation supporting member meets diagnostic criteria for Major Depressive Disorder. The documentation supports the patient's diagnosis. 3. Documentation includes comprehensive psychiatric evaluation, subsequent progress notes, psychiatric co-morbidities, which is met as this is supported in the documentation. 4. Documentation that the member is currently experiencing moderate to severe depressive episode confirmed with a self-reported, evidence-based rating scale using Patient Health Questionnaire (PHQ-9). This is shown in the documentation. 5. Depressive symptoms are evident on an evidence-based rating scale, member has failed 6-8-week trial of maximum dose to include three antidepressants from two different classes, intolerance to a medication trial, and has had concurrent evidence-based psychotherapy for treatment of major depressive disorder (MDD), which has been met. 6. Ability to supply documentation of standard evidence-based rating scales at least once per week to monitor TMS treatment. This is met per provided documentation. 7. TMS administered by United States Food and Drug Administration (FDA) approved device. The previous denial of care is overturned based on the patient not meeting plan criteria. The patient meets the plan criteria in whole.
Additionally, TMS is an Food and Drug Administration (FDA) approved treatment for Major Depressive Disorder and has been shown to be effective for the patient's condition. (1) 

Therefore, the requested health service/treatment of Transcranial magnetic stimulation is medically necessary.