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

Diagnosis: Global developmental delays and a muscle disorder. 
Treatment: Mobility Device (pediatric dependent push wheelchair - Convaid Cruiser). 
The insurer denied: Mobility Device (pediatric dependent push wheelchair - Convaid Cruiser). 
The denial is overturned. 

The patient is a toddler male. He is non-ambulatory with global developmental delays and a muscle disorder. He has been followed by a seating and mobility specialist for adaptive equipment assessment. Medical records noted hypotonia, dysmorphisms, and global delays with possible mitochondrial disorder. He is a dependent sitter. He has been prescribed Convaid Cruiser CX14 stroller with accessories. The health plan denied coverage of the request as not medically necessary. The denial is being appealed. 

The requested mobility device is medically necessary. 

In this case, the child has significant developmental delays due to hypotonia, global delays, and possible mitochondrial disorder. He is dependent for all activities of daily living (ADL) skills, and for required transportation for seating and mobility. Clinical evaluation suggested use of Convaid stroller as the best available option for this non-ambulatory child. Therefore, the requested health service is medically necessary. In this specific case, the child requires a reasonable mobility system. This extremely involved child's mobility needs have been assessed by the skilled providers including assistive technology professional (ATP) specialists, physical therapist, and a treating physician. Convaid stroller has been ordered. In this case, it is medically necessary due to the fact that it is prescribed due to the medical condition of the child, not for the convenience of a provider or caregiver. It is a standard of care to prescribe mobility device that is durable and can withstand repeated use.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical dystonia.
Treatment: Botulinum Toxin.
The insurer denied Botulinum Toxin.
The health plan's determination is overturned. 

The patient is a female with cervical dystonia secondary to Parkinson's disease. Treatment with Botulinum Toxin is the subject of this review. The drug was denied because there was no documentation that the patient has painful and repetitive spasms of the neck for at least six months. 

Treatment with Botulinum Toxin is medically necessary for this patient. Botulinum Toxin is Food and Drug Administration (FDA) approved for treatment of cervical dystonia. The records demonstrate that the patient is diagnosed with cervical dystonia and meets diagnostic criteria for cervical dystonia. The patient has abnormal positioning of the head and neck and painful and repetitive spasms of the head and neck muscles. The patient is under the care of a neurologist. As such, continued treatment with Botulinum Toxin is indicated. In the manufacturer's prescribing information, it is indicated that that doses of 120 U (units) and 240 U were studied and there were not clinically significant differences between these doses for treatment of cervical dystonia.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine Headaches

Treatment: Nurtec 75 milligram (mg) orally disintegrating tablet (ODT)

The insurer denied coverage for Nurtec 75 milligram (mg) orally disintegrating tablet (ODT)

The denial is overturned

This case pertains to a patient with a request for Nurtec 75 milligrams (mg) orally disintegrating tablet (ODT).

The patient presented for their annual physical. The patient has a diagnosis of migraine without aura. The record indicates to stop sumatriptan and to start Nurtec 75 mg every other day. Imitrex is not helping. 

The patient's wife called. The patient's wife was under the impression that the office was working on getting another medication for the patient's migraines. The patient refused Emgality because they won't take the injections. A prescription was sent for Ubrelvy. 

A denial letter was sent informing patient that the criteria for approval of Nurtec had not been met.

The patient's wife called to notify provider that the Ubrelvy was not helping. 

An appeal letter was sent noting that the patient had tried and failed Imitrex, Ubrelvy and Emgality. 

The plan policy states that Nurtec may be approved when the member has a clinical condition or needs a specific dosage form for which there is no alternative on the formulary or the listed formulary alternatives are not recommended based on published guidelines or clinical literature or the formulary alternatives will likely be ineffective or less effective for the member or the formulary alternatives will likely cause an adverse effect or the member is unable to take the required number of formulary alternatives for the given diagnosis due to a trial and inadequate treatment response or contraindication or the member has tried and failed the required number of formulary alternatives. Formulary alternative is Ubrelvy. 

The Food and Drug Administration (FDA) notes that Nurtec is indicated for the acute treatment of migraine, or the preventative treatment of episodic migraine 75 mg as needed. Rimegepant orally disintegrating tablets are an efficacious migraine treatment option with a novel mechanism of action, convenient dosage form, and limited adverse effect profile. Rimegepant should be prescribed to treat acute migraine with or without aura in adults. 

This case involves a patient with a history of migraine. The record indicates the patient has tried the formulary required drug Ubrelvy and it did not work. As such the request for Nurtec falls under the guidelines of the plan. 

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 drug is expected to be ineffective.

The not formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Nurtec 75 milligram (mg) ODT to treat migraine is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient presented with left lower quadrant (LLQ) abdominal pain. She previously had a partial colectomy for diverticulitis. She was afebrile and the vital signs were stable. The emergency room (ER) note and the Gastroenterology consult note did not find peritoneal signs. An abdominal computed tomography (CT) scan showed acute diverticulitis without an abscess or perforation. Intravenous (IV) antibiotics were given. She had a history of paroxysmal atrial fibrillation, but the ventricular rate was controlled. Her symptoms Improved on the antibiotics and her diet was advanced. She was discharged on oral antibiotics. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-150 for Acute Diverticulitis. Clinical indications for admission included hemodynamic instability, peritoneal signs, persistent gross bleeding, and a significant abnormality on imaging studies. This abnormality can be a fistula, obstruction, or free perforation. The patient did not have these conditions. She also did not require a drainage procedure, have bacteremia, severe vomiting, or inability to maintain oral hydration after observation care. 

This patient had acute diverticulitis and required antibiotics. She could have been given IV antibiotics with observation care and then been discharged on oral antibiotics. Her symptoms improved with treatment. She did not meet MCG criteria for admission for Acute Diverticulitis. 

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld    
Asked to review the case of a adult with no significant past medical history that presented to the hospital complaining of chest pain, palpitations and dyspnea. The patient reported using cocaine and drinking tequila on the day prior to admission. On arrival to the hospital vital signs were stable (Blood pressure [BP] 160/71, pulse 73 beats per minute [bpm]). Physical examination revealed no significant abnormalities. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm with right bundle branch block (RBBB) and nonspecific T wave abnormalities. Serum blood testing revealed no elevation of high sensitivity troponin 15 nanograms per liter (ng/L). Echocardiogram revealed a preserved left ventricular ejection fraction (EF) without wall motion abnormalities and an left ventricular ejection fraction (LVEF) of 55-60%. Computed tomography angiogram (CTA) demonstrated coronary artery disease (CAD) and a calcium score of 217. The patient was admitted to the hospital and scheduled for cardiac catheterization. Angiography demonstrated non obstructive coronary artery disease and the patient was discharged on medical therapy.   

The patient pretest probability of coronary artery disease is low. (Reference 1) Utilizing the HEART score (History, electrocardiogram, age, risk factor, and troponin) he was considered low risk. (Reference 2)  Utilizing the TIMI risk score (Thrombosis in Myocardial Infarction) the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  

Investigators studying more than 300,000 hospital admission for chest pain in the setting of cocaine, found that patients presenting with chest pain following cocaine and no other significant risk factors had a low risk of major adverse cardiac events and mortality. They concluded that most patients did not require hospital admission. (4). In conclusion, admission to the hospital to treat an acute cardiac event was 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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department with chest, back, and abdominal pain. The pertinent history included recent diagnoses of Helicobacter (H) pylori gastritis with treatment initiation. A urine pregnancy test was positive. An ultrasound revealed a yolk sac and cholelithiasis without evidence of cholecystitis. The patient was admitted to the hospital with an impression of atypical chest pain with plans to rule out acute coronary syndrome. An echocardiogram and stress test was pursued. The echocardiogram and stress test were essentially unremarkable. Cardiology consulted and ruled out acute coronary syndrome. General surgery consulted and did not recommend surgical intervention. The patient was discharged. At issue is the medical necessity of an inpatient stay.
Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
McConaghy et al. note the initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. The physician should consider patient characteristics and risk factors to help determine initial risk. Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions. For persons in whom the suspicion for ischemia is lower, other diagnoses to consider include chest wall pain/costochondritis (localized pain reproducible by palpation), gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth), and panic disorder/anxiety state. Other less common but important diagnostic considerations include pneumonia (fever, egophony, and dullness to percussion), heart failure, pulmonary embolism (consider using the Wells criteria), acute pericarditis, and acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities).[1]
The patient had a recent history of untreated H. pylori gastritis and presented with chest, back, and abdominal pain. Initial evaluation revealed a positive pregnancy test, cholelithiasis, and elevated HS troponins with subsequent readings leading to normalization. An electrocardiogram (EKG) was unremarkable. The admitting physician had an impression of atypical chest pain with plans to rule out acute coronary syndrome. No treatment was initiated for a myocardial infarction. An echocardiogram and cardiac stress test were pursued and were relatively unremarkable. Cardiology consulted and ruled out acute coronary syndrome. The following day after presentation, the patient was deemed medically stable and discharged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neonatal Jaundice.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is overturned.

The patient is a male infant. He is a former 38 6/7-week infant. He was born via spontaneous vaginal delivery. His bilirubin was 18.2 at 81 hours of life. Bilirubin the day before was 14.4. The rate of rise was 0.17 milligrams per deciliter in the prior 24 hours. A note states phototherapy threshold is 19.6.  The patient was admitted to the neonatal intensive care unit (NICU) for phototherapy. He had been breastfeeding every two to three hours during the day and every one to two hours at night. 
The patient's mother reports she is exclusively breastfeeding. The patient had four to six wet diapers and one dirty diaper in the prior 24 hours. The mother's blood type is A+. His birth weight was 3380 grams. The patient was admitted to pediatrics for phototherapy. His sodium was 146. Bilirubin on the next day was 10.3, 12 hours after phototherapy. Rebound bilirubin was 11 at 108 hours of life. The health plan denied coverage of the inpatient admission, noting, "We've re-reviewed the specific circumstances and health condition as documented in the appeal and clinical information you provided to us. The reviewer is a health plan Medical Director, a DO who is board-certified and specializes in Pediatrics. They recommend that we keep our previous coverage decision. Here's why: The request tells us your patient went to the hospital because of  
yellowish skin color in a newborn (neonatal jaundice). The plan clinical criteria consider a full hospital admission for this type of jaundice medically necessary when severe problems exist. 
These might include severe jaundice or the need to be given blood (exchange transfusion). The information we have does not show your patient having these or other severe problems. For this reason, the request for full admission is denied as not medically necessary but your General Nursery Care may be approved. It may help you to know that we reviewed this request using the MCG [Milliman Care Guidelines] guideline, Neonatal Jaundice (ORG: P-265)."
The denial is being appealed. 

The inpatient admission was medically necessary.

The MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care 26th Edition Neonatal Jaundice ORG: P-265(ISC) notes an inpatient stay is indicated due to serum bilirubin greater than 18 milligrams per deciliter at 72 hours of life with low-risk factors or more than 17 at 96 hours in medium risk infant. This infant has risk factors in that he is growth-restricted and exclusively breastfeeding. This infant meets the threshold for phototherapy per the criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
The patient presented with lower abdominal pain and fever. The patient had a low-grade fever but was hemodynamically stable. There was no abdominal rebound or guarding. There was no leukocytosis. A vaginal ultrasound was negative. A computed tomography (CT) scan suggested pyelonephritis. Intravenous (IV) antibiotics were given. The urine culture came back negative. The patient was discharged on oral Vantin. 

Clinical indications for admission for Urinary Tract Infection Milliman Care Guidelines (MCG M-300) include hemodynamic instability, altered mental status, worsening of clinical findings after observation care, ureteral or bladder outlet obstruction, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, bowel perforation or obstruction, bacteremia, or an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient required a workup for abdominal pain and fever. A urinary tract 
infection with pyelonephritis was suspected. This could have been treated with a course of antibiotics as an outpatient. No acute interventions were needed. The patient did not meet MCG criteria for admission for either Urinary Tract Infection or Undiagnosed Abdominal Pain. Inpatient admission was 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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient had a history of syphilis and a lung lobectomy. The patient presented with abdominal pain, vomiting and diarrhea. There was some minor rectal bleeding. The patient had a low-grade fever but was hemodynamically stable. The abdominal exam was benign. A computed tomography (CT) scan showed colitis and an indeterminate hepatic lesion. Blood and stool cultures were obtained. The patient was diagnosed with gastroenteritis and antibiotics were given. The patient's symptoms improved. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-170 for Gastroenteritis. Clinical indications for admission include having a suspected severe infection, peritoneal signs, hemodynamic instability, severe vomiting that is not responsive to antiemetics, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had a gastroenteritis. Intravenous (IV) hydration and stool testing could have been done in the emergency room (ER) with observation care. Afterwards, the patient could have been discharged on a course of oral antibiotics as an outpatient. The patient did not meet MCG criteria for admission for Gastroenteritis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was 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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient was admitted with complaints of asthma, shortness of breath (SOB), and cough. The patient has a past medical history (PMH) of asthma. Vital signs at presentation were: afebrile, pulse 119, respirations 18, blood pressure 144/72, and oxygen (O2) saturation of 96%. The patient had been discharged from the emergency department (ED) earlier. 

At this presentation the patient was noted to be wheezing. The patient was treated with intravenous (IV) steroids and Magnesium and placed on bilevel positive airway pressure (BIPAP). The patient improved with treatment in the ED. 

The patient was admitted to the hospital for asthma exacerbation. The patient was afebrile and hemodynamically stable. Wheezing was heard on exam of lungs. The patient was continued on steroids, bronchodilators (BD) and antibiotics. Electrolytes were normal. White blood cell (WBC) count was 16.2. Post treatment peak expiratory flow (PEF) was 350. The next day the patient continued to be afebrile and stable, on an oral steroid taper. The patient was stable to be discharged on oral (PO) medications with close follow-up in the outpatient setting. 

The patient did not need acute inpatient hospitalization. The patient could have been managed under the observation setting. Observation can be for up to 48 hours. During this period diagnostic testing and treatment could be done. 

The patient was stable to be discharged home after a period in 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 full hospital stay is not substantiated.