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

Diagnosis:  Neurofibromatosis type 1.
Treatment: Mekinist 2 Milligram Oral Tablets.
The insurer denied: Mekinist 2 Milligram Oral Tablets.
The denial is upheld.

The patient in this case is a teenaged female with Neurofibromatosis type 1 (NF1) and prior history of malignant peripheral nerve sheath tumor (MPNST) diagnosed 2 years ago. This was treated with chemotherapy, radiation and left hemipelvectomy. She has a plexiform neurofibroma in the right lower leg. She had been tried on selumetinib to treat this lesion but had to stop that medication because of nausea and vomiting. Trametinib was prescribed. A magnetic resonance image (MRI) identified a 14-millimeter lesion at the medial margin of the proximal tibial metaphysis, unchanged in size.

The health plan should not cover the proposed treatment.

There is only limited evidence showing that trametinib can be effective for the treatment of neurofibromatosis type 1 associated plexiform neurofibroma. Plexiform neurofibroma is a benign lesion which is typically either observed or treated with resection if causing symptoms or impending organ compromise. The lesion in this case is small. It is causing pain but is not growing and is not documented to be in a location where it poses risk to this patient. Based on this and the relatively limited evidence supporting the efficacy of trametinib, the health plan should not cover this treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Neurofibromatosis type 1.
Treatment: Mekinist 2 Milligram Oral Tablets.
The insurer denied: Mekinist 2 Milligram Oral Tablets.
The denial is overturned.

This is a teenaged female patient with diagnosis of plexiform neurofibroma with review for Mekinist. The patient has neurofibromatosis type I and confirmed malignant peripheral nerve sheath tumor. The patient's history includes left hemipelvis chemotherapy radiation and left hemipelvectomy. The patient has a plexiform neurofibroma of the right lower extremity that causes recurrent pain. The patient has previously been prescribed selumetinib but has not been able to tolerate it due to side effects. An alternative mitogen-activated protein kinase (MEK) inhibitor, trametinib, has been prescribed.

The health plan should cover the proposed treatment.

In this case the patient has a symptomatic plexiform neurofibroma that is inoperable. Surgery would be the first line treatment for this condition, but the patient cannot have surgery due to excessive morbidity. The patient has tried one mitogen-activated protein kinase (MEK) inhibitor which has been demonstrated in the literature to be efficacious in this setting. The patient was unable to tolerate it, so an alternative mitogen-activated protein kinase (MEK) inhibitor, trametinib has been prescribed; it is appropriate in this setting. The neurofibromatosis type 1 (NF1) product, neurofibromin, functions as a negative regulator of RAS oncogene activity. Lack of functional neurofibromin in patients with neurofibromatosis type 1 leads to dysregulated RAS oncogene and tumorigenesis. Mitogen-activated protein kinase (MEK) inhibition is a viable target based on the literature for these tumors. The dosing for Mekinist is well-established in the pediatric population and its use is appropriate in this setting. The available literature supports the use of the requested medication in the setting. The requested health service or treatment is more beneficial than any standard treatment for the patient's condition or disease. There are no other standard treatments feasible for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Neurofibromatosis type 1.
Treatment: Mekinist 2 Milligram Oral Tablets.
The insurer denied: Mekinist 2 Milligram Oral Tablets.
The denial is overturned.

The patient is a teenaged female with a history of neurofibromatosis type 1 with a history of malignant germ cell tumor who was treated with ifosfamide, Cytoxan and doxorubicin, radiation therapy and hemi-pelvectomy. She now has a plexiform neuroma which is causing severe pain. She was unable to tolerate selumetinib due to emesis. The provider is recommending treatment with Mekinist.

The health plan should cover the proposed treatment.

Neurofibromatosis 1 (NF1) is an autosomal dominant tumor predisposition disorder that affects about 1 in 3,000 people. The neurofibromatosis 1 gene is located on chromosome 17q11.2. It encodes for neurofibromin, a cytoplasmic protein that is expressed in the nervous system. Neurofibromin negatively regulates proto-oncogene RAS and acts as a tumor suppressor through the reduction of cell proliferation and differentiation by preventing the activation of downstream signaling pathways such as PI3K/AKT/mTOR and Raf/Mapk/MEK/ERK. As a result, an 
individual with neurofibromatosis 1 has a predisposition to develop both benign and malignant tumors. The characteristic lesion is benign neurofibroma, but there is also an 8%-13% lifetime risk of developing malignant peripheral nerve sheath tumor. Mekinist has been shown to be effective in the treatment of neuromas in these patients. McCowage reported an experience of 26 patients and wrote, "Twenty-six patients received trametinib (0.025 mg/kg/d(milligram/kilograms/day), n = 21; 0.032 mg/kg/d, n = 1; 0.040 mg/kg/d, n = 4). Median duration of exposure was 408 days (range, 360-429 days), and 8 patients (80%) had treatment ongoing. 2 of 26 patients (46%) had a partial response (20% volume reduction) and 10 of the 12 responses (83%) were ongoing". The patient has tried and failed selumetinib for this indication. Based on this data, the use of Mekinist would 
be medically necessary for this patient. 
Since the patient has failed selumetinib, the use of Mekinist would be considered more beneficial than any other treatments for plexiform neuroma.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess 
Treatment: Inpatient hospital stay
The insurer denied coverage for inpatient hospital stay.
The denial is overturned.

The patient is an adult who presented with a diagnosis of oropharyngeal pain and swelling. The patient was admitted for intravenous (IV) fluids and pain control, as well as antibiotics. The claimant ended up getting transferred and was determined to have a throat abscess. The pain was severe. The request of this review is to determine the medical necessity of an inpatient hospital admission.

The health plan did not act in the interest of the patient. The patient was diagnosed with oropharyngeal pain and swelling and was unable to tolerate the severe pain and this necessitated consultation by an Otorhinolaryngology (Ears, nose, and throat (ENT)) and admission for IV antibiotics, fluids, steroids, and pain control.    

The inpatient admission was considered medically necessary. According to
Head and Neck Disease GRG (General Recovery Care guidelines): Milliman Care Guidelines (MCG) Health General Recovery Care 26th Edition Clinical Indications for Admission to Inpatient Care, a hospital admission is needed for appropriate care of the patient because of one or more of the following: complicated infection, as indicated by one or more of the following: abscess or swelling causing significant swallowing difficulty, chills, and shortness of breath (MET). Significant Leukocytosis with Left shift and inpatient treatment is necessary (such as continued IV antibiotics, IV Steroids and IV Toradol) (MET).

The patient needed IV fluids, antibiotics, and pain control. The inpatient admission was considered medically necessary.

"Most causes of sore throat are nonbacterial and neither require nor are alleviated by antibiotic therapy. Accurate diagnosis is essential: Acute streptococcal pharyngitis warrants diagnosis and therapy to ensure prevention of serious suppurative and nonsuppurative complications. Life-threatening infectious complications of oropharyngeal infections, whether streptococcal or non-streptococcal, may manifest with mouth pain, pharyngitis, parapharyngeal space infectious extension, and/or airway obstruction. In many cases, the history and/or physical exam can help direct diagnosis and treatment, but the enormous number of potential causes is too large to address all of them." (Tanz, 2018)

"Throat pain is one of the most frequent complaints prompting patient visits to healthcare professionals. Primary care physicians being the first contact point are frequently encountered with symptoms such as sore throat and odynophagia. However, high level of diagnostic uncertainty exists when the oropharyngeal examination is normal despite patients' complaints of severe pain." (Peltekis, et al, 2012)

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for an inpatient hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a man admitted to the hospital for a complaint of tinea capitis. His dermatologist sent the patient due to a lack of improvement after treatment of tinea capitis with oral terbinafine. He developed areas of inflammation and fluctuance and complaint of diffuse lymphadenopathy. Vital signs in the emergency department (ED) included a temperature of 99.3, pulse rate of 97, respirations of 18, and blood pressure of 117/69. Examination showed four areas of the scalp appearing swollen with tenderness. The right parietal lesion was draining serous fluid.

Based on the documentation provided, an inpatient admission was not medically necessary. Care for this patient could be provided at a lower level of care. The patient is suspected of having tinea capitis and spent four days in the hospital, receiving an oral antifungal agent while a myriad of labs were ordered. The progress notes state the patient is afebrile, asymptomatic, and without evidence of severe sepsis. Procalcitonin was only borderline elevated, at 0.06, with a cutoff of 0.05. White blood cell count was completely normal. There was no organ dysfunction or risk to life or limb. No specific interventions were completed in the hospital that could not be provided at any other level of care. The scalp biopsy and the lymph node biopsies were postponed to the original outpatient scheduled setting. Therefore, an inpatient admission is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional/Obesity and Cardiac issues.
Treatment: Mounjaro 5mg (milligrams)/0.5ml (milliliter) Pen injector.
The health plan denied the requested Mounjaro 5mg/0.5ml Pen injector.
The health plan's determination is upheld.

This is a female with obesity, hyperlipidemia and hypertension. Her body mass index is 31.0 kilograms/meter squared (kg/m2). Glycated hemoglobin (A1C) is 4.8%. Fibrinogen is 477. Highly sensitive C-reactive protein (CRP) is 3.95.  A request for Mounjaro 5mg/0.5ml Pen injector is under review for medical necessity.

I uphold, in whole, the health plan's determination of medical necessity.

The requested Mounjaro is not medically necessary and was appropriately denied.
This request is for Mounjaro for weight loss for a patient with obesity, hyperlipidemia, and hypertension. Mounjaro is not Food and Drug Administration (FDA) indicated for weight loss. The Mounjaro prescribing information does not support the use of Mounjaro in this clinical situation. There are other drugs that are FDA indicated for weight loss. The Endocrine Society guidelines on the management of obesity does not support the use of off-label medications for the treatment of obesity. Mounjaro has risks, including nausea and vomiting. Therefore, no, the requested Mounjaro is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male. He was admitted for back pain, dizziness and dysuria. The patient was found to be hypotensive and was treated with IV (intravenous) fluid. He required pain management during this admission. He was noted to have abnormal creatinine, which responded to IV (intravenous) fluid. Abdominal and chest imaging were negative for acute process. His condition responded appropriately and was discharged in stable condition three days later.

The Inpatient Hospital Admission was not medically necessary.

The patient was hemodynamically stable, with normal oxygenation and negative cultures. The patient did not have persistent electrolytes disturbance or change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, no documentation of refractory pain beyond observation period. He was able to tolerate oral diet and did not require total parenteral nutrition. It was noted he had abnormal creatinine, but it responded to IV (intravenous) hydration and did not require kidney biopsy or renal replacement therapy. In addition, the patient had no indication for admission for the treatment of back pain such as acute neurologic deficit (e.g., cauda equina or conus medullaris syndrome). He did not have an etiology that required inpatient treatment (e.g., aortic dissection, epidural abscess, spinal instability), nor did he undergo urgent surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Rule out cerebral vascular accident (CVA)/transient ischemic attack.
Treatment:  Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

This case involves an adult under review for prior hospitalization. The emergency department note reported the patient had a chief complaint of stroke symptoms, as well as anxiety and dizziness. The patient reported falling down and vomiting once.  The patient also complained of shaky hands and left facial pressure. A stroke alert was called. The patient had difficulty answering questions.  A Computed tomography (CT) scan of the head showed no acute intracranial hemorrhage. The neurologist did not recommend a CT Angiogram. The patient was recommended for admission to telemetry for further management.  It was noted that the patient was hemodynamically stable with no acute distress and speaking in full sentences.  

Milliman Care Guidelines (MCG) recommends an inpatient admission for acute ischemic stroke when there is a National Institutes of Health Stroke Scale (NIHSS) score greater than 2, evidence of hemorrhagic transformation, altered mental status, dysphagia that warrants evaluation, significant arm or leg weakness, aphasia, gait impairment, findings on brain imaging that requires inpatient care, and/or clinical stability is unclear. In this case, the patient presented with stroke like symptoms. However, the NIHSS score was 1.  The initial CT scan was negative for acute pathology. By the time of admission, the patient was in no acute distress, was speaking in full sentences, and was hemodynamically stable. There is a lack of documentation that supports the need for inpatient admission versus continuation of monitoring and work-up under observation care.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Asthma, pain, arthritis, hypertension.
Treatment:  Personal Care Services, Level II.
The insurer denied: Personal Care Services, Level II.
The denial is upheld.

This adult female patient has asthma, anxiety, depression, allergic rhinitis, hyperlipidemia, arthritis, and hypertension. She is appealing the denial of level II personal care services. The request was denied because the patient's Uniform Assessment System evaluation performed 4 months ago showed no need for assistance with activities of daily living (ADLs) and personal care. The Uniform Assessment System (UAS) evaluation completed last year shows independent cognition and independent functioning, except total dependence with housework. There is a letter that notes the denial of services "hinders progress/maintaining/improving cognitive function". The patient has hearing loss, anxiety, and panic attacks. She takes several medications. She has occasional body weakness and fatigue.

The proposed treatment 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. This patient has multiple chronic conditions. She is appealing the denial of level II personal care services. The request was denied because Uniform Assessment System evaluation performed 4 months ago showed no need for assistance with activities of daily living (ADLs) and personal care. Uniform Assessment System (UAS) evaluation completed last year shows independent cognition and independent functioning, except total dependence with housework. The appeal statement does not support the patient's need for assistance with activities of daily living (ADLs). Personal care services are not indicated when no tasks are being performed. The proposed personal care services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: gastroesophageal reflux disease (GERD)
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This patient is a woman who presented with the diagnosis of gastroesophageal reflux disease (GERD). She had completed an outpatient diagnostic evaluation that established the surgical indication for operative treatment that included crural closure and Toupet fundoplication. She underwent laparoscopic repair of a hiatal hernia and fundoplication. She was admitted to the hospital. The operation included the mobilization of the distal esophagus and crural repair with posterior crural sutures and a 270-degree fundoplication. The operation was concluded without complication.

An inpatient level of care was not medically necessary for this patient. In this case, the patient tolerated the surgical procedure without adverse event, she was able to resume a diet and oral medications shortly following surgery, and was considered to be stable for discharge from the hospital after the initial recovery period on the first post-surgical day. A lower level of care would have satisfied the needs of this patient.
Appeal type: Medical necessity
Decision: Overturned

Substance abuse
Inpatient hospital

Diagnosis: alcohol intoxication
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male who initially presented to the emergency department with alcohol intoxication and a fall. Pertinent history included alcohol use disorder. Initial vital signs revealed a temperature of 98.4F (Fahrenheit), heart rate (HR) 104, blood pressure (BP) 138/93, respiratory rate (RR) 19, and peripheral capillary oxygen saturation (SpO2) 98% on room air. Initial examination documented the patient as alert and oriented with no focal neurologic deficits. Initial laboratory testing revealed a white blood cell count (WBC) 4.9, Hemoglobin (HGB) 11.8, platelets (Plt) 254, blood urea nitrogen (BUN) 11, Cr (creatinine) 0.7, Na (sodium)137, K (potassium) 4.0, carbon dioxide (CO2) 26, and Glucose 83. Urine drug screen was positive for barbiturates and benzodiazepines. The patient was placed in the hospital thereafter with an impression of alcohol withdrawal and witnessed fall with transient loss of consciousness. Treatment plan included Clinical Institute Withdrawal Assessment (CIWA) protocol with lorazepam as needed.

Based on the clinical documentation provided, the inpatient hospital admission was medically necessary. The patient had a history of alcohol use disorder and homelessness who presented to the emergency department with alcohol intoxication and a ground level of fall. Initial examination was unremarkable for significant traumatic pathology, however, the patient was noted to be tachycardic, tremulous, and anxious. Treatment plan included Clinical Institute Withdrawal Assessment (CIWA) with lorazepam as needed. The following day, the patient was documented as being tremulous in all extremities and the trunk despite pharmacotherapy. Moreover, clinical indications for admission to inpatient care were met. The patient had marked signs of withdrawal as indicated by a grossly visible tremor with inadequate response to pharmacotherapy in emergency department.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cirrhosis complicated by Ascites
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a medical history of cirrhosis complicated by ascites requiring paracentesis, chronic hepatitis C status post treatment, portal vein thrombosis, atrial fibrillation, and schizophrenia. He presented to the emergency department with ascites and anasarca starting approximately a week prior. He had undergone a paracentesis His vital signs were unremarkable. The physical examination was notable for a soft, distended abdomen without tenderness, a well-healed surgical scar, and midline reducible hernia.
A chest x-ray showed clear lungs without pleural effusions. An ultrasound of the abdomen showed moderate to large volume ascites. An Interventional Radiology consultation noted ascites, and recommended await imaging, labs the next morning, and hold anticoagulation until after procedure. He was incidentally found to have a coronavirus 2019 (COVID-19) infection. A hepatology consultation noted cirrhosis complicated by ascites with multiple paracenteses, and recommended continued furosemide, spironolactone, and ciprofloxacin, diagnostic and therapeutic paracentesis, discharge home with a plan for outpatient follow-up, and will need transjugular intrahepatic portosystemic shunt. Interventional Radiology performed a paracentesis with the removal of 8.5 liters (L); he was treated with intravenous albumin. He was discharged on ciprofloxacin, furosemide, lactulose, spironolactone, and methadone, with a plan for gastroenterology follow-up and a recommendation to quarantine for 10 days. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care was not medically necessary.
The patient presented with ascites and anasarca in the setting of a recent paracentesis, and history of cirrhosis complicated by portal hypertension [1]. Large-volume paracentesis can result in circulatory or renal dysfunction, but the patient did not have hemodynamic or renal decompensation, and there was no evidence of spontaneous bacterial peritonitis [2-6]. He was appropriately treated with antibiotics and albumin [3,4,9]. There was no hemodynamic instability, ascending cholangitis, acute liver failure, or other complications which would require the inpatient level of care [7-9]. His symptoms improved by the day after presentation. He incidentally tested positive for a COVID-19 infection but did not have markers of progressive or severe COVID-19, and was not treated for it [10,11]. For these reasons, the care provided during the dates at issue could have been provided at a lower level of care, without the inpatient level of care.