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

Diagnosis: Ulcerative colitis
Treatment:  Brand name Apriso
The insurer denied the  Brand name Apriso
The denial is overturned.

This patient is a male with ulcerative colitis who has been on brand name Apriso for several years with good clinical control.  The patient developed a flare with diarrhea and rectal bleeding when transitioning to the generic version.  The provider noted that the patient trialed Canasa, Lialda and generic Apriso.

Yes, the proposed treatment with brand name Apriso is medically necessary.
The five-aminosalicylic acid (5-ASA) derivatives available in oral formulations include balsalazide, mesalamine, olsalazine and sulfasalazine. 

Asacol, Asacol HD and Delzicol tablets contain a pH (potential of hydrogen)-sensitive film that dissolves at a higher pH (potential of hydrogen), thereby delivering mesalamine to the terminal ileum and proximal colon. Lialda and Apriso are formulated in a matrix that delays mesalamine release until it reaches the distal ileum and colon. Balsalazide, olsalazine and sulfasalazine are prodrugs that are cleaved in the colon following bacterial reduction to form mesalamine.  Pentasa is formed by packaging mesalamine in permeable microgranules. Permeable microgranules allow for mesalamine release throughout the intestinal tract.  Pentasa is more appropriate for Crohn's Disease because of its diffuse intestinal tract distribution. For ulcerative colitis, a Cochrane review showed no significant differences in the efficacy and safety of different formulations of oral five-ASA (five-aminosalicylic acid) used for induction and maintenance of ulcerative colitis.

This patient developed a flare with diarrhea and rectal bleeding when transitioning to the generic version of Apriso.  There is no literature to support that the ingredients of brand Apriso are the same as the generic form.  Therefore, Apriso (brand name) is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Per the plan, as per the FDA, "Other than the fact that it does not have the brand name on its label, it is the exact same drug product as the branded product." This authorized generic is made by the same manufacturer."

However, there is no literature to support that the ingredients of brand Apriso are the same as the generic form.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Atrial Fibrillation

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is overturned

This is the case of a male with a history of ischemic heart disease that presented to the Emergency Department (ED) with complaints of chest pain for many hours. Symptoms were accompanied by lightheadedness and began approximately two weeks prior to presentation. Past medical history was significant for prior coronary stent placement (LAD [left anterior descending] and RCA [right coronary artery]) and heart failure with reduced ejection fraction (25-30% (percent)) as well as implantable cardioverter-defibrillator (ICD) in situ. Upon arrival to the hospital, vital signs were stable with blood pressure (BP) 104/83 mmHg (millimeters of mercury) and pulse 78 beats per minute (bpm). Physical examination revealed an irregular pulse without other significant abnormality. Twelve-lead EKG (electrocardiogram) revealed atrial fibrillation without ischemic ST (interval on EKG) or T (interval on EKG) wave changes. Serum blood testing revealed an elevated Brain type natriuretic peptide (BNP) (204.1 pg./ml [picogram per milliliter]); serum troponin was not elevated. Cardiac catheterization was performed and revealed patient stents in the left anterior descending and right coronary arteries. The patient was discharged home on medical therapy.

This patient presented with chest pain and had a past medical history of heart failure and reduced ejection fraction and ischemic heart disease. The patient required percutaneous coronary intervention to the LAD and right coronary arteries. EKG on admission revealed atrial fibrillation (AF) which may have resulted in periods of rapid ventricular rates and symptoms of chest pain. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic atrial fibrillation. (2) In addition to AF, this patient had chest pain and a high pretest probability of significant coronary artery disease. (3) This patient had an elevated HEART (history, EKG, age, risk factors, and troponin) score and appropriately underwent cardiac catheterization prior to discharge. (4) In conclusion, acute inpatient admission was medically necessary in this case.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied implant placement on tooth 2, 3, 4, 5, 14, 18, 29, 31. 
The denial is upheld.

The patient is a female who presented to the office of her dental provider for evaluation and treatment of teeth #2, 3, 4, 5, 14, 18, 29, and 31. Included for review are previous letters of appeal and denial, a narrative from the provider, a full mouth panoramic radiograph from an unknown date, one page of American Dental Association (ADA) claim forms, a health history, and clinical notes. In question is the medical necessity of the planned treatment of implant placement for #2, 3, 4, 5, 14, 18, 29, and 31.

The health plan's determination is upheld in whole.

The medical necessity of dental implants in these sites has not been established. The provider's appeal letter indicates that the patient has difficulty with partials, in speaking (dysphasia), and nauseous (gag reflex), and the patient cannot eat (dysphagia). There is nothing in the documentation that indicates that the patient has had a partial denture provided and then that the partial denture did not function correctly. There is nothing in the provided documentation that shows that the patient even uses a partial denture currently. Further based on the provided documentation, the teeth do not appear to have been prepped for a partial denture in the past. There has been no evaluation of any current prosthesis by the doctor. The need for implants has not been established. Hence the treatment of implant placement for sites #2, 3, 4, 5, 14, 18, 29 and 31 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atherosclerotic cardiovascular disease and hyperlipidemia
Treatment: Repatha sureclick 140 milligrams/milliliter (mg/ml)
The insurer denied coverage for Repatha sureclick 140 mg/ml.
The denial is overturned.

This patient has a history of atherosclerotic cardiovascular disease and hyperlipidemia. Computed tomography (CT) angiogram revealed mild to moderate stenosis of the proximal left anterior descending artery. He has a history of myalgias on statin medication and cannot tolerate  (beta)-Hydroxy -methylglutaryl-CoA (HMG-CoA) reductase inhibitors. He was treated with ezetimibe 10mg (milligrams) daily. Cholesterol panel revealed: Total cholesterol 234, high density lipoprotein (HDL) 43, Low density lipoprotein (LDL) 147. His physician prescribed Repatha to reduce Low density lipoprotein- cholesterol (LDL-C). 

The patient's cholesterol panel revealed an elevated LDL-C of 147mg/dl (milligrams per deciliter). This patient could not tolerate statin therapy in doses sufficient to reduce LDL cholesterol below guideline recommended level (less than 70). Current American Heart Association and American College of Cardiology guidelines clearly note that in patients with ASCVD (atherosclerotic cardiovascular disease) and statin associated muscle symptoms should be treated with randomized trial proven non statin therapy (1). Repatha was demonstrated to reduce major adverse cardiovascular events by 15% (percent) in the Fourier randomized clinical trial (2). AHA/ACC (American Heart Association/American College of Surgeons) guidelines recommend the use of PCSK9 (class of drugs to reduce LDL) inhibitors in patients with atherosclerotic coronary disease and LDL levels greater than 70mg/dl in patients intolerant to statin therapy (1). Medical records clearly indicate that this patient suffered from statin induced myalgias. Given these findings, Repatha therapy is medically necessary and is considered to be the current standard of care according to recent guideline statements. (1,3). In conclusion, the proposed treatment is medically necessary. 

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for Repatha sureclick 140 milligrams/milliliter (mg/ml) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bradycardia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld

The patient is female admitted for elective placement of pacemaker for symptoms of bradycardia. Her co-morbidities include obesity, hypertension, CAD (coronary artery disease), MI (myocardial infarction) and OSA (obstructive sleep apnea).

The patient was hemodynamically stable, and she underwent an uncomplicated implantation. She was observed overnight, and she received IV (intravenous) antibiotics, lab and CXR (chest x-ray). She was discharged the next day.

No, the Inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

In this patient's case, an elective procedure was scheduled on an outpatient. Pacemaker implantation was uncomplicated as reflected in both cardiology and anesthesiology notes. None of the treatment or testing required a higher level of care.

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care.

There was no "complex" care that required inpatient level of care in this patient's care, post procedure. While there was always a potential for an adverse event, one did not happen, and no actual treatment was added. ASA (American Society of Anesthesiologists) score correlates with potential risk, not actual treatment given.

All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal Ideation
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The case involves a female diagnosed with longstanding schizoaffective disorder, depressed type. She presented to the emergency department with suicidal ideation, command auditory hallucinations prompting self-harm, and progressive chest pain with history of coronary artery disease. She was admitted to acute inpatient level services.

Inpatient Hospital Admission is medically necessary for this patient.
The patient's symptoms of psychosis (auditory hallucinations) and mood disorder with suicidal ideation together with continued risk of impulsive behavior, as well as the need for telemetry monitoring and cardiology and psychiatric consultation did warrant acute inpatient level structure and monitoring through discharge. The case is complicated by history of multiple suicide attempts, general medical comorbidity and recent active substance use with alcohol and cocaine. The risk for suicidal behavior, co-occurring substance use disorders, and treatment issues related to the need to rule out an acute coronary syndrome did necessitate the admission and inpatient stay. Additionally, the treatment team needed to arrange a clinically appropriate discharge plan with continued services at an acute inpatient level of care or with ACT (assertive community treatment) level services in the community to include safety monitoring and maintaining abstinence from substances of abuse with consideration of a referral for rehabilitation services. The continued inpatient stay thru discharge was therefore clinically appropriate and medical necessary in order to provide the necessary level of structure and monitoring, and the continued inpatient level structure and 24-hour monitoring with telemetry was medically necessary through the day of discharge when the patient had reached a level of stability that she could be discharged with clinically appropriate follow-up and aftercare.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient was a male with a past medical history significant for bronchial asthma and hemorrhoids who presented to the hospital with complaints of increased shortness of breath over the course of two days, which had been progressively worsening. The patient stated that he had a cough but denied fever, chills, nausea, vomiting, diaphoresis. It was reported that he ran out of his inhalers at home and did not have anything to give himself. This prompted his visit to the emergency department.
In the emergency department, the patient received treatment with albuterol, epinephrine, DuoNeb, magnesium sulfate, Solu-Medrol, and Dulera. The patient was admitted to the hospital with a diagnosis of severe persistent asthma with acute exacerbation. He was started on bronchodilators, nebulizers, Prednisone. The patient's respiratory status significantly improved while in the hospital. In fact, the discharging physician mentioned that the respiratory status improved quicker than expected.
The patient received a prescription for albuterol, and prednisone and was discharged home on the next day after the day of admission. At that time, the patient was in stable clinical condition. He was recommended to follow up with his primary care physician as an outpatient.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The hospital stated that the patient was hypoxemic and tachycardic with an increased respiratory rate while in the emergency department, which is true. The patient presented to the hospital with tachypnea and hypoxemia. However, after the patient received adequate treatment in the emergency department, his clinical condition significantly improved.
Taking into consideration all these facts, the patient presented to the hospital with acute asthma exacerbation, hypoxia, and tachypnea consistent with acute respiratory failure, however, his clinical condition improved quickly after he received treatment in the emergency department.
Since the patient's respiratory status has not recovered completely back to the baseline after the treatment provided in the emergency department, the admission to the hospital was reasonable.
At the same time, the acute asthma exacerbation was not associated with hemodynamic instability. The patient did not require any means of invasive or noninvasive mechanical ventilation. The asthma exacerbation was not associated with pneumonia, pneumothorax, or any other clinical condition requiring admission at the acute inpatient level of care.
The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Coronary Artery Disease/CAD.
Treatment: Pharmacy/Prescription Drugs/ Repatha.
The health plan denied the requested nonformulary prescription medication, Repatha. The health plan's determination is overturned.

This case involves a female with a history of mixed hyperlipidemia, cardiovascular disease, and severe intolerance to statin therapy who has been effectively treated with Repatha for hyperlipidemia. The patient has achieved significant benefit in low density lipoprotein (LDL) lowering and reduction in cardiovascular risk while taking Repatha. Repatha has been previously approved by the patient's health plan. However, due to change in the health plan formulary, PCSK9 inhibitor, Praluent has replaced Repatha which is now non-formulary. The patient's treating cardiologist has requested continued coverage for Repatha. Since Repatha is now non-formulary, coverage for Repatha has been denied due to the lack of medical necessity.

The health plan's determination of medical necessity for Repatha is overturned, in whole.

The patient has a history of mixed hyperlipidemia, cardiovascular disease, and significant intolerance to statin therapy due to severe myalgias. For these reasons, the patient has been appropriately treated with the PCSK9 inhibitor, Repatha for LDL lowering and cardiovascular risk reduction. Records show that the patient has tolerated the Repatha very well without side effects. Continued treatment with Repatha is both medically necessary and appropriate for continued LDL lowering and cardiovascular risk reduction as recommended by the patient's treating cardiologist. Due to change in formulary, Repatha is now a non-formulary medication. Given the patient's long-standing benefit with Repatha treatment, switching to Praluent is not appropriate nor in the best interest for medical management or safety of the patient in this case.

Repatha is medically necessary and appropriate for this patient for continued LDL lowering and cardiovascular risk reduction. The patient has achieved significant benefit in LDL lowering without side effects while taking Repatha, and switching to the alternative agent, Praluent, would not be in the best interest for treatment of hyperlipidemia in this case.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a male with type 2 diabetes on metformin, obesity, hypertension, hyperlipidemia, and atrial fibrillation who was referred to the emergency department by his primary care provider for a glucose > (greater than) 500 with urinary urgency, polydipsia, and genital yeast infection. He had one episode of vomiting. Blood pressure (BP) was 120/80, heart rate 80, respiratory rate 20, temperature 96.4, and O2 saturation 99%. Bicarbonate was 20.4 and potential hydrogen (pH) 7.37. He was treated with intravenous fluids, Lantus, and Lispro. His rash improved with clotrimazole.

The inpatient hospital admission was not medically necessary. This patient presented with hyperglycemia in the setting of known diabetes. He was hemodynamically stable. He had a genital yeast infection, but did not have evidence of sepsis or infection requiring admission. He had a mildly low carbon dioxide (CO2) of 21.6 (22-30) but with a normal pH and therefore, he did not have acidosis to support a diagnosis of diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar state. He did not have renal failure. His glucose improved with hydration and subcutaneous insulin therapy. Therefore, the requested inpatient hospital admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gynecological. 
Treatment: Infertility Treatment. 
The insurer denied In Vitro Fertilization using fresh eggs. 
The denial was overturned. 

The patient is a female seeking in vitro fertilization (IVF) for infertility. She has previously had oocyte cryopreservation performed for elective fertility preservation. She is requesting IVF using fresh eggs.
At issue is the medical necessity of In Vitro Fertilization using fresh eggs.

The health plan's determination of medical necessity is overturned in whole.

The requested health service of In Vitro Fertilization using fresh eggs is medically necessary for this patient.
The patient has previously cryopreserved eggs for use in the future, especially for a time when her fresh eggs will not be a viable option for creating a pregnancy. She has infertility and the current ability to use her fresh eggs to create viable embryos. Though oocyte cryopreservation is no longer experimental, it is not as efficacious as using fresh eggs to yield a viable pregnancy egg-for-egg. Using fresh eggs to create viable embryos now and saving the eggs cryopreserved, as is in this patient's case, is the best plan for her future fertility potential.
Therefore, In Vitro Fertilization using fresh eggs is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional 
Treatment: Pharmacy/Prescription Drugs 
The insurer denied Natesto. 
The denial was upheld. 

The patient is a male with history of anxiety, hypomania and hypogonadism, who presented with low testosterone and symptoms of low libido. The patient was started on a trial of Clomid after workup showed secondary hypogonadism. A magnetic resonance imaging (MRI) scan of the pituitary was normal. Clomid was discontinued and the medication Natesto was recommended.

At issue is the medical necessity of Natesto 5.5 milligrams (mg) gel.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Natesto 5.5 mg gel is not medically necessary for this patient.

The medication Natesto is not medically necessary, as the patient has not tried other testosterone formulations. Although the patient prefers not to do injectable therapy, there are other topical testosterone therapies that the patient has not tried. Additionally, although the provider states that Natesto is short acting and has less effects of spermatogenesis suppression, long term studies are still needed. (2) Another initial study that evaluated Natesto did not have a placebo group. (3) There are no studies to show that Natesto is superior to other testosterone formulations.

Therefore, the requested health service/treatment of Natesto 5.5 mg gel is not medically necessary.