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

Diagnosis: Migraine

Treatment: methylergonovine (Methergine)

The insurer denied coverage for methylergonovine (Methergine). The denial reversed.

This patient is a female with chronic migraine and medication overuse headache. She takes many prophylactic and abortive medications including Topamax, aimovig, Botox, sumatriptan, and Methergine. Her neurologist prescribes Methergine up to .4mg TID PRN but notes that two medication holidays totaling 6 months are needed each year to reduce the risk of retroperitoneal fibrosis. The patient avoided for two mid-year months and was recommended to do so again from the time of the last office visit for several months in late 2019. It seems that when the patient went to fill her Methergine prescription it was denied even though she has been taking this medication at this dose for many years.

The insurer has denied coverage for methylergonovine (Methergine), as not medically necessary. Methergine has been used for many years as a treatment for migraine.  A dose of .2 - .4mg TID is a standard dose found in the peer reviewed literature. The patient is prescribed and has been taking a standard dose of this medication for many years with success.  With the six months per year drug holiday recommended by her neurologist, the maximum number of .2mg pills she should be allowed to take in a year is 1095.   While this would be considered off label use, there is support in the literature for this medication in this setting.   
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.   The health plan is not acting reasonably in limiting this patient to only 28 pills per year.  No rationale is given for this limit. This medication is prescribed by her neurologist and has been helpful in decreasing her headache frequency.  She has been taking it for many years.
  
Based on the above, the medical necessity for methylergonovine (Methergine) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a female with no past medical history who presents with umbilical abdominal pain x 1 day. She states the pain started gradually earlier in the afternoon prior to eating. Pain went away and then the patient ate White Castle and Beefaroni and the pain started again shortly after. Pain is constant since then moving slightly to the right lower quadrant (RLQ). Pain is worse when jumping on right foot, better when lying down on stomach. Patient had Motrin prior to arrival to the emergency department (ED). She had one episode on non-bloody non bilious emesis prior to coming to the ED and 1 while arriving to the ED. The patient denies recent travel, sick contacts, changes in urination, dysuria or hematuria.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient presented with 1 day history of abdominal pain and a few episodes of emesis. She was never described as experiencing PO intolerance. CT scan done in the ER ruled out appendicitis and was more suggestive of enteritis. There were no signs of significant dehydration on exam. Vital signs were stable. She had essentially normal labs and was nontoxic appearing with no fevers. There was not any mention of a failed PO trial in the Pediatric ER. The patient did not have any further emesis after admission to the hospital. Her findings suggested she would most likely stabilize and a determination concerning admission would be reasonably expected within 48 hrs. She was described as pain free and in no distress at the time of admission. Her mother signed her out AMA less than 24 hours after admission. The Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Near syncope
Treatment: Inpatient admission
The Inpatient admission was not medically necessary.

The patient is a male with multiple co-morbidities, including diabetes mellitus, blindness, hypertension, past history of cerebrovascular accident, and seizures. He presented to the emergency room after an acute episode of loss of consciousness for approximately 10 minutes. The patient had prior history of a syncopal episode, and at that time, he was found to have seizure activity on EEG and was prescribed anti-epileptic medication.  

In the emergency room, there were no focal neurological findings, and imaging did not reveal any new pathology. Lab work showed abnormal lactic acid, glucose, sodium, and magnesium levels. The patient's Keppra dosage was increased, and he was admitted for observation. Differential diagnoses included syncope versus new change in seizure activity. Clinical workup was negative, and he remained hemodynamically stable.   

As of the following day, the patient had no further events, was feeling better, and wanted to go home. It was noted the patient had an extensive workup for syncope, which was negative. The patient was discharged two days after arriving, at which time it was noted he remained seizure-free. He was to continue his Keppra and undergo a tilt table test as an outpatient as well as neurological follow-up.  

The patient's evaluation was completed by the second day. The patient was clinically and neurologically stable, was normal vital signs and normal neurological status. Therefore, the patient's neurological needs could have been addressed at a lower level of care, such as observation status and continued as an outpatient. Acute inpatient admission for the timeframe indicated was not medically necessary.

The patient was neurologically stable, and therefore acute care admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital

The patient is a male who presented to the emergency department (ED) with palpitations and chest pain. His palpitations started one and a half our prior to presentation. His chest pain lasted for more than one hour and was associated with chest discomfort and generalized weakness. He mentioned that his heart was jumping out of his neck and he had burning in the center of his chest. The patient had previous similar episodes and they were self resolving. The patient did not have significant co-morbidities.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient spontaneously converted to sinus rhythm in less than 24 hours after presentation. The rest of his hospital stay was unremarkable. Evaluation by electrophysiologist and ablation could have been accomplish on outpatient basis. The episode of tachycardia caused myocardial damage which was reflected by elevated troponin. However, the patient remained stable. There were no wall motion abnormalities on his echo. There were no end organ damage. The troponin elevation was real, but very mild. Based on above, this admission did not meet inpatient admission criteria. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Blood clot
Treatment:  Inpatient hospital stay

The patient is a generally healthy female who was taking oral contraceptives for several months who presented to the hospital with complaints of back pain, which was aggravated by laying down.  Prior to the admission she went to an urgent care clinic and was diagnosed with muscle spasm.  The patient's primary care doctor raised a concern that the patient could have a pulmonary embolism.  She had her D- dimer checked.  This study came back positive, and the patient subsequently underwent computed tomography (CT) angiogram of the chest that demonstrated bilateral lower extremity pulmonary embolism, left lower lobe wedge infarct.  In addition to that, the patient was found to have a pancreatic cyst in the tail.  The patient was admitted to hospitalist service and received treatment with unfractionated heparin infusion.  She underwent endoscopic ultrasound with a fine-needle aspiration of the pancreatic cyst.  It was reported that a clear fluid was aspirated and sent for pathology.  The health plan's determination is upheld in whole.  The inpatient stay was not medically necessary for this patient at the inpatient level of care based on the mild severity of the pulmonary embolism defined by pulmonary embolism severity index (PESI) score.  According to the Pulmonary Embolism Severity Index (PESI), a risk stratification tool that predicts a 30-day outcome in patients with pulmonary embolism using 11 clinical criteria, the patient received 0 points.  Therefore, the patient had an overall low risk of mortality or severe morbidity.  However, considering the presence of a pancreatic cyst in the setting of newly diagnosed pulmonary embolism, the decision to perform fine-needle aspiration of the pancreatic cyst was definitely appropriate before the patient was started on long-term anticoagulation.  Considering the circumstances of this particular patient, it was appropriate to admit this patient at a lower level of care, and during this period to perform endoscopic ultrasound with fine-needle aspiration, as well as to transition the patient to long-term anticoagulation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gallbladder polyp

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was upheld.

This patient is a female with no previous medical history who presented to the Emergency Room (ER) with fever, dizziness, weakness, frequency in urination and a few episodes of vomiting.  Her temperature was 101.3, heart rate 114, respiratory rate 20, blood pressure 145/73, blood glucose 431, BUN 31, creatinine 0.7, 137, K 98, Urine Glucose>1000, pH 7.4, lactic acid 3.4, and elevated A1c 8.3.  She was treated with intravenous fluids, insulin coverage, and intravenous antibiotics.  She had x-ray that showed mild congestion.  Ultrasound of the abdomen revealed small gallbladder polyp, no cholecystitis, blood cultures were negative.  The patient remained in the hospital until and was discharged on Metformin and Omega 3. The insurer has denied coverage for the inpatient hospital admission as not medically necessary.

In reviewing this case and calculating the plasma osmolarity that is 319, is not justifying diagnosis of HHS (Hyperglycemic Hyperosmolar State) in which plasma osmolarity should be >320.  The patient also has no diabetic ketoacidosis (DKA), Anion Gap =11, pH 7.4 after hydration, BUN came down to 22 and blood cultures were negative.(1,2) The high BUN/creatinine ratio, and elevated lactic acid level suggest dehydration.   For that and evaluation of new onset fever ER level of care with fluids and insulin treatment is sufficient.(3)

In view of the above care in the ER is justified for dehydration and lactic acidosis, but hospital admission is not justified. The health plan acted reasonably with sound medical judgment in the best interest of the patient. The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient substance abuse treatment 
The Inpatient substance abuse treatment was not medically necessary for this patient.

The patient in this case was using heroin on a continuous daily basis. The patient presented as cooperative and motivated to receive detoxification treatment in the absence of severe symptoms of opioid withdrawal and in the context of two recent detoxification treatments within the last eight days prior to admission. Mental status examination was free of severe symptoms, and the patient was noted to deny suicidal ideation at the time of admission. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have required inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical presentation was not serious enough to warrant inpatient level treatment or 24-hour monitoring. Moreover, the patient did not present with severe psychosocial stressors that would have posed a problem if detoxification treatment was provided in a less restrictive treatment setting at a lower level of care.  Thus, the detoxification treatment (and referral for rehabilitation services) could have been effectively provided at a lower level of care, as the health plan asserts. 

Medical necessity is not met in this case for the time interval under review, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, as well as the appropriate application of NY State OASAS LOCADTR Criteria/Guidelines.

The Substance use disorder inpatient admission with detoxification services and withdrawal management could have been safely and effectively provided at a lower level of care in this case scenario. Thus, the requested service of Substance use disorder inpatient admission for detoxification and other medical services is not reasonable in this case scenario. The patient's presentation and clinical features of opioid use disorder did not warrant the intensity of inpatient level services or inpatient level structure or monitoring in keeping with New York State Level of Care for Alcohol and Drug Treatment Referral Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Endocrine/Metabolic/Nutritional
Treatment:  Pharmacy/Prescription Drugs

The patient is a female diagnosed with diabetes mellitus (DM).  This request is for Trulicity.  As reported, she was hospitalized for 3 days requiring intravenous (IV) insulin for diabetic ketoacidosis (DKA).  She was having polyuria, polydipsia, and she was noted to have elevated blood glucose (BG) levels of 400-500.  Her A1C was 5.4 % while on Basaglar.  Her C-peptide level was 1.62.  She likely has ketosis prone DM with positive AB.  She stopped insulin in the beginning of this year.  She had a positive glutamic acid decarboxylase (GAD) antibody.  The patient managed to stop insulin due to hypoglycemia without developing diabetic ketoacidosis off insulin.  She is being treated as a type II diabetic.

The subject under review is the medical necessity for Trulicity.

The health plan's determination is overturned, in whole. 

Yes, the requested treatment with Trulicity is medically necessary for this patient.  Trulicity is a GLP1 agonist that is used in the treatment of type 2 diabetes.  It has been shown to be an effective once weekly treatment for diabetes (1,2,3).  Trulicity is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.  It is a glucagon-like peptide 1 (GLP-1) receptor agonist.

The patient does not have type I diabetes, as she has been off insulin without developing diabetic ketoacidosis and has a normal C-peptide 6 months after diagnosis. The patient has type II diabetes (2-5).

The requested medication meets the Food and Drug Administration (FDA) label and is consistent with generally accepted standards of medical practice.  The policy criteria requiring a trial with metformin are not consistent with the American Association of clinical endocrinologists recommendations, which recommend GLP-1 receptor agonists such as Trulicity as initial therapy.

The patient should not be required to try a medication in a different class such as metformin.  Therefore, the requested medication is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endocrine Disorder 
Treatment: Pharmacy/Pescription Drug 

The patient has a diagnosis of testicular hypofunction. He is requesting coverage for Testim brand-name 1% transdermal testosterone gel. It is noted that Axiron brand caused a rash under his arm and Androderm patch caused a rash where the patches were placed. At issue is whether the formulary drug (testosterone gel [generic Androgel 1.62%], testosterone solution, Androderm) will be or has been ineffective, would not be as effective as the non-formulary drug, (Testosterone Gel) or would have adverse effects. The health plan's determination is upheld. 

No, the formulary drug, generic testosterone gel, 1.62% would not be less effective than the non-formulary drug, and would not have adverse effects. There is some confusion in terminology. Androderm transdermal patch is a product manufactured by Allergan Sales. It is a different product than all of the transdermal gels manufactured by multiple other pharmaceutical firms. Allergan Sales does not have any other listed testosterone products. It is common for patients to develop a sensitivity to the patch adhesive. It is very unlikely that the patient would have trouble tolerating one of the several generic brands of testosterone gel.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Pharmacy/Prescription Drugs

This is a male with history of osteoporosis (OP). Per records provided, dual-energy x-ray absorptiometry (DXA) showed L1-L4 with Z score of -3.4. The patient had multiple compression fractures of L1, L2, L4, L5 which were sustained after coughing fit. There is no previous use of bisphosphonate or other osteoporosis (OP) therapy. Review of clinical records also show the patient also had left hand and wrist fractures, and multiple fractures in a motor vehicle accident three years ago. Review of labs show ionized calcium of 5.2 and serum calcium of 10.5, phosphorous 2.9, parathyroid hormone (PTH) 30-40s, and bone specific alkaline phosphatase of 6.9 (range 7.7-21.3), testosterone 527. There is no family history of osteoporosis.
The subject under review is the medical necessity for the requested Forteo.

The health plan's determination is overturned.

Forteo is medically necessary.
This patient falls into a category of very high risk of fracture. He has severe osteoporosis defined by the World Health Organization (WHO) as bone density less than (<) T-2.5 (in his case Z score) with osteoporotic fractures (Czerwinski et al. 2007). Additionally, his Z score is very low at the spine (-3.4), which further increases his risk for fracture because bone mineral density (BMD) decreasing by 1 standard deviation increases fracture risk 1.7-2.6 times (Marshal et al. 1999).
Quality head to head trials between anabolic agents, denosumab and bisphosphonates are lacking, however a recent metanalysis by Barrionuevo et al. 2019 (and as discussed in the 2019 Endocrine Society osteoporosis guidelines) suggest teriparatide, abaloparatide, denosumab, and romosozumab have the highest efficacy in reducing fracture risk reduction, whereas ibandronate and selective estrogen receptor modulators had among the lowest efficacy rates.
Both Forteo (teraparatide) and Tymlos (abaloparatide) are both anabolic agents that increase bone density at the spine and hip and reduces risk of vertebral and nonvertebral fractures - in the head to head randomized ACTIVE trial (Miller et al. 2016), over 18 months abaloparatide increased BMD more than teraparatide at the total hip (4.18% versus 2.29%) and femoral neck (3.6% versus 1.54%) and they both increased BMD similarly at the lumbar spine (about 8%), and they both showed similar reduction in vertebral and non-vertebral fractures.
Prioritization of plan preferred medications over anabolics is not recommended in this patient with severe osteoporosis and previous fragility fracture - because initial treatment with antiresorptive therapy decreases the incremental fracture reduction and/or bone density improvements if followed by anabolic therapy - this is seen with both bisphosphonate to teraparatide switch (Cosman et al. 2014), as well as denosumab to teraparatide switch (Leder et al. 2015).
Thus, Forteo would be more effective than plan preferred alternative drugs and is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Genitourinary/kidney disorder
Pharmacy/Prescription Drugs

This is a female with anemia and chronic kidney disease. The patient is stated to have a hemoglobin of 9.9 g/dL. Her most recent nutritional assessment (1/17/20) revealed a ferritin of 261 ng/mL, and iron saturation of 25%. The use of Procrit is under review.

The health plan's determination is overturned. Procrit is medically necessary for this patient. Anemia is common among non-dialysis chronic kidney disease (CKD) patients and Procrit is approved for use in patients with a hemoglobin < 10 g/dL who are iron replete (serum ferritin greater than or equal to 100 mcg/L and serum transferrin saturation greater than or equal to 20%). This patient meets these criteria which are detailed in the package insert, peer-reviewed literature, and by the authors of UpToDate. For these reasons, the use of Procrit in this clinical scenario is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, gait ataxia
Treatment: Increase In personal care services, 24 Hours a Day, 7 Days a week (Live in)

The proposed treatment of an increase in personal care services, to 24 Hours a Day, 7 Days  A week (Live in) is not considered medically necessary. 

The patient is a female with a history of dementia and gait ataxia. For these reasons, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of an increase in personal care services, 24 Hours A Day, 7 Days a week (Live in) to offer increased assistance with completion of the patient's ADLs.

This is a female with a history of dementia and gait ataxia. For these reasons, she requires assistance for completion of the majority of her activities of daily living (ADLs). However, a recent in home assessment of the patient's functionality and ADL needs was completed. During this assessment, the RN noted that the patient previously lived alone on the second floor of a two family house with her daughter residing on the first floor. In the home, the patient has numerous durable medical equipment items including shower chair, grab bars and a commode. In addition, she has a rolling walker. For these reasons, the currently approved plan of Personal Care Services 8 hours/day, 6 days a week and 4 hours a day, 1 day/week for a total of 52 hours/week is deemed sufficient to meet the patient's current needs. There is no documentation indicating that the patient has sustained additional functional decline since the date of this assessment. For these reasons, the proposed treatment of an increase in personal care services, to 24 Hours A Day, 7 Days a week (Live in) is not considered medically necessary.