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

Diagnosis: Diabetic ketoacidosis (DKA).
Treatment: Inpatient hospital

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

According to the medical records, this is an adult male with a history of type 1 diabetes, asthma, coronary artery disease (CAD), hypertension, and alcohol abuse. He presented to the emergency room (ER) with complaints of hyperglycemia. He reported being unable to use insulin for one day because of quarantining from a COVID (coronavirus) exposure. The patient was on 30 units of Lantus a day and 16 units of Lispro with meals. His blood pressure was 134/80, heart rate was 127, respiratory rate was 20, temperature 98.6, and oxygen saturation was 98% on room air. Labs revealed with a glucose level of 631, anion gap (AG) of 21.5, bicarbonate ion (HCO3) 17.5, sodium 133, chloride 94, blood urea nitrogen (BUN) 27, creatinine 1.31, blood gas 7.29/40, lactate 2.7, beta hydroxybutyrate 4.5, and glycated hemoglobin (A1c) 12.4. The urinalysis showed glucose and ketones. The patient was started on an insulin drip and two liters of intravenous (IV) fluids. A chest x-ray was negative for infiltrate. The patient was admitted for inpatient care. Intravenous (IV) fluids were given with electrolytes replaced, and his home medications were continued. The patient's DKA resolved, and he was discharged.

According to Dhatariya, K. K., & Vellanki, P., "The US guidelines suggest using a glucose threshold of >250 mg/dL [milligrams per deciliter] (13.9 mmol/L [minimoles per liter]), presence of positive serum and urine ketones with an anion gap, and arterial pH [potential hydrogen] <7.3 to make the diagnosis of DKA."

Lizzo JM, et al. write that, "Commonly accepted criteria for diabetic ketoacidosis are blood glucose greater than 250 mg/dl, arterial pH less than 7.3, serum bicarbonate less than 15, and the presence of ketonemia or ketonuria. The normal anion gap is 12. Anion gap greater than 14-15 indicates the presence of an increased anion gap metabolic acidosis.[17] Arterial pH may be normal or even raised if other types of metabolic or respiratory alkalosis coexist."

While the patient met criteria for DKA upon arrival, he improved after receiving an insulin drip treatment in the ER (emergency room). Specifically, upon arrival he had an elevated anion gap of greater than 10, urine ketones, elevated glucose of greater than 250, and low serum bicarbonate, but after treatment his bicarbonate was 42, and his blood glucose had improved. The patient remained stable, and he did not have any acute process that would meet admission criteria. 
 
Based on the medical facts from the available records, the hospital admission was not considered medically necessary treatment for the patient's condition. 

The inpatient hospital admission is considered not medically necessary for this patient, as he already improved after acute treatment. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Crisis.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male with sickle cell anemia.

The patient presented to the emergency department.  He was afebrile. His heart rate was 87, blood pressure 129/70, and temperature 98.7.  His CXR (chest x-ray) and UA (urinalysis) were normal.  He was given IV (intravenous) fluids and morphine, with no improvement.  He was given further morphine then Dilaudid, and then admitted. 

No, the Inpatient admission was not medically necessary.

This patient could have been managed in a lower level of care such as observational status on the dates of service in question. Uncomplicated sickle cell pain crisis does not warrant acute level hospitalization.  These individuals can be managed on observational status initially according to the MCG (Milliman Care Guidelines).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: S/P (status post) CVA (cerebrovascular accident).
Treatment: Long Term Custodial Care Service.

The insurer denied the Long Term Custodial Care Service.  The denial is overturned. 

The patient is a male with a history of prostate cancer, acute prostatitis, mixed hyperlipidemia, schizophrenia, heart failure, hypothyroidism, vitamin deficiency, and nicotine dependence.  He was admitted to the facility from another nursing home due to CVA (cerebrovascular accident) with residual left hemiparesis.

The appeal is denial of long term custodial care service.  The request was denied because the patient does not need help with ADLs (activities of daily living).  He is able to ambulate and perform ADLs (activities of daily living).  Clinical notes indicate that the patient requires supervision with ADLs (activities of daily living) and help with part of bathing.  He requires reminders with medications due to short attention span and is noncompliant due to paranoia.  He is on half hour monitoring due to elopement risk.  Psychiatry indicates that the patient is not able to make his own medical decisions and needs supervised living.

Yes, the Long Term Custodial Care Service is medically necessary.

Medically necessary services are those which are:  1) safe, 2) effective, 3) generally accepted national standard of medical practice, 4) not provided primarily for convenience of the patient or the practitioner, and 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested long term custodial care service is medically necessary, because it is in accordance with generally accepted national standard of medical practice.

Custodial care is care primarily for the purpose of assisting a patient in ADLs (activities of daily living) or in meeting personal rather than medical needs and which is not specific treatment for an illness or injury.  Supervision of medication that usually can be self-administered is considered custodial care.  This patient is able to perform ADLs (activities of daily living).  However, he requires assistance with medication administration.  Psychiatry notes that the patient is unable to make medical decisions and needs supervised living.  Long term custodial care service is medically necessary to meet this patient's needs of supervision with medication management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melanoma

Treatment for bone and/or joint imaging whole body, a special picture study of the whole body using a nuclear radiotracer

The insurer denied coverage for bone and/or joint imaging whole body, a special picture study of the whole body using a nuclear radiotracer.

The denial is upheld.

According to the medical records, the patient has a history of melanoma. The attending provider (AP) has requested positron emission tomography-computed tomography (PET/CT) for surveillance.

Swetter et al in the recently published guidelines note that "Regular clinical follow-up is recommended as the most important means of detecting CM [cutaneous melanoma] recurrence. Findings from the history (review of systems) and physical examination should direct the need for further radiologic or laboratory studies to detect local, regional, and distant metastatic disease." They further state "The utility of PET-CT, CT [computed tomography], and MRI [magnetic resonance imaging] in CM surveillance is directly correlated to the stage of disease, meaning that patients with stage III [3] and IV [4] CM are more likely to demonstrate clinically occult metastasis than are patients with stage I [1] or II [2] disease. The highest yield of imaging occurs when a patient is disease recurrence." Therefore, bone and/or joint imaging whole body, a special picture study of the whole body using a nuclear radiotracer is considered not medically necessary for this patient.

"FDG [fluorodeoxyglucose ] PET/CT is an important clinical tool for cancer evaluation because it combines metabolic and anatomic imaging to provide guidance in staging locoregional and distant metastases, as well as monitoring response to therapy. However, the utility of FDG PET/CT in cancer varies based on the cancer type, stage, and clinical course. Knowledge of the particular indications in which FDG PET/CT is best utilized is important to appropriately guide clinicians to order the correct study, ensure optimized protocols for imaging, and generate relevant reports." (Anderson, T. 2017)

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.      

The use of routine PET/CT for surveillance of resected melanoma is of no established benefit. The National Comprehensive Cancer Network (NCCN) states that the use of surveillance imaging is a 2b (may be considered) recommendation.  Either CT or PET/CT can be used and therefore the AP can use a CT scan.  The majority of the studies of imaging in melanoma are retrospective and not surprisingly the majority of recurrences are discovered by physical exam and laboratory values. 

The insurer's denial of coverage for bone and/or joint imaging whole body, a special picture study of the whole body using a nuclear radiotracer is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes Mellitus with Hyperglycemia
Treatment: Formulary exception for Invokamet, Pre-service
The insurer denied the Formulary exception for Invokamet, Pre-service.
The denial is upheld. 

The patient is a female diagnosed with T2DM (type 2 diabetes mellitus) with hyperglycemia. This request is for Invokamet. As reported, her A1C (glycated hemoglobin) was 6.4 % when she was on Invokamet 50-1000 mg (milligrams), which had decreased from 7.3 %. She was prescribed Xigduo XR (extended release), Onglyza, and metformin. She was unable to tolerate these due to adverse side effects, including nausea, malaise, and vomiting.

No, the health plan should not cover the Formulary exception for Invokamet.
Farxiga (Dapagliflozin), Jardiance (Empagliflozin) and Invokana (Canagliflozin) are SGLT-2 (sodium-glucose cotransporter-2) inhibitors used to treat type II diabetes [1, 2]. SGLT-2 (sodium-glucose cotransporter-2) inhibitors are good options for treating diabetes, based on the latest American Association of Clinical Endocrinologists recommendations [3-6]. They are at the same level as GLP1 (glucagon-like peptide-1) agonists and DPP4 (Dipeptidyl Peptidase-4) inhibitors on the latest AACE (American Association of Clinical Endocrinologists recommendations) recommendations [6].

The requested medication is a combination of metformin and Invokana. There are no studies showing superiority of the requested medication over the formulary alternative Synjardy or Synjardy XR (extended release). The side effect profile is similar between the requested medication and the formulary alternatives.  The patient can try the formulary alternatives. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructive sleep apnea.
Treatment: Polysomnography (95810 x 1) in a sleep center.
The insurer denied the Polysomnography (95810 x 1) in a sleep center.
The denial is upheld. 

The patient is a male with obstructive sleep apnea. He is having difficulty wearing his CPAP (continuous positive airway pressure).  He is suspected by his primary to have central sleep apnea, and therefore an in-lab sleep study was ordered.  The patient is on chronic steroid use after pituitary surgery, and he has gained 60 pounds in relation to the steroid use.

No, the Polysomnography (95810 x 1) in a sleep center is not medically necessary.
Medical necessity for the in-lab study was not established. As noted in the prior denial, the patient could have a split night study ordered, which would give the diagnostic information necessary to determine if the patient has central apnea, as the provider asks. Additionally, therapeutic parameters for servo ventilation and CPAP (continuous positive airway pressure) settings could be determined simultaneously.

The recommendation for the patient to have a split night study is appropriate and represents the best interests of the patient for diagnosis and plan for therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal Muscular Atrophy.
Treatment: Evrysdi, Pre-service.
The insurer denied the Evrysdi, Pre-service.
The denial is upheld. 

The patient is a male with a history of spinal muscular atrophy (SMA) type II. His diagnosis has been confirmed via genetic testing that showed homozygous deletion of survival motor neuron one (SMN1) and three copies of survival motor neuron two (SMN2). The patient's symptoms (of spinal muscular atrophy) were first noticed at four months of age. He had an electromyogram (EMG) showing findings consistent with Werdnig-Hoffman syndrome. He underwent gastrostomy (G)-tube placement. He was enrolled in the IONIS clinical trial (Spinraza) and was in the placebo arm of the trial. He was then enrolled in the open label extension. At a pediatric neurology follow-up visit, the patient's mother expressed interest in starting Evrysdi while the patient was on Spinraza.  At pediatric neurology follow-up visit, the patient's most recent Expanded Hammersmith Functional Motor Scale (HFSME) score was 11. His Revised Upper Limb Module (RULM) scores were 14 and 15.

No, the requested Evrysdi is not medically necessary.
The medical records provided for review readily support that the patient has a history of spinal muscular atrophy (SMA). He is noted to have previously been treated with Spinraza (via the IONIS clinical trial and the open label follow-up study). The notes from the neurology visit indicated that the patient's mother was seeking coverage of Spinraza and Evrysdi concurrently. The follow-up note was silent on any recent or continued use of Spinraza. In this setting, it cannot be confirmed that Evrysdi would be used in a manner consistent with the way in which it has otherwise been studied to date (as monotherapy for spinal muscular atrophy).

It is noted that the patient has spinal muscular atrophy - a condition for which Evrysdi is Food and Drug Administration (FDA) approved for use. However, the issue in this case was one of the "appropriate" use of the requested medication. As noted earlier, the notes from the neurology follow-up visit suggested that the patient would be using this drug concurrently with Spinraza.  

Evrysdi has only been studied to date (and continues to be studied) as "monotherapy" for spinal muscular atrophy (SMA). There is not yet literature available showing that the concurrent use of Evrysdi with Spinraza affords any benefits to patients. 

It was otherwise unclear from the most recent medical records provided for review if the patient is going to remain on Spinraza (were therapy to Evrysdi be approved). Given that the drugs have not been studied together and there is a lack of information in the medical records provided about the proposed course of therapy, medical necessity is not supported at this time.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Multiple Sclerosis
Treatment Mavenclad
The insurer denied coverage for Mavenclad
The denial is upheld

The patient is a male currently diagnosed with relapsing-remitting multiple sclerosis (MS). The patient noted he was doing well until a week and a half before the office visit when he started noticing some issue with gait unsteadiness, which had persisted, though slightly improved. The patient underwent a magnetic resonance imaging (MRI) of the brain showing a small new enhancing right superior cerebellar peduncle demyelinating lesion. The patient was on the medication Rebif Rebidose. The provider indicated after discussing the pros and cons of different medications, the provider decided to start the patient on Mavenclad. The patient was also to undergo a 3-day course of Solu-Medrol.  

The appeal letter noted that the provider decided that Mavenclad would be the appropriate medication to switch to since there was a recent new lesion. Mavenclad was noted to be perfect because it consisted of 2 months of treatment per year and was finished after year two.

The medical literature notes that Mavenclad is a purine antimetabolite indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include relapsing-remitting disease and active secondary progressive disease, in adults. As per UpToDate  "Cladribine is approved in the United States by the Food and Drug Administration (FDA) for the treatment of adults with relapsing forms of MS, including relapsing remitting multiple sclerosis (RRMS) and active secondary-progressive multiple sclerosis (SPMS). Because of its adverse effect profile, cladribine is generally reserved for patients who do not tolerate or have inadequate response to other drugs for MS." (2)

The formulary drugs are not likely to cause the patient an adverse reaction. The only formulary medication that had been trialed was Rebif (interferon beta-1a) per the numerous office visits that were provided. The formulary drug Rebif would be considered ineffective based on the new finding for the MRI. There are no published studies that have compared Mavenclad with all of the formulary medications for use and superiority. As per UpToDate, when there is inadequate response to interferon, "escalation can be achieved by switching to high-efficacy infusion disease modifying therapies (DMT) using natalizumab or ocrelizumab, or by switching to intermediate-efficacy oral DMT using a fumarate (dimethyl fumarate or bioequivalent) or a sphingosine 1-phosphate receptor modulator (eg, fingolimod, siponimod, ozanimod)." (3)

There is no indication the requested drug would be more effective than the formulary drugs which include dimethyl fumarate, Gilenya, Mayzent, or Zeposia. Therefore, the formulary exception of Mavenclad is not supported.

The insurer's denial of coverage for Formulary Exception for Mavenclad is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growing thyroid nodule.

Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission. 

The denial is overturned. 

This is a female patient with a history of a growing thyroid nodule. She complained of choking due to compression who presented to the hospital for a scheduled thyroidectomy. She had a history of high blood pressure. She was found to have large 6 centimeter (cm) left thyroid nodule and a 3cm isthmus nodule.  She underwent a total thyroidectomy. The procedure note described the large nodule pushing the trachea over to the right, adhered to trachea and recurrent laryngeal nerve. The nurses note stated " transfer to floor in fair condition with tracheostomy tray at bedside." The operative note describes " sudden rapid growth...causing compressive symptoms of choking and dysphagia and mild dyspnea. CAT [Computerized Axial Tomography] scan revealed a large compressive goiter pushing the trachea, displacing the trachea to the right." The postoperative note describes "resting comfortably...admits to sore throat...without hoarseness or voice changes...no complications." 

A typical total thyroidectomy patient can go home from the hospital as ambulatory or observational. This patient has multiple potentially problematic issues. The surgery and CAT scan showed she had tracheal deviation which is indicative of tracheal/airway narrowing or compromise. That narrowing won't simply go away immediately once the mass is removed because of post-operative swelling and any blood collection subcutaneously (even if there is no visible hematoma there is always some degree of blood internally and this can compress the trachea - thyroids tend to bleed intraoperatively and postoperatively). She had preoperative " sudden rapid growth...causing compressive symptoms of choking and dysphagia and mild dyspnea...CAT scan revealed a large compressive goiter pushing the trachea, displacing the trachea to the right." These are all potentially worrisome problems that can further manifest postoperatively. The note describes that she had a tracheostomy set at the bedside which is indicative of the concern for her airway. The mass on CAT scan and the operative report and in the photo was very substantial and its removal would create a dead space in which fluid or blood could accumulate causing compression (even if the dead space was filled intra-operatively). She also has hypertension which can increase bleeding risks.  Lastly, if she went home ambulatory or observational and had bleeding, her inability to get a transfusion could have been an issue. Overall, she appears to have had an increased risk of post-operative airway complications. Her post-operative course was in fact uneventful but that does not negate her increased risks. It would appear that her hospital stay would be most consistent with an admission. 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 full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a female with history of acute low back pain radiating into the left leg. The pain is associated with numbness and severe weakness, with inability to move the left lower extremity. She presented to the ED (emergency department). She was previously in the ED (emergency department) two days prior and discharged. She returned because of increasing pain and inability to move left lower extremity.

The ED (emergency department) physician noted increased weakness when she presented with muscle strength of 2/5 with decreased sensation, paresthesia, with inability to ambulate. She was admitted to control her pain and further evaluation for the weakness. She was treated with pain medications and oral steroid with improvement. She was admitted to acute medical unit due to difficulty in ambulation and high risk of fall. The admission was to further workup in view of her high risk of fall. 

The patient was also followed by Neurosurgery. MRI (magnetic resonance imaging) showed multiple level DDD (degenerative disc disease) and mild spinal stenosis. She has relevant past medical history of chronic low back pain, and lumbar herniated disc.

Yes, the Inpatient admission was medically necessary.
The patient was admitted for severe acute low back pain radiating into Left extremity with associated weakness, numbness and tingling, difficulty in ambulation, difficulty in weight-bearing with high risk of fall. The patient had been in the previous 24 hours discharged from the same ED (emergency department) and returned with worse symptoms and signs. The medical necessity for admission to discharge was met, because at presentation in the ED (emergency department), as stated above, it was clinically prudent to admit her to ensure that she was stable before discharge home.

The acute inpatient admission was medically necessary, with clinical evidence, that is was reasonably expected to be health beneficial for the patient, and withholding it, in whole or in part, would have been reasonably expected to affect the patient's health adversely. The patient was in hospital with such history as stated above, making it clinically prudent to admit her to ensure that she was stable before discharge home.