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

Diagnosis: Exercise-induced rhabdomyolysis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with morbid obesity who presented to the hospital with bilateral lower extremity and low back pain following recent strenuous exercise.  The patient was afebrile with a blood pressure 134/90.  Labs were notable for a white blood cell count of 8.7, hemoglobin of 13.3, creatine kinase (CK) of 29,620, potassium of 4.4, bicarbonate of 25, sodium of 137, and creatinine of 0.7.  The urinalysis was negative.  Intravenous fluids and as needed analgesics were provided.  The CK level peaked at 41,670 before dropping to 16,216.  Pain improved.

No, the inpatient admission was not medically necessary.

The patient had evidence of exercise-induced rhabdomyolysis.  However, renal function remained normal, and there was no evidence of muscle necrosis.  There was no evidence of muscle weakness.  After a rise in CK to 41,670, it promptly dropped to 16,216.  There were no electrolyte abnormalities.  The urinalysis was negative.  The patient did not require intravenous fluid administration beyond observation level of care.  The patient did not have inability to maintain oral hydration and did not have altered mentation.  There was no evidence of pain requiring frequent or continuous administration of parenteral analgesics.  Inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the member in making its determination.
Appeal type: Medical necessity
Decision: Upheld

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

The patient was a female patient who had a history of hyperlipidemia, asthma, migraines, and allergy to unknown allergens. The patient had presented to the ER of the facility filing the appeal with the report of abdominal pain in the left lower quadrant. This pain was noted to be a severity of ten out of ten.  The patient also noted nausea, hematochezia four times, and a recent episode of hives which had resolved.

The patient noted a recent colonoscopy showed mild diverticulosis with bleeding after the procedure.  A computed tomography (CT) of the abdomen/pelvis showed severe colonic wall thickening and submucosal edema involving the splenic fixture and concerning for watershed ischemic colitis. The patient received intravenous (IV) morphine and a consultation was placed for surgery due to concerns about ischemic colitis.  Stool studies and a Gastroenterology (GI) consult were also requested. The patient received intravenous (IV) fluid and supportive care.

The patient was admitted with an impression of ischemic colitis, rule out (r/o) inflammatory bowel disease (IBD) versus infection. The patient was made nothing by mouth (NPO), was given IV fluids, IV Cipro, and IV Flagyl. On examination, the abdomen was non-distended, soft, diffusely tender to deep palpitation. The patient was found to have ischemic colitis of the splenic flexure. The lactic acid was 3.1; the calcium (Ca) was 4.49; the glucose was 134; the total bilirubin was 1.4.  

No, the proposed inpatient admission was not medically necessary.

The treatment as provided was medically appropriate but not medically necessary at the level at which the care was provided as described below.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had probable mild ischemic bowel; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged NPO status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/circulatory problems.
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial was upheld in whole. 

The patient is a female with a history of hypertension and diabetes. She presented to the emergency room complaining of left-sided chest pain that radiated down her left arm and was exacerbated by movement. It was associated with mild dyspnea. Her blood pressure was 109/68 millimeters of mercury (mmHg) with a heart rate of 86 beats/minute. Her room air oxygen saturation was 97%. Her cardiopulmonary exam was unremarkable.
An electrocardiogram showed sinus rhythm without acute ischemic changes. Her serum troponin level was normal. She was treated with aspirin and admitted to the hospital to rule out acute coronary syndrome. A repeat troponin level was normal. The patient's pain was thought to be musculoskeletal in origin. She was discharged. The subject under review is the medical necessity for an inpatient stay.

The health plan's determination is upheld in whole. 

This patient, with multiple cardiac risk factors, presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was reasonable and prudent. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient stay and could have been managed at a lower level of care status. This approach has been shown to be both safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems
Treatment: Dental/orthodontic procedure
The insurer denied the crown fabricated abutments as not medically necessary. The health plan's determination is upheld in whole.

The patient presents to the office of the dental provider for evaluation and treatment of implant teeth #4 and 5. There are panoramic radiographic images from an unknown date prior to implant placement in site #4 and 5 submitted for review. In question is the medical necessity of the planned treatment of crown abutments for implants #4 and 5 (6057).
The requested health service/treatment of crown fabricated abutments (6057), are not supported by the provided documentation and thus are not medically necessary.
There is no evidence provided by the provider for why there needs to be crown fabricated abutments for implant sites #4 and 5 and why a standard abutment could not support both restorations. The single radiographic image does not support the need for crown fabricated abutments and there are no clinical notes provided by the provider nor any other form of communication regarding the position of the implants, angulation, issues related to emergence profile, nor platform height relative to the opposing occlusion. There is no support for the planned treatment of crown fabricated abutments for implants #4 and 5 (6057), hence the requested treatment is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Kidney-Pancreas Transplant (Z94.0).
Treatment: Envarsus XR 4MG.
The insurer denied the Envarsus XR 4MG.
The denial is upheld. 

The patient is a male who underwent a kidney pancreas transplant.  The immunosuppressive regimen has included mycophenolate (the dose of which was increased during a recent hospitalization for neutropenia), prednisone, and Envarsus XR.

No, the health plan should not cover the proposed Envarsus XR four milligrams (4MG).

Published literature for cyclosporine formulations (including Gengraf) demonstrate it to be associated with a higher rate of acute and chronic rejection in kidney and pancreas transplants.  However, the patient has no contraindication to use of tacrolimus capsule; the patient has not failed or been intolerant to this medication.  In addition, a review of published literature demonstrates no statistically significant difference in side effects or organ rejection when comparing to tacrolimus and extended release to tacrolimus when subjects were studied out to four years.  In summary, the plan should not cover Envarsus XR.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleep apnea
Treatment: Sleep Center CPAP Titration Study 
The insurer denied the Sleep Center CPAP Titration Study.
The diagnosis is upheld.

The patient is a female who was diagnosed with severe obstructive sleep apnea (OSA).  The patient is using continuous positive airway pressure (CPAP) and is compliant with it.  The CPAP compliance data shows that the patient has used the CPAP 77% of the nights averages six hours 42 minutes.  The patient is set at seven centimeters (cm) of CPAP, the apnea hypopnea index (AHI) on seven cm of CPAP is 6.5, leakage is 5.5 liters (L) 95th percentile of the time.  The requested is for a repeat CPAP titration study.

No, the proposed sleep center CPAP titration study is not medically necessary.

Based on the information provided for this case, standard of care would be either empirically increasing the CPAP pressure and re-evaluating the patient's compliance in four weeks, or changing the fixed CPAP to AutoPap.  This would be as effective and safe as performing a repeat CPAP titration in the laboratory.  Therefore, repeating a CPAP titration in the laboratory to titrate the CPAP is not medically necessary in this patient as equally effective and safe alternatives as mentioned above are available.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Birth Control.
Treatment: NuvaRing.
The insurer denied NuvaRing.
The denial was overturned.  

This is a female patient who was maintained on Nuvaring brand and was doing well. It was noted that she tried the generic vaginal ring and experienced mood swings, acne, and breakthrough bleeding.

The insurer has denied coverage for the NuvaRing; preferred formulary alternatives were etonogestrel-ethinyl estradiol ring; Annovera-ethinly estradiol and segesterone. 

The provider explained that the patient had been on Nuvaring 0.12-0.015 mg/24hr ring for several years and had tried numerous alternatives such as Yaz 28 as well as generic etonogestrel-ethinyl estradiol ring which resulted in adverse reactions such as mood swings, acne, and breakthrough bleeding.

Combined (estrogen-progestin) hormonal contraception is available as an oral pill, transdermal patch, or vaginal ring and is highly effective when used consistently and correctly.  Commonly available combined hormonal contraceptive rings include the etonogestrel/ethinyl estradiol ring (ENG/EE, commercial name NuvaRing, EluRyng) and the segesterone acetate/ethinyl estradiol ring (SA/EE, commercial name Annovera).  The hormonal contraceptive vaginal rings offer the same benefits as the other estrogen-progestin combined methods but have the advantage that daily or weekly user compliance is not required. 

The etonogestrel/ethinyl estradiol (ENG/EE, commercial names NuvaRing, EluRyng) ring is a flexible device measuring 54 mm in diameter and 4 mm in cross-section that is worn vaginally for three weeks and then removed (and discarded) for one week.  Anoverra-segesterone acetate ethinyl estradiol is 56 mm in diameter and 8.4mm cross section- thus somewhat different than NuvaRyng. Also, the unintended pregnancy rate appears to be higher for Annovera. (Uptodate) 

With regard to the generic version of NuvaRing, the patient's physician indicates she has had adverse effects.  It should be noted that EluRyng was just approved at the end of 2019 and thus there is less information regarding its potential side effects since it was approved via the ANDA (abbreviated new drug application)  process. She has had success for many years now with NuvaRing. Annovera,the other formulary approved ring, in addition, to being a different combination also may have lesser efficacy. 

The carrier's denial of Request for Formulary Exception for NuvaRing is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Irritable Bowel Syndrome. 
Treatment: Omeprazole/Sodium Bicarbonate Capsules. 

The insurer denied coverage for Formulary Exception for Omeprazole/Sodium Bicarbonate Capsules. 

The denial is upheld. 

This female patient has a long history of chronic gastroesophageal reflux disease.  The chart indicates that she has failed multiple proton pump inhibitors (PPIs) and was taking Zegerid before she ran out.  She also had chronic constipation and iron deficient anemia. 

The American Gastroenterological Association (AGA) has published a guideline on the Management of Gastroesophageal Reflux Disease.  PPI therapy is a recommended treatment for gastroesophageal reflux disease (GERD).  The guideline states that circumstances in which one anti-secretory drug might be preferable to another relate to side effects or when rapid onset of medication is needed.  If there is a side effect then the patient should be switched to another PPI.  For rapid symptom relief, combining antacids with a PPI is advised. 

UpToDate has an article titled "Proton Pump Inhibitors: Overview of Use and Adverse Effects in the treatment of Acid Related Disorders."  The article states that a systematic review of 12 randomized trials examining the relative effectiveness of different PPI doses and dosing regimens found no consistent differences in symptoms resolution and esophageal healing rates.  It is advised to switch PPIs when there are side effects. 

This patient has GERD and requires PPI therapy.  However, it has not been shown in the medical literature that one PPI is superior to another.  The chart does not indicate that she had side effects to all of the formulary PPI alternatives.  The formulary drugs are not likely to cause the patient an adverse reaction.  The chart indicates that other PPIs have been tried, although there is no record submitted that Dexilant, Lansoprazole, and Pantoprazole have been tried.  The requested drug has not been shown to be more effective than the formulary drugs because all of the PPIs have been shown to have similar symptom resolution and esophagitis healing rates.  

The carrier's denial of the Request for Formulary Exception for Omeprazole/Sodium Bicarbonate Capsules is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute inflammatory demyelinating polyneuropathy
Treatment:  Continued SNF 
The insurer denied the Continued SNF.  The denial is upheld.

The continued stay in SNF rehabilitation from is not medically necessary and should not be covered by the health plan. 

The patient is a male with history of acute inflammatory demyelinating polyneuropathy (AIDP) involving the cranial nerves with associated complications including acute hypoxic respiratory failure with ventilator dependence, pneumonia, UTI (urinary tract infection), autonomic dysfunction with associated neurogenic bladder/bowel, dysphagia requiring PEG (percutaneous endoscopic gastrostomy) tube feeding and general debility with tracheal decannulation and PEG removal.  His is s/p (status post) IVIG (intravenous immunoglobulin).  He has relevant past medical history of Parsonage-Turner syndrome.

Prior to admission, the patient was independent working in real estate and active in swimming, running and biking, lived in a two story-house with his wife, three steps to enter and full-flight of stairs to second floor.

The patient was admitted to SNF (skilled nursing facility).  He was maximum-assist to dependent on bed-mobility, transfers, rolling side-to-side, supine-to-sit, sit-to-supine, feeding, grooming, bathing/dressing upper/lower extremities, toileting and unable to ambulate, although the video sent showed maximum assistance with ambulation in parallel bars with no date.

The plan is to DC (discharge) the patient to home and continue with outpatient PT/OT (physical therapy/occupational therapy).

The patient has no shown tangible improvement in rehabilitation.  He was admitted to SNF.  He was maximum-assist to dependent on bed-mobility, transfers, rolling side-to-side, supine-to-sit, sit-to-supine, feeding, grooming, bathing/dressing upper/lower extremities, toileting and unable to ambulate with no tangible change, although the video sent showed maximum assistance with ambulation in parallel bars with no date.

The continued SNF stay is not medically necessary, in whole or in part, and not reasonably expected to be beneficial for the patient, and/or withholding the treatment would not reasonably be expected to affect the patient's health adversely, as there is no documented evidence of the continued need to stay in the SNF rehabilitation.  The patient's status, as stated above, was such that the patient had not shown tangible improvement over a period of about four weeks of rehabilitation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sinusitis; right hand cellulitis
Treatment: inpatient admission
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

This patient is a female with past medical history significant for a liver disease, polysubstance abuse, and status post broken nose due to a recent fall, who presented to the Emergency Department with complaints of facial pain and right hand erythema. The patient's vitals on presentation included: Temperature 98.1 F, Blood Pressure128/82, Pulse-107, Respiratory Rate 18, O2 sat-100% on Room Air. Laboratory results included: WBC-7.47, Hgb-10.5, Hct-32.7, creatinine-0.66, glucose-106. The patient was started empirically on IV antibiotics (Vancomycin and Unasyn) for possible right hand cellulitis. CTA of the head showed opacification of the left maxillary sinus. CT scan of the spine showed mild degenerative disc disease. X-ray of the hand showed no acute fracture or evidence of osteomyelitis. Infectious Diseases consulted. The patient remained afebrile, hemodynamically stable and clinically improved. The patient was discharged on oral antibiotics to follow-up as an outpatient.

According to documentation, the patient presented with possible sinusitis from a previous nose fracture and right hand cellulitis. Otherwise, she was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. There was no evidence for a disseminated infection. The patient met criteria for observation level of care. Based on above finding, the patient did not meet criteria for acute inpatient admission.  
The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar II Disorder-depressed episode, and Alcohol and Substance Use Disorder
Treatment: Viibryd 10 mg or tabs
The insurer denied coverage for Viibryd 10 mg or tabs.
The denial is upheld. 

This patient is a male with a history of mood symptoms including depressed mood, irritable and angry mood which reportedly resulted in past legal and occupational issues. The patient's past history was significant for being a victim of physical and emotional abuse. The patient was noted to be in a major depressive episode, and his diagnoses included Bipolar II Disorder-depressed episode, and Alcohol and Substance Use Disorder. The patient reported past history of trialing on these following medications: Carbamazepine and Depakote as mood stabilizers, and Sertraline and Fluoxetine which resulted in sexual side effects, and also Bupropion which resulted in aggression as a side effect. The patient also reported taking Viibryd prior to taking Sertraline and Fluoxetine, and reported that the medication was effective in treating his symptoms. 

According to the Up to Date, first line medication for bipolar depression include quetiapine- a dopamine antagonist and lurasidone-a dopamine antagonist and among second line medications is Symbiax which is Olanzapine (also a dopamine antagonist) and Fluoxetine combination. Antidepressants are not first line medications for bipolar depression as they can increase the risk of manic or hypomanic episodes. Viibryd is an antidepressant FDA approved for major depressive disorder. It is a serotonin reuptake inhibitor and 5HT2 antagonist as well as a 5HT1A agonist. It was FDA approved for the treatment of major depressive disorder in 2011. It is not among the medications listed in Up to Date used to treat bipolar II disorder-depressed. There were no reports in the medical records that he tried and failed other FDA approved medication for bipolar depression. There was no reported medical record documenting that the patient tried FDA-approved Quetiapine, Lurasidone, and Symbiax which is Olanzapine and Fluoxetine combination) which are all FDA approved medications for bipolar depression which was this patient's primary diagnosis. In addition, Viibrdy is not included in the medications for bipolar depression in the Up to Date section.  Lastly a search of PubMed using the terms "vilazodone and depression and bipolar" yielded no results. As a result, the recommendation is to uphold the previous decision and deny the request for coverage for Viibryd for the treatment of bipolar depression.

It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interests of the patient then.

The carrier's denial of coverage for Viibryd 10 mg or tabs is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Likely drug-related rash 
Treatment: Inpatient hospital admission 

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

This patient is a male with a past medical history significant for an infection of the liver and hypertension who presented to the Emergency Department (ED) with complaints of fever and rash. The patient's vitals on presentation included; Temperature in triage was 36.8 C, Blood Pressure-110/72, Pulse-97, Respiratory Rate-20, Oxygen (O2) saturation-96% on Room Air. The patient's laboratory values were notable for the following: White blood Cell (WBC) count-4.9, Hemoglobin (Hgb)-14.3, Hematocrit (Hct)-41.6, creatinine-1.0, and glucose-92. The patient was admitted for a rash which started a couple days prior several days after starting the antibiotic. The impression was possibly secondary to allergic reaction to doxycycline (antibiotic) that he was taking for his left foot cellulitis.  The patient's computed tomography (CT) scan of chest and abdomen were negative. While in ED, his temperature increased to 38.4. Infectious Disease was consulted for possible infection. Their impression was "likely drug-related rash" and recommended holding medications. Hematology evaluated the patient for pancytopenia. All cultures remained negative. The patient remained afebrile, hemodynamically and clinically stable. The patient was discharged to continue outpatient management. 

According to documentation, the patient presented with allergic reaction, which was a skin rash to a medication, doxycycline. The patient's laboratory results were unremarkable, except for a mildly decreased platelet level. There was no evidence for a systemic infection or a severe allergic reaction. Based on the above findings, the patient met criteria for observation level of care. The patient did not fulfill the clinical criteria for acute inpatient hospitalization. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.