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

Diagnosis: vomiting
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

The patient is a young boy who presented with vomiting, loose stools, and decreased oral intake. He was well until a week prior to presentation when he developed upper respiratory symptoms and a fever to 100.2 F (Fahrenheit). He was seen in the emergency department and was prescribed amoxicillin. However, his symptoms progressed, and he developed vomiting and decreased oral intake. On the day of presentation, he had 5 loose stools.

Inpatient Hospital Admission was medically necessary for this patient.
This is a very young boy who presented with vomiting, loose stools, and decreased oral intake. He had signs of dehydration including dry mucous membranes and a low bicarbonate level as well as tachycardia, and he was also found to have hypoglycemia. He received appropriate care in the emergency department setting but did not improve significantly. He therefore required hospital admission for ongoing treatment with intravenous fluids, anti-emetics as needed, and close monitoring with additional treatments as needed.
Hospital admission for intravenous rehydration therapy is needed for children with gastroenteritis and dehydration who are unable to take oral replacement therapy. This patient had persistent emesis along with multiple loose stools, and therefore required inpatient hospital admission for intravenous fluids along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated Blood Sugar
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a female with a medical history significant for type 1 diabetes, chronic pancreatitis, and sickle cell trait who was referred to the emergency department (ED) by her pediatrician for an elevated blood sugar and questionable compliance with medications. She had presented to urgent care earlier in the day because of vaginal discharge and discomfort, with an incidental blood sugar over 400, diagnosed with vaginal candidiasis.
 The examination was significant for being alert, with clear lungs, regular heart rate and rhythm, benign abdomen, strong pulses, no rashes, and non-focal neurologic exam.  She was treated with a normal saline bolus with improvement in the bedside glucose to 265. She was given an oral dose of fluconazole for vaginal candidiasis. Because of concerns for compliance, in the absence of diabetic ketoacidosis, she was admitted for diabetic education and management of hyperglycemia.
Admission orders included Humalog insulin before meals, Lantus 6 units (U) at bedtime, consideration for insulin pump therapy after assessing compliance with continuous glucose monitoring, carbohydrate counting with insulin correction, follow-up labs, placement of continuous glucose monitoring. She did well overnight with glucose less than 250 (range 102-232). Following education review, she was deemed stable for discharge home. At issue is the medical necessity of an inpatient stay.

This female teen with history of insulin-dependent diabetes mellitus (IDDM) and questionable medication compliance presented with an incidental finding of hyperglycemia. Laboratory testing did not demonstrate metabolic acidosis (diabetic ketoacidosis), but she was admitted because of need for education and better glucose control. While it was reasonable to monitor her overnight while reviewing appropriate education and making recommendations for ongoing and future treatment, she was overall hemodynamically stable with no evidence of metabolic acidosis or other diabetes complicating factors. She did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heart failure
Treatment: inpatient stay
The insurer denied the inpatient stay
the health plan's determination is overturned. 

The patient is a male who presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of dyspnea, cough, fever, chills and lower extremity edema. EMS reported a room air oxygen saturation of 90 percent (%). His medical history was remarkable for paroxysmal atrial fibrillation, chronic kidney disease, type 2 diabetes, hypertension, obesity, heart failure with preserved ejection fraction and a recent admission for decompensated heart failure. 

Based on the documentation provided, an inpatient hospital admission was medically necessary.
This patient presented to the hospital with pneumonia and concomitant decompensated heart failure. He was febrile and hypoxic with leukocytosis and pulmonary infiltrates on chest X-ray and met criteria for a diagnosis of sepsis. The risk for mortality with sepsis is substantial; inpatient admission with aggressive fluid resuscitation and intravenous antibiotics is recommended in this situation. Based on his Pneumonia Severity Index score his risk category was Class IV with an 8.2-9.3% risk for mortality. Management of this high-risk patient required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: osteoporosis
Treatment: Prolia
The insurer denied Prolia
The health plan's determination is overturned. 

The patient is a female with osteoporosis. Her past medical history (PMH) also includes cervical stenosis of spine, spondyloarthropathy, inflammatory bowel disease (IBD) associated arthritis. Per chart review, the bone density T-score is -3.4. She also has a history of a left clavicle fracture. The patient has tried oral and intravenous (IV) bisphosphonates (Reclast x (times) 4 as well as oral agents (stopped due to gastrointestinal (GI) upset)) and remains at high risk for fracture.

Prolia is medically necessary for this patient. The patient clearly has osteoporosis and has already sustained a fracture to the left clavicle. She has tried and failed or had an intolerance to IV and oral bisphosphonates. A trial of Prolia is reasonable at this time as she is high risk for fracture.
As per UpToDate, 'denosumab is a fully human monoclonal antibody to the receptor activator of nuclear factor kappa-B ligand (RANKL), an osteoclast differentiating factor. It inhibits osteoclast formation, decreases bone resorption, increases bone mineral density (BMD), and reduces the risk of fracture'.
Prolia is used for patients such as this at high risk for fracture, who are intolerant to or unresponsive to other therapies (such as the patient in this case), or for patients who have markedly impaired kidney function. As published in the N Engl J Med in 2009, 'denosumab given subcutaneously twice yearly for 36 months was associated with a reduction in the risk of vertebral, nonvertebral, and hip fractures in women with osteoporosis'.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a previously healthy woman who presented to the emergency department (ED) with the complaint of abdominal pain of 4-days duration. She was evaluated with surgical consultation that identified bilateral lower abdominal tenderness. Vital signs identified a normal heart rate and blood pressure at the time of presentation. The white blood cell (WBC) count was normal at 7.6. A computed tomography (CT) scan was completed showing findings that were equivocal for acute appendicitis (dilated appendiceal tip). 

The inpatient hospital admission was not medically necessary. The medical records support that this patient could have been reasonably and safely monitored and treated at a lower level of care.
This patient presented with abdominal pain. The evaluation with examination, follow up assessment, lab data, and CT scan supported the diagnosis of acute appendicitis. The diagnosis and indication for surgery was established. She underwent uncomplicated appendectomy. Afterward, she was clinically stable following surgery and was started on a diet. Pain medications were transitioned to oral medications. She was discharged from the hospital.
A lower level of care designation would have provided for presurgical assessment, operative treatment and post-surgical monitoring and antibiotics. This lower level of care would have also allowed for overnight monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Postoperative bleeding after adenoidectomy/tonsillectomy surgery
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a preschool female with a history of postoperative bleeding from the throat after adenoidectomy/tonsillectomy surgery one week prior to presentation. On presentation, the patient's hemoglobin was 8.5 with a hematocrit of 26.2. Vital signs were stable, and she was febrile. There was no respiratory distress. A clot was seen in the right tonsillar fossa. She was admitted as an inpatient. While on the patient care floor, bleeding began, and the patient was taken to the operating room for cauterization. She was discharged on the same day. The inpatient stay was denied coverage by the health plan. The denial is being appealed.

The inpatient hospital admission was not medically necessary.

The patient had a history of postoperative bleeding from the throat after adenoidectomy/tonsillectomy surgery one week prior to presentation. On presentation, the hemoglobin was 8.5 with a hematocrit of 26.2. Vital signs were stable, and she was febrile. There was no respiratory distress. A clot was seen in the right tonsillar fossa. She was admitted as an inpatient. While on the patient care floor, bleeding began, and the patient was taken to the operating room for cauterization. She was discharged on the same day. There was no infection and no complications after the tonsillar bed cautery. Pain was controlled, and the patient was tolerating her diet. She was discharged the same day as admission. Based on the above, the inpatient admission would not be confirmed as medically necessary, as the patient's condition could have been managed at an observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic axial low back pain

Treatment: Pain injection (64493 x 2, 64494 x 2)

The insurer denied coverage for pain injection (64493 x 2, 64494 x 2)

The denial is overturned

The patient has chronic axial low back pain. The patient has had greater than 6 months of physical therapy (PT) and is doing a home exercise program. The patient's medication trials have included non-steroidal anti-inflammatory drugs (NSAIDs), Gabapentin and Tylenol. The patient had gastric sleeve surgery and cannot take NSAIDS regularly. The patient's x-ray shows lumbar spondylosis.  Magnetic resonance imaging (MRI) shows disc bulges and facet spondylosis.  The request is for diagnostic medial branch blocks at L (lumbar) 3, L4, and L5.
Clinical practice guidelines (1,2) support the performance of diagnostic medial branch blocks in this patient. The Health Plan objects are without merit: the patient has failed conservative therapy after 6 months of PT. The imaging confirms that the patient has facet pathology and there is no other significant spine pathology noted. 

Based on the above, the insurer's denial must be reversed. 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 pain injection (64493 x 2, 64494 x 2) is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes

Treatment: Mounjaro 15 milligrams (mg) /0.5 milliliter (ml) pen

The insurer denied coverage for Mounjaro 15 milligrams (mg) /0.5 milliliter (ml) pen

The denial is upheld
 

This is an adult male diagnosed with Type 2 Diabetes (T2DM). This request is for Mounjaro. As reported; he is not able to tolerate metformin; Ozempic; Trulicity with suboptimal glycemic response, and adverse reaction including nausea, vomiting and diarrhea. 
As per visit note he stopped Ozempic due to gastrointestinal (GI) issues. 
As per the letter, he started on Mounjaro with subsequent improved glycated hemoglobin (A1C) and improved glucose levels. He has a history of taking Ozempic 0.25 mg with adverse reactions of nausea, gastric pain, and discomfort. 

The preferred formulary alternatives include Ozempic, Trulicity and Victoza. The patient is reported to have only failed Ozempic and Trulicity due to GI issues. There is no documentation of trial and failure of Victoza. The remaining formulary alternative is not likely to cause the patient an adverse reaction.

The requested medication Mounjaro (Tirzepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes.  It is a glucagon like peptide 1 (GLP)-1 and Glucose-Dependent Insulinotropic Polypeptide (GIP) receptor agonist.  It has been shown in clinical trials to lead to improvement in hemoglobin A1C (glycated hemoglobin) as well as weight loss (1-3).There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 receptor agonists as a 1st line agent. There is no preference for the requested medication over GLP-1 receptor agonists(4). 

The patient can try the formulary alternative Victoza, as it is as effective as the requested therapy.  

The request is not consistent with generally accepted standards of medical practice.

The formulary drug, Victoza, is not expected to cause adverse effects. 

The formulary drug, Victoza, was not tried and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non- formulary drug is not expected to be more effective than the formulary alternative.

The carrier's denial of a request for a Formulary Exception for Mounjaro 15 milligrams (mg) /0.5 milliliter (ml) pen for use in the treatment of Type 2 diabetes mellitus without complications is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is overturned.

The patient is a female with a Class II Division 1 malocclusion with maxillary and mandibular crowding. She has a 7 millimeter (mm) overjet and 2 mm overbite. She is treatment planned for 24-30 months of orthodontics with extraction of teeth 5 and 12 to correct her malocclusion. At issue is the medical necessity of braces.

This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. (1) Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (2) Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. There is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjet, which this patient has. (3) For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who came to the emergency department (ED) with 2 days of dyspnea, wheeze, and cough.
In the ED, temperature was 36.8oC, blood pressure (BP) 111/75, heart rate (HR) 93, respiratory rate (RR) 22, and oxygen saturation 97% on room air (RA). She was not in distress, heart was regular, and she tachypneic with accessory usage, retractions and wheezing. She was alert and oriented. White blood cell count (WBC) was 10.1, Na (sodium) was135, bicarbonate 20, blood urea nitrogen (BUN) /Cr (creatinine) 9/0.7, and venous blood gas (VBG) 7.38/35.9. A chest x-ray (CXR) was clear. She was given intravenous (IV) steroids and nebulizers. She had persistent wheezing, and was given IV magnesium, and epinephrine.

The inpatient hospital admission was not medically necessary.
The patient presented with dyspnea, cough, and wheeze and was diagnosed with an acute asthma exacerbation. She had no organ dysfunction other than respiratory distress but had no gas exchange abnormality or need for ventilatory support or supplemental oxygen. Her peak flow was not severely reduced. She had no additional or alternative diagnoses. Within the first 12 hours, she did seem to improve, and her attending noted a change to oral steroids and possible discharge later that day. The only possible provided admission criteria that she met would be lack of improvement, and while she did against medical advice (AMA) the attending did feel she had improved sufficiently for steroids to be changed from intravenous (IV) to PO (by mouth) and to consider discharge later that day. As she was not severely ill, was unlikely to become so (no prior intubation, no other cardiac or lung disease, no recent oral steroids, etc.), a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a woman who presented following an fall down 15 stairs. She complained of vaginal bleeding at the time of presentation. There was no loss of consciousness. Comorbid health conditions included transient ischemic attack (TIA), stroke and current use of the anticoagulant, Eliquis. Vital signs were normal at presentation and Glasgow coma score was normal at 15. Imaging evaluation identified no acute fractures, intracranial, intrathoracic or intra-abdominal injury.

The inpatient hospital admission was not medically necessary. The patient was clinically stable with normal vital signs at the time of presentation. She was tolerating a diet and pain control was provided with oral medications. It was determined that there was not need for acute surgical intervention. In this case, the care and treatment provided could have safely been rendered at a lower level of care.
Inpatient admission may be required when there is a newly diagnosed or suspected bone, joint or orthopedic device infection, fracture, dislocation or other musculoskeletal injury that requires inpatient care, severe rheumatologic disease, severe vasculitis, severe crystal arthropathy, rhabdomyolysis, severe myopathy, post-amputation complication, severe pain requiring inpatient management, or other musculoskeletal condition for which emergency and observation care have failed.
In this case, none of the above conditions existed to justify inpatient admission.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atopic Dermatitis. 
Treatment: Opzelura (ruxolitinib). 
The insurer denied coverage for Opzelura (ruxolitinib). 
The denial is overturned. 

The patient is an adult female with a diagnosis of atopic dermatitis and pruritus. The patient has failed therapy with Eucrisa, tacrolimus, clobetasol, triamcinolone, and fluticasone. The request is for Opzelura cream. 

Based on the submitted documentation, Opzelura is the appropriate medication selection.  The patient has failed numerous steroids of varying strengths, including triamcinolone and clobetasol. The patient has also failed therapy with non-steroidal topicals, including Eucrisa and tacrolimus. Opzelura is Food and Drug Administration (FDA) approved for treatment of atopic dermatitis and would be an appropriate alternative or adjuvant therapy. Opzelura is a Janus Kinase (JAK) 1 and JAK2 inhibitor approved for patients with mild to moderate atopic dermatitis aged 12 and older. Opzelura has shown to specifically decrease atopic dermatitis symptoms as well as pruritus compared to control. Based on the documentation provided that the patient has failed reasonable steroid and non-steroidal options for the treatment of atopic dermatitis, the formulary exception for use of Opzelura is approved.  

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were tried, and the patient did not have an adverse reaction or contraindication. 

The formulary drugs are 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 Opzelura to treat atopic dermatitis is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder
Treatment: Transcranial magnetic stimulation (TMS) therapy.
The insurer denied TMS therapy.
The determination is overturned.

The patient is a female with a history of major depressive disorder, recurrent and moderately severe without psychotic features and comorbid generalized anxiety disorder. The patient has a documented history of multiple failed medication treatments for depression including treatment with more than two disparate classes of medication (Lexapro, Zoloft, and Wellbutrin), as well as augmentation with thyroid hormone (levothyroxine). Additionally, the patient has received treatment with hydroxyzine and clonazepam targeting associated symptoms of anxiety and insomnia related to the mood disorder and comorbid generalized anxiety disorder. She has been treated with an evidence-based psychotherapy [cognitive behavioral therapy (CBT)] without a response or remission of depressive symptoms. Current treatment includes ongoing psychotherapy and continued use of Wellbutrin and thyroid hormone and Vitamin D3 and other supplements with only modest effect. The patient has no history of psychiatric hospitalization or suicide attempts or suicidal behavior.

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

The requested health service/treatment of TMS is medically necessary for this patient.
Repetitive TMS therapy as a primary or adjunctive therapy for treatment of major depression has generally been evaluated in patients who have treatment refractory or pharmaco-resistant depression, as defined by one or more antidepressant medication treatment failures with or without augmentation, and with or without psychotherapy, especially CBT. TMS therapy, as applied in major depression, is considered to be a safe treatment by the Food and Drug Administration (FDA). The data as reflected in peer reviewed medical literature supports this assertion. Specifically, when treatments with antidepressant medication with or without augmentation, electroconvulsive therapy, and/or psychotherapy (especially CBT) have failed, then TMS is an appropriate treatment for major depressive disorder. This assertion is noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder, referenced below, and consistent with the scientific literature pertaining to TMS and its application to depressive disorder. The patient has also failed to achieve a remission of symptoms with combined treatment with psychotherapy (CBT) and medication regimens.