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

Diagnosis: Anxiety/depression
Treatment: Viibryd (vilazodone) 
The insurer denied Viibryd (vilazodone). The health plan's determination is upheld. 

This is a case review for a female being prescribed Viibryd (vilazodone) for the diagnosis of insomnia due to other mental disorder modified; anxiety disorder, generalized; schizoaffective disorder, depressive type.

A formulary exception in this case is not indicated. The documentation provided does not demonstrate whether or not the patient has had a trial (with documented ineffectiveness or intolerance) to any of the formulary medications.
The requested non-formulary medication is an option for treatment resistant depression, but it is not considered by most experts to be preferred first line option. According to Craske et al, "Clinical trials have found vilazodone, a selective serotonin reuptake inhibitor (SSRI) and a 5-HT1A (serotonin 1A receptor) receptor partial agonist, to be as efficacious as other SRI (Serotonin Reuptake Inhibitor) in GAD (generalized anxiety disorder); in our clinical experience vilazodone has no unique advantages compared with other SSRIs. Vortioxetine has shown mixed results compared with placebo in clinical trials for GAD."
The available medications on the patient's formulary are in the SSRI (selective serotonin reuptake inhibitor) class and would be considered typical first line treatment options. There is no documentation provided regarding why the requested medication is indicated for the patient and why she cannot use a typical first line treatment. There is insufficient data in clinical trials to demonstrate superior efficacy of vilazodone over other SSRI medications.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus. 
Treatment: Semglee 100U/mL (milliliters) Injection. 

The health plan denied coverage for the member's requested Semglee 100U/mL Injection, as a formulary exception had not been established. 

The reviewer upholds the health plan determination, as medical necessity has not been established for a formulary exception. 

This is a female diagnosed with T2DM (type 2 diabetes mellitus). This request is for Semglee 100U/mL (milliliters) Injection. The provider states she is getting chemotherapy for pancreatic cancer and the Oncologist doesn't want any change on medication and also wants her to continue on Semglee. 

On a date last year, her glucose was 223; Hemoglobin (HGB) A1C was 8.7 % (percent) while on Lantus. 

The health plan's determination is upheld. 

There are no studies demonstrating superiority of the requested medication over the formulary alternative. The formulary alternatives have not been ineffective. The patient has not tried the formulary alternatives. The patient can try the formulary alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer, bipolar disorder, PTSD (post-traumatic stress 
disorder), and hip replacement
Treatment: Consumer Directed Personal Assistance Service
The insurer denied: Consumer Directed Personal Assistance Service
The denial is upheld.

The patient is an adult female. Denial of consumer directed personal assistance service is being appealed. She has a history of cancer treatment, bipolar disorder, PTSD (post-traumatic stress disorder), and hip replacement. Uniform Assessment System evaluation performed two months ago shows independent cognition and functional status: maximal assistance with shopping; extensive assistance with meal preparation and transportation; and independent with managing finances and medications, bathing, personal hygiene, dressing, locomotion, walking, toileting, bed mobility and eating. The patient's son picks up and delivers her meals and assists with mopping and cleaning. She is continent of bowel and bladder. A letter from the patient's provider notes that the patient is undergoing cancer treatment and needs help with the bathroom, cooking, light chores, and ambulation. Her legs are weakening.

The requested Consumer Directed Personal Assistance Service is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of consumer directed personal assistance service is being appealed. The health plan denied coverage of the services, because the patient is able to perform ADLs (activities of daily living) on her own. Uniform Assessment System evaluation performed two months ago shows the patient can perform independently, except with shopping, meal preparation and transportation. She orders food, and her son delivers it for her. She does not have incontinence. The appeal letter notes that the patient has weak legs and needs assistance with the bathroom, cooking, light chores, and ambulation. The information provided does not support that the patient has functional needs requiring consumer directed personal assistance services. The requested consumer directed personal assistance services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain/alcohol withdrawal.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This case involves a man with polysubstance abuse history of deep vein thrombosis (DVT) and physical exam (PE), who presented to the emergency department (ED) with chest pain and shortness of breath. He was seen the late evening and reported smoking cocaine the previous day and continuing to drink about 3 L (liters) of vodka per day. He had previous hospital admissions for similar complaints.

On arrival, the patient's vital signs included a normal temperature, pulse rate of 89, and blood pressure of 176/101. He appeared disheveled on the exam, with fairly normal cardiac and pulmonary exams. The psychiatric exam showed normal mood and behavior. He was oriented x3 on the neurologic exam.

Based on the provided documentation, the inpatient hospital admission was not medically necessary. The documentation, from the date the patient left states he is alert and oriented, able to make health decisions, and therefore was allowed to leave. Patients with severe alcohol withdrawal typically have altered sensorium and abnormal vital signs. In reviewing his history, the patient does have a history of withdrawal symptoms related to discontinuation of alcohol; however, there is no documentation of prior seizure disorder or delirium tremens. He has a mild decrease in his ejection fraction to 45% (percent), by no means severe cardiomyopathy. The only CIWA (Clinical Institute Withdrawal Assessment for Alcohol) score documented in the hospital was 9 prior to the administration of benzodiazepines. The documentation states there are no hallucinations, visual or auditory.

Based on the limited information, before leaving AMA (against medical advice), the severity of alcohol withdrawal seemed to be mild. Therefore, based on the available information, a lower level of care is appropriate for this presentation.
Appeal type: Medical necessity
Decision: Upheld

Respiratory
Pharmacy/prescription drugs

Diagnosis: hereditary angioedema (HAE) 
Treatment: Firazyr
The insurer denied Firazyr
The health plan's determination is upheld. 

This is a male patient who has a diagnosis of hereditary angioedema (HAE) with normal C1 inhibitor (C1-esterase inhibitor). Firazyr has been requested and is under review.

Firazyr is not medically necessary for this patient.
The patient has a history of swelling of his tongue and throat. He did not respond to epinephrine. There is no clear documentation of family history of HAE. The patient does not have a low C4 (complement component 4) level or low C1 inhibitor level or function. There is insufficient documentation to support a diagnosis of HAE with normal C1.
Per Busse et al. 2020, HAE with normal C1 requires at least 1 of the following: (1) Demonstration of a mutation associated with the disease; OR (2) A positive family history of recurrent angioedema and documented lack of efficacy of high-dose antihistamine therapy (ie, cetirizine at 40 mg/d (milligrams /day)or the equivalent) for at least 1 mo or an interval expected to be associated with 3 or more attacks of angioedema, whichever is longer. The patient does not meet these conditions. Furthermore, the patient has not trialed and failed Ruconest. There is no high-quality study demonstrating that the requested medication is more effective and safer than Ruconest.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.


This is a female patient who presented to the emergency room for evaluation of dizziness, nausea, vomiting, and abdominal cramping. The patient was hypertensive on presentation. An initial computed tomography (CT) scan of the head was unremarkable. The patient was subsequently referred for magnetic resonance imaging (MRI) of the brain which showed an acute lacunar infarct in the cerebellum. The patient had persistent symptoms of vertigo despite initial treatment with meclizine, benzodiazepines, and anti-emetics. The patient was subsequently admitted to the hospital for further care. The patient was evaluated by stroke neurology who recommended treatment with dual antiplatelet therapy. The stroke was considered cryptogenic as the patient did not have significant risk factors. Placement of a loop recorder was recommended. The patient later developed chest pain but an ischemic evaluation was negative. However, subsequent electrocardiogram (EKG)/telemetry showed that the patient had Wolf Parkinson White phenomenon. The patient required consultation with cardiology. Cardiology agreed with the placement of a loop recorder to look for any cryptogenic arrhythmia. Cardiology also recommended an ischemic evaluation with a nuclear stress test as an outpatient. At issue is the medical necessity of an inpatient level of care.

Acute inpatient admission is medically necessary for care of this patient. The patient presented to the hospital with signs and symptoms of a posterior circulation stroke. The patient had nausea, vomiting, and dizziness. The patient underwent evaluation for a stroke including a CT scan of the head and an MRI of the brain. The MRI of the brain confirmed a stroke. The patient had persistent symptoms. The symptoms were disabling because the patient required ongoing care including meclizine, benzodiazepines, and anti-emetics for treatment of the nausea and vomiting due to the cerebellar symptoms. While the patient had a low National Institute of Health (NIH) stroke scale, this does not change the intensity of the services provided as all acute strokes require work up and evaluation for a cause. During the hospitalization, the patient's course was complicated by chest pain and the discovery of an arrhythmia. The patient required consultation with multiple specialists including a neurologist and cardiologist. A loop recorder was recommended and subsequent ischemic work-up was recommended. The services provided were for greater than 48 hours. This is longer than the standard observation time frame. The hospital provided an intensity of service that is consistent with the inpatient/acute level of care. While transient ischemic attack (TIA) may be appropriate for a lower level of care, an acute ischemic stroke always demands an inpatient evaluation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ear pain/jaw pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a woman with a history of hypertension. She presented to the emergency room with a 7-day history of left sided facial pain, dysphagia, jaw pain, and ear pain. Five days prior to presenting, she was prescribed oral antibiotics but there was no improvement. The vital signs were normal. She was in no acute distress. Physical exam revealed left mandibular tenderness, poor dentition, and a tender left lower jaw tooth with some gum erythema. Labs were non-contributory. There were no acute intracranial changes on head computed tomography (CT) scan, and the facial bone CT scan was unremarkable. 

The inpatient admission was not medically necessary for this patient.
Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, persistent hypoxia, stridor, or severe metabolic disarray. The services provided -intravenous antibiotics, corticosteroids, oral medications - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with history of diabetes mellitus, hypertension, and severe peripheral artery diseases status/post (s/p) multiple interventions who was sent from the vascular surgery clinic for concerns of bilateral upper extremity weakness and paresthesia of several week duration. Initial vital signs found the patient to be afebrile and hemodynamically stable. Initial examination documented the patient as alert oriented, and unable to elevated upper extremities over head or elevate lower extremities. Initial laboratory testing relatively unremarkable. Recent imaging included a computed tomography (CT) head which noted no evidence of acute infarct or hemorrhage, but did note likely chronic infarctions involving the right gangliocapsular region and right genu of the corpus callosum. Magnetic resonance (MR) brain revealed recent small infarcts within the left occipital lobe. MR cervical spine revealed severe central canal narrowing. Carotid ultrasound revealed carotid stenosis. The admitting physician documented an assessment of bilateral upper extremity and lower extremity weakness. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient had a history of peripheral arterial disease and was directed to the hospital for concerns of bilateral upper and lower extremity weakness for about a two month duration. A comprehensive evaluation was performed which revealed severe cervical canal stenosis, recent small infarcts within the left occipital lobe, and moderate carotid artery stenosis. The mitral regurgitation (MR) imaging was actually performed two days prior to presentation. Following hospitalization, the patient's neurologic deficits remained stable. Neurosurgery consulted, had an impression of presenting symptoms related to cervical stenosis, and cleared the patient for outpatient management. Vascular surgery did not recommend surgical intervention on the carotid artery. The hospital course primarily consisted of diagnostic testing. No acute intervention was performed either medically or surgically. Moreover, clinical indications for admission to inpatient care were not met. The patient did not have a neurologic finding requiring inpatient care, altered mental status, dysphagia, evidence of hemorrhagic transformation, finding on brain imaging that requires inpatient, or unclear clinical stability.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID-19 (coronavirus disease 2019)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who was admitted for worsening of shortness of breath. She tested positive for COVID-19 and was started on an anti-viral. A computed tomography was negative for pulmonary embolism. She was found to have abnormal creatinine and was started on intravenous fluid and her kidney function improved. The patient was discharged in stable condition on day #3.

The requested health service was not medically necessary.

The patient was hemodynamically stable, with normal oxygenation and negative cultures and did not have significant electrolytes disturbance or irreversible change in kidney function. She did not have cardiac arrhythmias, altered mental status, or persistent nausea and vomiting with dehydration. There was no documentation of refractory pain, and the patient was able to tolerate oral diet and did not require total parenteral nutrition and her condition improved in 48 hours. When taking into account the patient's exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, she had no requirements for inpatient level of care. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Tooth decay
Treatment: Crown (D2740) on Tooth Numbers 3, 4 and 5; Build Up (D2950) on Tooth Number 4; and Root Canal (D3320) on Tooth Number 4
The insurer denied: Crown (D2740) on Tooth Numbers 3, 4 and 5; Build Up (D2950) on Tooth Number 4; and Root Canal (D3320) on Tooth Number 4
The denial is partially overturned.

The patient is an adult male requesting crowns on teeth numbers 3, 4 and 5. He is also requesting root canal treatment and core build up on tooth number 4. The prior denial was due to the teeth being considered "periodontally compromised" due to bone loss.

The crown, build up and root canal for tooth number 4 were medically necessary; however, the crowns for teeth number 3 and number 5 were not medically necessary.

Tooth number 4 has severe decay into the pulp requiring the root canal treatment, build up and crown. It only has one "4mm (millimetre)" probing depth, which is on the palatal side (out of 6 total areas 
probed). Tooth number 4 is not periodontally compromised according to the probing depths and the bone levels present on the x-rays provided. However, crowns are not needed for teeth number 3 and number 5 according to the x-rays provided. Tooth number 3 has a conservative carious lesion on the mesial side and tooth number 5 has a conservative lesion on the distal side. According to the x-rays, crowns would be overtreatment. Photos presented did not show the "severe decay" reported. Based upon the photos and x-rays, there was no need to restore teeth 3 and 5 with crowns.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
The patient has a history of asthma and presented to the Emergency Department (ED) with complaints of shortness of breath and wheezing.  The patient stated that they had run out of their medications.  Vital signs on arrival to the ED were as follows: Temperature 97.8 degrees Fahrenheit (F), pulse 106, respiratory rate 20, blood pressure 99/78.  The patient's oxygen saturation was 100% (percent) on 8 liters of oxygen.  The patient was noted to have bilateral wheezing.  The patient was awake and alert.  

In the ED, the patient received intravenous (IV) steroids, bronchodilators via nebulizer, Magnesium, Ceftriaxone, and Doxycycline.  The patient was admitted to the hospital for asthma exacerbation. The patient was placed on bilevel positive airway pressure (BiPAP), transiently, improved, and was placed back on low flow oxygen.  The patient's condition improved after treatment in the ED.  

The patient's labs were notable for a white blood cell (WBC) of 22.5, although patient had previously been on steroids.  The chest X-ray (CXR) showed no acute infiltrates.  The patient's electrocardiogram (EKG) showed normal sinus rhythm.  Per the history and physical, the patient was in no acute distress and was not using any accessory muscles of respiration. The lung exam revealed bilateral wheezing.  Cardiovascular exam revealed heart sounds in S1 and S2 with no murmur noted.  The patient was alert and oriented x (times) 3.  

The patient was placed on tapering steroids, Montelukast, and continued on bronchodilators.  The second day, the patient was feeling better.  Vital signs were temperature 98.4 degrees F, pulse 94, blood pressure 145/85, respirations 20, and oxygen saturations 96% on room air. The wheezing had decreased. The patient's steroids were further decreased and plan was to start inhaled corticosteroids.  The patient's antibiotics were changed to oral Azithromycin.  The patient remained stable and was discharged home the next day on oral medications.    

This patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated, for up to 48 hrs.  The patient had improved after treatment in the ED.  The patient remained stable after admission. There was no pneumonia or pneumothorax on chest X-ray.  The patient's WBC was elevated secondary to her use of oral steroids.  The patient was afebrile with no signs of acute infection.  The patient was able to tolerate oral intake. This patient was stable to have switched to oral meds and inhalers after a period in observation and could have been discharged home with close follow-up in the outpatient setting.

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: Overturned

Diagnosis: Respiratory syncytial virus (RSV) bronchiolitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is a toddler male. At seven months of age, the patient was with known fever, increased work of breathing and increased heart rate with decreased urine output. On exam, the patient was noted to have coarse breath sounds, a respiratory rate of 50 and elevated heart rate. The patient required high flow oxygen and continued to require intravenous fluids due to his increased respiratory rate. The patient was weaned to room air and oral feeds as tolerated and was discharged when he demonstrated a safe respiratory rate, good oral intake (PO) and no fever.

The proposed inpatient hospital admission was medically necessary.

As the infant was noted to be tachypneic with coarse breath sounds on exam, this resulted in oral feeding being medically inappropriate due to the risk of aspiration. The patient was febrile and required oxygen support. As the patient was unable to maintain an appropriate respiratory rate, he was at risk for respiratory fatigue and failure. Along with inability to feed, the patient was at risk for dehydration and further decompensation. Noting the multiple presentations that showed increased respiratory effort, which had been continuing for over two days, and with decreased feeds and urine output with a need for oxygen, the admission was medically necessary as the patient was at risk for respiratory failure.