Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned



Diagnosis: Bipolar Disorder.
Treatment: Transcranial Magnetic Stimulation.
The health plan denied: Transcranial Magnetic Stimulation.
The health plan's determination is overturned.

The patient is an adult female with a history of a mood disorder best characterized as bipolar II disorder with the most recent episode, major depressive disorder, severe and recurrent. The patient has a documented history of multiple medication treatments including treatment with Prozac, Lexapro, Wellbutrin, and Effexor extended-release (XR) prescribed over the past several years without sustained benefit or remission. She has received augmentation with Seroquel, risperidone, Abilify, Rexulti, Latuda, and Lithium, and supplemental treatment with buspirone targeting anxiety, as well as five rounds of electroconvulsive therapy (ECT) and augmentation with Spravato. Due to adverse effects, or lack of efficacy or sustained benefit, the patient has continued to experience severe symptoms of depression and functional impairments scoring as much as 19 on the Patient Health Questionnaire - 9 (PHQ-9) in the severe range of depression and 15 on the General Anxiety Disorder 7 (GAD 7) reflecting severe symptoms of anxiety. 

TMS is likely to be more beneficial than any standard treatment or treatment for the insured's life-threatening or disabling condition or disease. TMS therapy as a primary or adjunctive therapy for the treatment of depression has generally been evaluated in patients who have treatment-refractory depression, as defined by one or more, antidepressant medication treatment failures with or without augmentation. TMS therapy for unipolar or bipolar depression has been established as a safe treatment; and, 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 cognitive behavioral therapy, have failed to produce a response or remission, then TMS is an appropriate consideration. 

At least four or more alternative therapeutic medication trials with augmentation together with other therapeutic measures have been provided, as clinically appropriate. The patient has received treatment with antidepressants with a disparate mechanism of action together with mood stabilizers, as well as appropriate augmentation agents. The treatment is to be administered by a psychiatrist with experience in the use of TMS therapy. Thus, in this case, the TMS therapy is considered clinically appropriate and more likely to be beneficial than any additional standard treatments. The proposed repetitive transcranial magnetic stimulation (rTMS) therapy is reasonable and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Chronic Migraines.
Treatment:  Cambia (diclofenac packet).

The insurer denied coverage for Cambia (diclofenac packet).  The denial is upheld.

This case pertains to a patient and a request for a non-formulary medication, Cambia.

The patient presented for follow-up. The patient is diagnosed with chronic migraine disorder. The patient has tried and failed Ubrelvy, Emgality, Imitrex, and Maxalt. The patient is currently using Nurtec 75 milligrams (mg). The patient preferred Cambia, but it was no longer covered by insurance. The patient also takes Qulipta 60mg. The patient reports significant improvement in their migraines with the use of Qulipta and less need for abortive agents. The patient's medication list includes Nurtec, Qulipta, Diclofenac Sodium, Cimetidine, Loperamide, Vitamin D2, Amlodipine, Breztri Aero Sphere, Alprazolam, Potassium Chloride, Albuterol Sulfate, Ondansetron, Hydrocodone/Acetaminophen, and Rosuvastatin. 

The insurer sent a denial of coverage letter to the patient. They noted that the requirements had not been met. The coverage of Cambia is approved when a patient has tried and had an inadequate response or intolerance to the required number of formulary alternatives. Alternatives are Diclofenac Sodium, Diflunisal, Etodolac, Ibuprofen, Meloxicam, Nabumetone, Naproxen (except Naproxen controlled release (CR) or Naproxen Suspension), Naproxen Sodium, Oxaprozin, Sulindac. The plan requirement is a trial and failure of all the formulary alternatives, but not more than three. 

The review of plan, clinical, and literature found the patient has control of their migraines and that Cambia is a patient preference. The plan has formulary medications that are required to be utilized. The approval of Cambia requires that the formulary medications are ineffective or intolerable. It is also noted that on the visit the patient did indicate that they preferred Cambia but that it was no longer covered. Also, Nurtec was being used. On the most recent clinical note, the medication list now shows Diclofenac sodium delayed release oral tab as prescribed. However, the note provided no information regarding its efficacy. It should also be noted that the patient was on at least 8 different drugs, which could affect their migraines. This makes any determination of additional efficacy of Cambria versus the formulary listed diclofenac difficult to determine.

The formulary drugs are not likely to cause the patient an adverse reaction. The patient currently takes a formulary medication Diclofenac Sodium 50mg. 

The formulary drug(s) have not been ineffective based on the clinical history. The patient takes Diclofenac Sodium 50 mg. There is no documentation of ineffectiveness of any other NSAIDs.

The requested drug would not be more effective than the formulary drug. Cambia (diclofenac powder) does have a 15-minute response time when compared to the pill version; however, it has not been proven to be more effective than other NSAIDs. 

The carrier's denial of a request for a Formulary Exception for Cambia (diclofenac packet) to treat chronic migraines is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Longstanding diarrhea, cramping, and urgency
Treatment: Sucraid 8500/ML (milliliter) Solution
The insurer denied: Sucraid 8500/ML (milliliter) Solution
The denial is upheld.

The patient is an elderly female with longstanding diarrhea, cramping, and urgency. Colonoscopy and upper gastrointestinal (GI) endoscopy were done, but small bowel biopsies with disaccharidase enzyme testing was not performed. Sucrose breath test was low. The doctor is requesting treatment with Sucraid.

The requested Sucraid is not medically necessary.

The standard of care for the diagnosis of sucrease-isomaltase deficiency is either genetic testing or small bowel biopsy with disaccharidease testing. Sucrose breath test is non-specific for the diagnosis. Therefore, as the patient does not have a documented contraindication to small bowel biopsy for disaccharidase testing, the requested Sucraid is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain, back pain and headache with pregnancy.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

This is an adult female, who presented to Labor and Delivery department (L&D) with complaints of abdominal and back pain and headache. Blood pressure was 152/105 on presentation. Upon observation, in the triage area, the blood pressure normalized to 137/82. The patient was 36.1 weeks gestation. Laboratory evaluation was normal. Fetal heart rate was reactive.

The patient was admitted for observation. She remained stable with normal blood pressure. Induction of labor was started 2 days after admission and the patient vaginally delivered a newborn weighing 2994 grams with Apgar 9/9.

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 mm Hg [millimeters of mercury] or higher, or diastolic blood pressure of 110 mm Hg or higher) should be diagnosed with preeclampsia with severe features. These severe ranges of blood pressure increase the risk of morbidity and mortality. According to American College of Obstetricians and Gynecologists (ACOG), ambulatory management at home is an option only for women with gestational hypertension or preeclampsia without severe features and requires frequent fetal and maternal evaluation. Hospitalization is appropriate for women with severe features. 

This patient did not have pre-eclampsia. She had an episode of elevated blood pressure that stabilized without any treatment. In addition, there was no protein in the urine and her laboratory evaluation was normal.

This patient could have been observed.  Once her laboratory evaluation returned to normal and her blood pressure stabilized, she could have been sent home without the need for admission. Please note that neither the patient nor the fetus was in any jeopardy. Fetal heart rate was reassuring. There was no evidence of ruptured membranes.

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: root canals, crowns, and prefabricated post and core for teeth #8, 9 and 28
The insurer denied root canals, crowns, and prefabricated post and core for teeth #8, 9 and 28.
The determination is overturned.

The patient is a female who presented for the treatment of teeth number (#) 8, 9 and 28. Provided for review are letters of appeal and denial, letters of medical necessity, a letter from the patient, letters from other experts, clinical notes, clinical images, radiographic images, scientific literature, and health plan language. At issue is the medical necessity of the treatment of root canal therapy anterior tooth for #8 and 9 (3310), root canal therapy pre molar #28 (3320), porcelain fused to metal crowns #8, 9, 28 (2751), pre-fabricated post and core #8,9,28 (2954).

The requested health service/treatment of root canals, crowns, and prefabricated post and core for teeth #8, 9 and 28 is medically necessary for this patient, The teeth have extensive decay and loss of tooth structure which requires removal of infection, restoration of loss of tooth structure and function. Therefore, the requested services are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a family history of coronary artery disease (CAD) who presented to the emergency department (ED) for evaluation of left-sided chest pain radiating to her left arm. Her vital signs (VS) were stable. The physical examination was unremarkable. A chest x-ray (CXR) was clear. The cardiac troponins were negative, and an electrocardiogram (EKG) was non-ischemic. The patient was admitted to the telemetry service under an inpatient level of care for rule out acute coronary syndrome (ACS). Computed tomography (CT) of the abdomen demonstrated a paraumbilical hernia. An echocardiogram was normal. The patient underwent a stress test which was also reportedly normal. The patient was discharged home in stable condition. At issue is the medical necessity of an inpatient level of care.
The inpatient level of care was not medically necessary in this case. The patient presented with chest pain and ruled out for acute coronary syndrome (ACS). The patient remained hemodynamically stable. The patient's calculated HEART [history, EKG, age, risk factors, troponin] score was 2, low risk for short-term adverse cardiac events. According to the well validated HEART pathway and the 2022 American College of Cardiology (ACC) expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department, given there was no evidence of ACS and ECG was non-ischemic, inpatient level of care was not medically necessary in this case (1-3). A lower level of care would have been medically appropriate and safe for evaluation and management of this patient in this case.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman who presented with upper abdominal pain and vomiting of two days duration. At the time of presentation, the patient was without fever and vital signs were normal. She was tender in the right upper quadrant. The white blood cell (WBC) count was elevated at 13.7. The complete metabolic panel identified normal liver enzymes and normal bilirubin. Abdominal ultrasound showed gallstones within the gallbladder and gallbladder wall thickening. She was admitted to the hospital with the diagnosis of cholecystitis.

The inpatient hospital admission was not medically necessary. This patient is a woman who presented to the hospital with abdominal pain and vomiting. She was determined to have symptomatic cholelithiasis/cholecystitis. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, or any other condition requiring inpatient admission. The indication for cholecystectomy was established and she underwent surgery to remove the gallbladder. The patient responded favorably to treatment and the records support that she was stable for discharge from the hospital on the first post-surgical day with planned follow up. The Acute inpatient level of care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care. A lower level of care would have provided for ED assessment, surgical assessment and monitoring, laparoscopic cholecystectomy, provision of IV antibiotics and fluid, and overnight care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypothyroidism
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld  
This is an adult patient with past medical history (PMH) of hypothyroidism. The patient was admitted to the hospital for fatigue, shortness of breath, dizziness, bloating, nausea caused by hypothyroid exacerbation due to noncompliance with medication. The patient had hypothyroidism and stopped taking replacement therapy 2 months ago due to insurance change. The patient was previously hospitalized in 2020 for similar/worse symptoms.

Labs were notable for: Thyroid stimulating hormone (TSH) 316, aspartate aminotransferase (AST) 327, alanine transaminase (ALT) 264, triiodothyronine (T3) 21, thyroxine (T4) 1.6. Vital signs were: Oxygen saturation (SPO2) 98%, Heart Rate 70, Blood Pressure 106/74 which increased on the 26th to 123/86 with a Heart Rate 86. Glucose 87, Potassium 4.8, Creatinine 0.98, serum carbon dioxide (CO2) 24, albumin 5.7, anion gap 16, sodium 139, estimated glomerular filtration rate (eGFR) 84. Inpatient care included intravenous (IV) Synthroid, lab tests, and monitoring hemodynamic stability. The patient was discharged when hemodynamic stability was achieved.

Treatment of hypothyroidism including severe hypothyroidism is with oral levothyroxine. Indications for admission are severe symptoms like myxedema coma(1-7). The patient had hypothyroidism and had not had access to her medications. The patient had fatigue a 40 pound weight gain, nausea, myalgias. There were no other severe symptoms. The patient did not require intravenous levothyroxine. The patient could have been examined and found to have hypothyroidism and restarted on oral levothyroxine. The patient could have been discharged from the emergency room. The request is not consistent with generally accepted standards of medical practice and is therefore 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 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-ischemic heart failure
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
Asked to review the case of a patient with a non-ischemic heart failure and reduced ejection fraction (EF) that presented to the hospital with several days of dyspnea on exertion and pedal edema. Past history was significant for hypertension, diabetes mellitus, and obesity- status post lap-band surgery. On arrival vital signs were stable: Blood Pressure (BP) 114/58 mmHg (millimeters of mercury), pulse 75 bpm (beats per minute). Physical examination 2 + pitting edema of the lower extremities, no elevation of jugular venous pressure and clear lung examination. 12 lead electrocardiogram (EKG) demonstrated sinus rhythm without significant ST or T wave abnormalities. Pro-B type natriuretic peptide was not elevated (254pg/ml) (picograms per milliliter). The patient was treated with intravenous (IV) Furosemide and admitted to the hospital.  Echocardiogram with contrast was a technically difficult study and showed no significant change in left ventricular ejection fraction 60%. The patient was treated with diuretics and discharged home with follow-up.

This patient presented with dyspnea and a normal pro brain natriuretic peptide (BNP) level. Pedal edema was evident on physical examination, but lungs were clear and there was no elevation in jugular venous pressure. The patient noted dyspnea on exertion. Pedal edema resolved with diuretic therapy. The patient was appropriately treated with guideline directed medical therapy (Reference 1).  Masri et al. compared patient outcomes following treatment of acute congestive heart failure in observation and inpatient settings and demonstrated no difference in mortality between the two groups. (Reference 2). This patient was diagnosed with heart failure with preserved ejection fraction and discharged home.  In conclusion this patient could have been treated at a lower level of care and did not require inpatient admission. Acute inpatient hospital 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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left inguinal lymphadenopathy
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned.
Patient is an adult with benign past medical history who presented to the emergency department (ED) with complaints of fever, and left groin pain.

Vital signs on presentation included: Temperature 102.7 Fahrenheit, Blood Pressure -120/67, Pulse -114, Respiratory Rate -19, oxygen (O2) saturation -97% (percent) on room air (RA). Laboratory results included the following: White blood cell count (WBC) -6.79k (thousand), hemoglobin (Hgb)-11.8, hematocrit (Hct) -36.1, creatinine -0.86, glucose -118, urinalysis - negative. 

The patient was started empirically on intravenous (IV) antibiotics (Vancomycin and Rocephin) for left inguinal lymphadenopathy. Computed tomography (CT) scan showed non-specific left inguinal lymph node, 2.3 centimeter (cm) and a 3.6 cm adnexal cyst. Infectious Diseases (ID) consulted and work-up was negative for human immunodeficiency virus (HIV), syphilis and other sexually transmitted infections. Patient remained afebrile, clinically, and hemodynamically stable. The patient was discharged to continue outpatient follow-up on oral antibiotics. 

According to documentation, patient presented with inguinal lymph node swelling of unclear etiology. Patient was febrile (102.7 Fahrenheit) and tachycardic (Heart Rate -114). CT scan showed lymphadenopathy of unclear etiology-infectious versus malignancy. Based on above findings, hospital admission was medically necessary for administration of intravenous antibiotics and additional diagnostic evaluation.  

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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Elective placement of a biventricular pacemaker internal cardioverter defibrillator (ICD).
Treatment:  Inpatient Hospital Admission.

The insurer denied Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult male that was hospitalized for elective placement of a biventricular pacemaker internal cardioverter defibrillator (ICD). His past medical history included chronic congestive heart failure (CHF), nonischemic cardiomyopathy with ejection fraction (EF) 20-25% (percent), hypertension, diabetes, sleep apnea not treated with continuous positive airway pressure (CPAP), morbid obesity, asthma, stage 3 chronic kidney disease, anemia, and anxiety. There were no procedural complications. The patient's potassium was 5.8 and was treated with Lokelma and Kayexalate. A repeat of the potassium prior to discharge was 4.9. The requested coverage for inpatient hospital admission has been denied based on the patient's policy, and the patient is appealing the decision.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, acute myocardial infarction, cerebrovascular accident (CVA), serious bleeding complication, infection/sepsis, life-threatening cardiac arrhythmia, cardiac perforation, pneumothorax, vascular access complication requiring surgery, or hyperkalemia requiring dialysis or any other procedural complications or other medical instability or acute care needs that would require acute inpatient management. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received, management of mild hyperkalemia following the otherwise uncomplicated biventricular pacemaker implantable cardioverter defibrillator (ICD) insertion like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the requested health service was not medically necessary.