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

Diagnosis: Right Tibia Fracture
Treatment: Inpatient Admission to Alternate Level of Care
The insurer denied the inpatient admission to alternate level of care. 
The health plan's determination is overturned.

The patient is a female with a medical history notable for fracture of the right tibia and schizophrenia. The patient underwent an inpatient admission to an Alternate Level of Care and coverage was denied by the health plan, who stated that the patient did not meet criteria for the requested dates. This denial is the subject under review.
The patient was admitted to a skilled nursing facility after she sustained a fracture of the tibia from a motor vehicle strike as a pedestrian. She received appropriate care including physical and occupational therapy. Notes state that the patient had a discharge plan in place to return to her independent living facility. The notes stated that the discharge would need to be delayed because they needed to ensure that the patient had a wheelchair accessible room; she was still non-weightbearing at this time.
The health plan denied the request for Alternate Level of Care (ALOC) for the requested dates. They state that it was not medically necessary. They state that Alternate Level of Care is appropriate for individuals who have an established discharge date or for whom a discharge plan cannot be executed because of one or more variables that must be resolved before the discharge is completed.
The nursing facility feels that ALOC (Alternate Level of Care) was medically necessary because the patient was not ready for discharge by the proposed discharge date. She was still non-weightbearing and required a wheelchair accessible room, which is what delayed her discharge. They state that it was not safe to discharge the patient until these arrangements had been made.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service of inpatient admission to the Alternate Level of Care is medically necessary for this patient. The patient sustained a fracture and was admitted for short-term rehabilitation. She was supposed to be discharged on a set date, but a safe discharge plan was not in place at that time. She was still on a non-weight-bearing status and required a wheelchair accessible room. The plan states that Alternate Level of Care is medically necessary "for individuals who have an established discharge date or for whom a discharge plan cannot be executed because of one or more variables that must be resolved before the discharge is completed." The patient fits this criteria for medical necessity. She could not have been safely discharged until the wheelchair accessible room was secured.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic idiopathic constipation
Treatment: Motegrity
The insurer denied Motegrity.
The health plan's determination is upheld. 

The patient is a female with chronic idiopathic constipation. She has had severe constipation, with hospital admission requiring disimpaction; she has had concurrent abdominal pain. She has failed Linzess, Dulcolax, senna, and Miralax.

A formulary exception is not indicated.

The American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as lubiprostone (Amitiza) should be used if non-pharmaceutical laxatives fail. Lubiprostone has shown safety and efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain. Motegrity has not demonstrated higher safety or efficacy than lubiprostone in a direct controlled comparison. For these reasons, the use of Motegrity is not supported indicated over the use of lubiprostone in this case.
Appeal type: Medical necessity
Decision: Upheld


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

The patient is a female who initially presented with chest pain and epigastric pain of one day duration. Pertinent history included hypertension, hyperlipidemia, and heavy drinking. Initial vital signs revealed a temperature of 98.6oF, heart rate (HR) 69, blood pressure (BP) 144/62, respiratory rate (RR) 18, and peripheral capillary oxygen saturation (SpO2) 100%. Initial examination documented reproducible chest wall tenderness. 

Based on the clinical documentation provided, the inpatient hospital admission was not medically necessary. The patient presented with left-sided chest pain and epigastric pain. Initial examination documented the patient as afebrile, hemodynamically stable, and with reproducible chest wall tenderness. Serial cardiac enzymes were negative. EKG(electrocardiogram) was relatively unremarkable. Chest radiograph unremarkable. Urgent ischemic evaluations were not deemed necessary. Following observation care, presenting symptoms had resolved and the patient was discharged with plans for outpatient evaluations.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain. 
Treatment: Pain Management/ Ablative Nerve Treatment in the Spine. 

The insurer denied Ablative Nerve Treatment in the Spine. The health plan's determination is overturned. 

The patient is a female with a five-year history of low back pain. Her pain is tight and aching mostly in the low back bilaterally. Her prior treatments include pain medications, radiofrequency ablation (RFA), transforaminal injections, and facet injections, however, none of these provided her adequate pain relief. 

Ablative Nerve Treatment in the Spine is medically necessary for this patient.
This patient has persistent back pain consistent with vertebrogenic pain. She had tried extensive conservative treatments without adequate pain relief. Her pain is severe enough to interfere with her activities of daily living (ADL). Further treatments are medically necessary to improve her pain and functionality. 

The Intraosseous nerve ablation procedure (INTRACEPT) is designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple well-designed clinical trials demonstrated the effectiveness of Intracept in alleviating vertebrogenic pain. 

This patient's persistent low back pain is consistent with vertebrogenic pain. This patient's pain is severe with negative impact on her ADLs and quality of life. Further interventions are medically necessary to improve her pain and function. Other potential treatment options are long-term use of medications (opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the requested procedure is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the emergency department with concerns of abdominal pain, nausea and vomiting. Pertinent history included chronic pain syndrome on methadone, heroin abuse, alcohol abuse, hepatitis C, hypertension, anxiety, and gastroesophageal reflux disease. Initial vital signs revealed a temperature of 99.7F, heart rate (HR) 60, blood pressure (BP) 146/101, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 98% on room air. Initial examination documented mild abdominal tenderness without peritoneal signs. Initial laboratory testing revealed a white blood cell count (WBC) 1.9, Hemoglobin (HGB) 14.2, platelets (Plt) 77, blood urea nitrogen (BUN) 15, Cr (creatinine) 0.96, Na (sodium)134, K (potassium) 4.0, and carbon dioxide (CO2) 25. An electrocardiogram (EKG) did not reveal an acute ST-Elevation Myocardial Infarction (STEMI). A chest x-ray (CXR) relatively unremarkable. A computed tomography angiography (CTA) Thoracoabdominal aorta was essentially unremarkable. The patient was placed in the hospital thereafter. The admitting physician had an impression of acute gastroenteritis likely foodborne, but possibly related to COVID-19 with an associated lymphopenia and thrombocytopenia. Treatment plan included intravenous fluids, analgesia, proton pump inhibitor, and stool studies.

Based on the clinical documentation provided, evidence based literature and standards of care, the inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient presented with abdominal pain, nausea and vomiting with the admitting physician providing a diagnosis of acute gastroenteritis. An extensive evaluation was performed including laboratory testing and computed tomography (CT) imaging which was relatively unremarkable. Treatment included supportive care and intravenous fluids. To note, cardiology consulted and ruled out acute coronary syndrome. Following observation care, presenting symptoms had resolved, or significantly improved, and diet was tolerated. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke.
Treatment: Personal care assistance, live in aide 7 days per week.
The insurer denied personal care assistance, live in aide 7 days per week.
The determination is overturned.

This is a female patient with a medical history notable for cognitive and functional impairments. The patient is approved for 84 hours per week of personal care assistance. The patient and her care team requested an increase to a live-in aide, 7 days per week and this request was denied by the health plan.
The patient's child wrote a letter of support for this appeal. He has been living with his mother since his father passed away to provide the needed support, but he lives and works in Michigan and must return. Therefore, he can no longer continue to provide this support. He currently cares for her after 8 PM (Post meridiem) after the aide leaves. He describes multiple personal care functions that need to occur throughout the night, including changing soiled diapers, feeding, and assisting with medications. The patient's spouse used to be the patient's primary caretaker, and he is no longer alive. There is no other informal family support.
A physician's assistant from the patient's primary care office wrote a letter of support for this appeal. The letter states that the patient has a history of stroke and is wheelchair bound. She is completely dependent on others for activities of daily living (ADLs). 24 hour care was requested.
A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was minimally impaired. She was alert to self only but was self-directing. She is not able to call for help in an emergency. For her Instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, finances, stairs, and transportation. She requires maximal assistance for managing medications. For her ADLs, she requires total dependence for locomotion. She requires maximal assistance for bathing, dressing, toilet transfer, toilet use, and bed mobility. She requires extensive assistance for hygiene. She is frequently incontinent of urine and uses pullups for incontinence care. Compared to a prior Uniform Assessment System (UAS), she showed significant functional decline across multiple domains. At issue is the medical necessity of personal care assistance, live in aide 7 days per week.

The requested health service/treatment of personal care assistance, live in aide 7 days per week is medically necessary for this patient.
The patient has personal care needs which can be expected to be continuous and unscheduled throughout any 24 hour period. She is not capable of performing any ADLs without assistance. She is incontinent of urine and requires changes of pullups. By definition, these care needs will be unscheduled. Her family has been providing informal support but they are no longer able to continue to do so. Therefore, it is medically necessary to increase the patient's personal care service hours to live-in to provide coverage for all of her personal care needs. Failure to do so could result in skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cystic Fibrosis and Bronchiectasis
Treatment: Durable Medical Equipment (replacement of chest vest)
The insurer denied: Durable Medical Equipment (replacement of chest vest)
The denial is overturned

The patient is an adult female who has a history of Cystic Fibrosis and bronchiectasis. At issue is health plan authorization for her chest wall oscillation vest (The Vest). According to correspondence from the health plan, there was not enough evidence in the literature and information to show that this device is medically necessary for her condition.

Correspondence from the patient's clinical advocate asked that the health plan reconsider its decision in light of the benefits of high-frequency chest wall oscillation (HFCWO) therapy for CF (cystic fibrosis) and bronchiectasis being widely recognized in the medical community and that the patient has managed her airway clearance needs effectively for years with The Vest. An earlier letter indicated that she has been using The Vest since last year and that her current device was no longer functioning properly and needed replacement.

Further notes from her the patient's physician, indicate that the patient has a history of bronchiectasis secondary to Cystic Fibrosis variant. Pulmonary function tests show severe obstructive lung disease with air trapping and reduced DLCO (Diffusion Capacity). FVC (forced vital capacity) was 1.44 L (liters) (47% predicted) FEV1 (forced expiratory volume 1 second) was 0.93 L (38% predicted) and FEV1 (forced expiratory volume 1 second)/FVC (forced vital capacity) was 64% at that time. She was noted to be a never smoker. Her medications included Breo Ellipta 200/25 daily and were noted to include Ipratropium-Albuterol solution via nebulizer four times a day.

The requested health service is medically necessary.

The patient is described in several clinical notes by her physician as having a CF (cystic fibrosis)-variant, severe obstructive lung disease and bronchiectasis. She has been using The Vest (high-frequency chest wall oscillation) with benefit, and is looking to replace a defective unit rather than duplicate her current machine. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epilepsy.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is: Upheld.

The patient is a male with human immunodeficiency virus (HIV) and epilepsy, who was brought into the hospital for a witnessed seizure event lasting 2 minutes. The patient reported experiencing breakthrough seizures at home weekly for three weeks. He denied fevers, chills, or chest pain. He follows up with a neurologist, last seen two months before this presentation. The patient complained of neck and back aching, prompting a cervical spine computed tomography (CT). It was negative for fractures, and the CT head was negative for intracranial pathology. The chest x-ray was clear as well. During the imaging studies, the patient experienced another seizure and was given Ativan, loaded with Keppra. Neurology was contacted, who recommended monitoring in the hospital and titration of antiepileptic medications. This was offered to the patient; however, he declined. He signed the against medical advice (AMA) form but returned the following day, which is this admission, because he experienced another breakthrough seizure at home. He felt drowsy and lethargic but had no bowel or bladder incontinence.

The patient was given Xcopri and continued on Vimpat, Briviact, and Keppra. He agreed to be monitored in the hospital. However, a few hours later, the patient left AMA again and reported he would follow up with his neurologist the following week.

The question is whether the above presentation warranted an inpatient level of care.

The inpatient hospital admission is not medically necessary. The patient has a known seizure disorder and is experiencing some breakthrough episodes; treated with Keppra in the ED and restarted on the home regimen of antiepileptic medications. The brain imaging did not reveal any acute intracranial pathology; there were no major electrolyte derangements, signs of infection, or any other inciting factors that would require treatment, to prevent recurrent seizures. The patient left the hospital alert and oriented, hemodynamically stable. The patient could have been managed at a lower level of care; inpatient admission is not warranted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Febrile illness
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission
The denial is upheld 

The patient is an adult with a benign past medical history who was referred to the emergency department for complaints of intermittent subjective fever.

Vitals on presentation included Temperature max of 102.5 degrees Fahrenheit, Blood Pressure 102/66, Pulse 90, Respiratory Rate 20, oxygen (O2) saturation 97% on Room Air. Laboratory values were notable for white blood cell count (WBC) 4.9, hemoglobin 12.3, hematocrit 37.0, creatinine 1.2, glucose 111, procalcitonin 0.57, erythrocyte sedimentation rate (ESR) 42, and C-Reactive Protein (CRP) 15.4.

The patient was admitted for evaluation of fever. Multiple serologic tests and cultures were ordered and came back negative. The patient was not empirically started on antibiotic therapy. Chest x-rays (CXR) were normal and computed tomography (CT) scan of abdomen/pelvis was negative for any acute findings. Infectious Diseases consult agreed with holding off antibiotics. The patient remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient management. 

According to medical records, the patient initially presented with complaints of fever; otherwise, remained hemodynamically stable; fever defervesced with acetaminophen. Laboratory results were unremarkable including a normal WBC (white blood cell count) and procalcitonin. Imaging studies were all negative. The patient had no evidence of any acute infection; no intervention requiring acute inpatient care. Based on above findings, the patient met criteria for observation level of care.
 
Prior determination of denial of inpatient hospitalization is upheld. 

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: Parkinson's Disease.
Treatment: Dhivy 25-100 MG (milligram) Tab.
The insurer denied: Dhivy 25-100 MG (milligram) Tab.
The denial is upheld.

The patient is an adult male with Parkinson's disease. He is currently taking samples of Dhivy. The medication helps with tremors for three to four hours after taking it. The patient has tried and failed Azilect, Requip and amantadidne. The provider wishes to prescribe Dhivy. The request was previously denied as patient had not tried formulary alternatives.

The proposed Dhivy is not medically necessary.

The patient has not tried and failed all formulary alternatives. Furthermore, Dhivy is a brand of levodopa/carbidopa and there is no evidence that it is superior to formulary alternatives which also include levodopa/carbidopa.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces, monthly visits and a retainer
The insurer denied braces, monthly visits and retainer.
The determination is overturned.

This is a female patient with a Class I malocclusion with protrusive maxillary incisors. She has a 7 millimeter (mm) overjet and a 100 percent (%) deep bite. She has minor maxillary spacing and moderate mandibular crowding. She has treatment planned for orthodontics to correct this malocclusion. At issue is the medical necessity of braces, monthly visits and a retainer.

Teeth number (#) 8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (1) Evidence shows that orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. Additionally, this patient's overjet is greater than 6 millimeters (mm). Overjets of this magnitude are shown to negatively affect the oral health quality of life. (2) For these reasons, the requested treatment is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Dry eyes
Treatment: Tyrvaya (varenicline)
The insurer denied Tyrvaya (varenicline).
The determination is overturned.

This is a female patient with dry eyes for whom coverage of Tyrvaya is the subject of review. Coverage was previously denied as it was not identified that the patient had failed or had intolerance or contraindication to the required number of formulary alternatives. The formulary alternative is identified as Xiidra.

Reportedly, the patient previously used Xiidra which caused adverse reactions including redness, long-term blurriness, and severe burning. The patient has also tried Cequa and Restasis which caused the same reactions. Additionally, the patient is reported to have tried and failed various artificial tears and tear gels.

An exam dated documents the patient being prescribed Tyrvaya (varenicline) nasal spray and a 2 week course of prednisolone acetate. The patient was taking ocular lubricants as well as oral azathioprine. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The provider reports that the patient has tried and demonstrated intolerance to the formulary drug, Xiidra (lifitegrast). In addition, the patient has tried and demonstrated intolerance to topical cyclosporine products (Restasis and Cequa). Therefore, as the patient has also tried and failed ocular lubricants as recommended by the Preferred Practice Patterns of the American Academy of Ophthalmology, the medical necessity or Tyrvaya is indicated per standard of care.

Tyrvaya (varenicline solution) nasal spray is a cholinergic agonist Food and Drug Administration (FDA) approved in 2021 for the treatment of the signs and symptoms of dry eye disease. Wirta et al evaluated the efficacy and safety of OC-01 (varenicline solution) nasal spray for the treatment of patients with dry eye disease. Theirs was a randomized, multicenter, double-masked, vehicle-controlled, phase 3 study.  The authors concluded that OC-01 nasal spray was well tolerated and showed a clinically meaningful effect on signs and symptoms of dry eye disease.