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

Diagnosis: Alzheimer's disease, osteoarthritis, anemia, and urinary incontinence
Treatment: Increase Personal Care Aide (PCA) Services to a Split Shift for a Total Amount of 168 Hours per Week
The insurer denied: Increase Personal Care Aide (PCA) Services to a Split Shift for a Total Amount of 168 Hours per Week
The denial is upheld.

This is an elderly male patient that has medical conditions that include Alzheimer's disease, osteoarthritis, anemia, and urinary incontinence. The denial of an increase in personal care aide 
(PCA) services to a split shift for a total amount of 168 hours per week is being appealed. The health plan approved a total of 66.5 hours per week. The Uniform Assessment System (UAS) evaluation completed 5 months ago shows severely impaired cognition and functional status requires maximal assistance to total dependence with all activities of daily living (ADLs). The patient has a bladder catheter and occasional bowel incontinence. Compared to the Uniform Assessment System evaluation completed last year, there has been a decline with personal hygiene and locomotion.

The requested health service is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous 
or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual who needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions, including severe cognitive impairment due to Alzheimer's disease. The denial of an increase in personal care aide (PCA) services to a split 
shift for a total amount of 168 hours per week is being appealed. The health plan approved a total of 66.5 hours per week. The Uniform Assessment System (UAS) evaluation completed 5 months ago shows the patient needs maximal assistance to total dependence with all activities of daily life (ADLs). He has an indwelling catheter and occasional bowel incontinence. Compared to the Uniform Assessment System evaluation complete last year, there has been a decline with personal hygiene and locomotion. The information provided does not support that the patient has continuous needs that would not allow an aide five hours daily of uninterrupted sleep during the aide's shift. Personal care aide is not indicated for safety supervision. The requested increase in personal care aide to a split shift for a total amount of 168 hours per week is not medically indicated.
Appeal type: Formulary Exception
Decision: Upheld

Immunologic Disorders
Pharmacy/Prescription Drugs

Diagnosis: Food Allergy
Treatment: Auvi-Q

The health plan denied: Auvi-Q
The decision is: Upheld

The patient is a male with a history of food allergies. The request is for Auvi Q. This is preferred due to anxiety.

The health plan's determination for request of Auvi Q is upheld in whole.

The alternatives are epinephrine auto-injector, EpiPen, and EpiPen JR., which have not been shown to be ineffective or have adverse effects. A trial would be reasonable. In this case, the patient has anxiety and prefers Auvi Q. Anxiety is not a contraindication to the alternatives, and the alternatives can be tried for his food allergies.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine headaches

Treatment: Nurtec 75 milligram (mg) oral disintegrating tablet (ODT)

The insurer denied coverage for Nurtec 75 milligram (mg) oral disintegrating tablet (ODT).

The denial is upheld. 

This patient suffers from Migraine headaches and was tried on the following preventative medications: Topamax and Amitriptyline, and in terms of abortive therapies has failed Rizatriptan and Sumatriptan. 

This patient has failed the standard medications used for the prophylactic management of migraines and should be placed on the next level of medications called the Calcitonin gene-related peptide inhibitors (CGRP's).  These agents include Ajovy, Aemovig and Egality. The oral counterparts are the Nurtec and Qulipta.

Based on the current literature, the decision to deny Nurtec is upheld because of the above indicated reasons that other Subcutaneous medications approved by the insurance plan, Ajovy and Egality and the other oral CGRP medication called Qulipta which is also on formulary and should be tried first. As per Up to Date, "Small-molecule CGRP antagonists ("gepants") are oral agents first shown effective for acute migraine treatment. Rimegepant (Nurtec) and atogepant (Qulipta) are orally formulated gepants that have also shown benefit for migraine prevention." 

The formulary drug(s) is not likely to cause the patient an adverse reaction.

The formulary drug(s) has not been ineffective based on the patient's clinical history. As the patient was never tried on the formulary medications. 

The requested drug would not be more effective than the formulary drug. Qulipta (atogepan) should be equivalent in efficacy as Nurtec. 

The decision to deny Nurtec is therefore upheld.

The carrier's denial of a request for a Formulary Exception for Nurtec 75 milligram (mg) oral disintegrating tablet (ODT) to treat migraine is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Proteinuria.
Treatment:  Farxiga 10 mg (milligrams) Tablet.
  
The insurer denied Farxiga 10 mg (milligrams) Tablet.  The health plan's determination is upheld in whole.

This is a case review for a patient prescribed Farxiga 10 milligrams (mg) tablets for the diagnosis of proteinuria. Coverage for this medication was denied by the health plan, and this denial is the subject under review.

The health plan denied coverage for this non formulary medication because they were unable to establish that the patient has had a trial of one of the formulary alternatives. The formulary alternative available to treat the patient's condition is Jardiance. There is no documentation that the formulary alternative will likely be ineffective or less effective than the requested medication, would cause an adverse effect, or would not be tolerated by the patient.

Office visit notes were provided for review. The patient is treated for essential hypertension, hypertriglyceridemia, and hypothyroidism. The patient received routine blood work to monitor these conditions and was found to have an elevated urine microalbumin. The requested medication was started due to this result. There is no discussion of a type 2 diabetes diagnosis or congestive heart failure diagnosis in the notes submitted for review.

For patients with chronic non-diabetic kidney disease with proteinuria, defined as albuminuria of greater than or equal to 300 milligrams (mg) per day, current guidelines recommend beginning a sodium-glucose cotransporter-2 inhibitor (SGLT-2) medication to slow the progression of chronic kidney disease. This is based on results of a large randomized controlled trial where patients with elevated microalbumin excretion were randomly assigned to either empagliflozin or placebo. Treatment with empagliflozin showed favorable outcomes in progression of renal disease and all-cause mortality. Therefore, recommendations are now for SGLT-2 inhibitor therapy in patients with non-diabetic chronic kidney disease and albuminuria (Curhan).

This new recommendation does not specify any particular drug in the SGLT-2 inhibitor class as preferable. Empagliflozin, also known as the brand name Jardiance, is available on the plan formulary and is a medication which has shown to be effective in treating this condition. Therefore, the requested exemption for the non-formulary drug Farxiga is not more effective than the formulary drug for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Acute respiratory failure
Treatment: Inpatient stay- LTACH (Long-Term Acute Care Hospital)
The Health Plan denied the LTACH admission as not medically necessary. The reviewer has upheld in whole the Health Plan's determination.

The patient has a past medical history of hypertension, hyperlipidemia, coronary artery disease, non-insulin dependent diabetes mellitus, chronic obstructive pulmonary disease, peripheral arterial disease, previous cerebrovascular accident with left hemiplegia who was initially admitted for acute hypercapnic respiratory failure secondary to hemorrhagic cerebrovascular accident requiring feeding tube placement and tracheostomy placement with nocturnal mechanical ventilator dependence. Currently, the patient still requires ventilator support during the night and is on tracheostomy collar during the daytime. He has failed one trial of nocturnal mechanical pressure support ventilation.
At issue is the medical necessity of the admission to the Long-Term Acute Care Hospital. 

The requested health service/treatment of Long-Term Acute Care Hospital (LTACH) Stay is not medically necessary for this patient at this time.
This patient was admitted for acute hypercapnic respiratory failure secondary hemorrhagic cerebrovascular accident requiring feeding tube placement and tracheostomy placement with nocturnal mechanical ventilator dependence. Per the most recent clinical information, the patient is afebrile, hemodynamically stable, awake, and responsive, is on tracheostomy collar (fraction of inspired oxygen (FiO2) 40%[percent]) during the day but is still requiring pressure support ventilation during the night (positive end-expiratory pressure of 10-centimeter (cm) water (H2O) and FiO2 40%[percent]). The patient should be able to wean from the ventilator as evident by tolerating tracheostomy collar during the daytime. In addition, the patient is not on any antibiotics, does not have any severe electrolyte abnormalities, has stable renal and liver function testing, and does not have any severe anemia or bleeding diathesis. However, the patient is only documented to have failed one trial off the ventilator during the night. Although the patient has a wound vac, there is no documentation that the wound would require more than minimal wound care or require daily physician supervision due to necrosis or need for debridement. Currently, he is doing physical therapy for less than 1 hour per day with moderate assistance and the physical therapist recommends skilled nursing facility on discharge for continued rehabilitation. In addition, there is no documentation to support the need for frequent nursing care for greater than 6.5 hours per day or daily physician assessments and there are no physical therapy notes documenting he would benefit from acute rehabilitation at an LTACH (Long-Term Acute Care Hospital) level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep bite and gum damage
Treatment: D8080 Comprehensive Orthodontic Treatment
The insurer denied D8080 Comprehensive Orthodontic Treatment.
The denial is overturned.

The patient is a teenage male. The request is for orthodontic treatment. The patient has severe upper and lower jaw crowding. He has a deep bite and gum damage due to bite. There is moderate upper and lower anterior incisor protrusion. The prior denial was due to a handicapping index score of 19.

The requested health service is medically necessary.

The patient has multiple permanent anterior teeth in crossbite. He also has clinical attachment loss and recession of the gingival margins. These are automatic qualifiers for orthodontic treatment according to the handicapping index scale. This case has medical necessity, and orthodontic treatment is needed to correct the malocclusion.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizure.
Treatment:  Inpatient admission.

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

This case involves a patient seeking coverage for the inpatient admission.  The patient presented to the hospital.  There was a history of hypertension, anemia, migraine headache, and traumatic brain injury.  The patient reported that they had an episode of seizure activity with admission to the hospital with testing completed.  The patient denied being prescribed seizure medication. The patient's roommate reported that the patient had a seizure. The patient stated that they awoke with emergency medical services standing over them. The patient described a mild headache.  There was a small cut to the left tongue. Vital signs of the patient with emergency medical services noted blood sugar of 108, blood pressure 147/73, heart rate of 101 and regular, and oxygen saturation of 99% (percent) on room air.  The patient had 5 out of 5 strength in the bilateral upper and lower extremities.  The patient's sensation was intact.  There was a plan to admit the patient to medicine for laboratory testing and computed tomography of the head. Laboratory results noted potassium of 3.5, glucose of 87, platelets of 137, creatinine of 0.8, and blood urea nitrogen (BUN) of 10.  A computed tomography (CT) of the head noted normal findings. The patient had a witnessed seizure while at the hospital and Ativan was given. The patient stopped seizing after approximately 1.5 minutes.  The patient was followed by neurology.  Magnetic resonance imaging of the brain showed no acute findings. The patient was started on Keppra and there was a plan for outpatient electroencephalogram. The patient was deemed appropriate for discharge.

In this case, the patient presented to the hospital with reported witnessed seizure.  The patient had a second seizure while in the hospital.  It was argued that the inpatient admission was medically necessary.  The patient's care could not have been completed in the outpatient setting per the hospital.  Breakthrough seizures could be extremely unpredictable and may result in very rapid progression and decompensation.  An inpatient admission was the only reasonable course of action for the patient.  However, while the documentation reported recurrent seizure in a patient with baseline of infrequent seizures, the recurrence was readily modifiable with medication management.  Thus, the patient's care could have been completed at a lower level such as observation to establish appropriate medication regimen and for ongoing monitoring.  As such, the denial of coverage for the inpatient admission is upheld.

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

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

Diagnosis: Ruptured brain aneurysm
Treatment: Medical Equipment (E0261 x1, E0185x 1) Semi-Electric Hospital Bed and a Special Mattress
The insurer denied: Medical Equipment (E0261 x1, E0185x 1) Semi-Electric Hospital Bed and a Special Mattress
The denial is overturned.

The patient is an adult female. She has a past medical history of ruptured brain aneurysm status post nine brain operations, status post percutaneous endoscopic gastrostomy (PEG) tube displacement, urinary incontinence, congestive heart failure (CHF) with supraventricular tachycardia (SVT), and deconditioning (generalized muscle weakness) who is non-ambulatory and wheelchair dependent. A hospital bed is being requested. Her previous appeal was denied coverage by the health plan due to it being deemed not medically necessary.
Notes indicate that the patient is severely debilitated, unable to care for self, and at risk for pressure injury, aspiration, and further medical complications. The denial letter notes, "Records do not show that you have a condition that requires special body positioning medically necessary for your condition. ... Records do not show that you have a condition that that requires special body positioning that is not possible in an ordinary bed with 
the use of wedges or pillows. Records do no show that you require head elevation more than 30 degrees for serious hear or choking swallowing problems, we do not see that you need frequent and immediate changes in body position that you can make happen by yourself with bed controls, your records do not show that you are completely unable to move or that you are unable to make any changes in your body position enough to relieve pressure." The denial is being appealed.

The requested health service is medically necessary.

Notes indicate that patient is severely debilitated due to brain aneurysm rupture status post multiple brain surgeries. She has urinary incontinence, immobility and generalized weakness that leads her to be unable to care for herself. She is at risk for pressure injury, aspiration, and further medical complications without the proper medical equipment. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fall
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department (ED) following a fall down 3-4 steps. His comorbid health conditions included diabetes. The emergency department (ED) and trauma history and physicals (H&Ps) indicate that the initial vital signs included an elevated respiratory rate of 24 breaths/minute. The heart rate was normal at 78 beats/minute. There was no reported loss of consciousness. He was initially evaluated in the ED. The oxygen saturation was 98 percent (%) on room air. At the time of surgical assessment, the Glasgow coma score was 15/15. His evaluation with a physical exam and imaging identified rib fractures of the right ribs 8-10.
He was admitted to the hospital per the trauma service. He was treated with multimodal pain medication and incentive spirometry. He was cleared to ambulate. His diet was advanced. The patient was evaluated by the physical therapy service. He was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.
An inpatient level of care was not medically necessary per medical standards for this patient.
The care and treatment provided could have been rendered with a lower level of care. This patient presented to the ED following a fall down 3-4 steps. He was clinically stable at the time of presentation. While the respiratory rate was elevated at the time of presentation, this normalized on subsequent assessment. He was able to ambulate and was able to tolerate a diet. He was provided pain medications and physical therapy was requested. He remained clinically stable throughout the period of monitoring. An lower level of care would have provided for the treatment necessary for this patient. He was found to have right sided rib fractures of ribs 8-10. These injuries did not require operative treatment.
The Milliman Care Guidelines (MCG) [1] state that inpatient admission may be indicated in the setting of rib fractures for hemodynamic instability, flail chest, acute respiratory failure, pain management that requires inpatient treatment, associated injury, infection, new hypoxemia, tachypnea that persists despite observation care, immediate surgery needed. In this case, these conditions did not exist to warrant inpatient care. Pain management was with a combination of oral medications. He was stable for discharge in less than one day of presentation. The care provided in this case could have reasonably and appropriately been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult male with a history of coronary artery disease and chronic obstructive pulmonary disease. He presented after passing out four days ago. He has a history of vertigo. The patient's vital signs were stable, and he was afebrile. His exam was unremarkable. Computed tomographic angiography (CTA) of the neck showed no stenosis. Computed tomography (CT) of the brain showed no acute disease. Chest x-ray showed no acute disease. Pertinent labs revealed hemoglobin 11.5. Electrocardiogram (EKG) showed sinus rhythm with right bundle branch block (RBBB). The patient was admitted for a syncope workup. A psychiatry consultation was performed. On day #3, the orthostatic tests were negative. Echocardiogram had no valvular pathology. The plan was for a non-stress test (NST), computed tomographic angiography of the chest, magnetic resonance imaging (MRI) of the brain, and electroencephalogram (EEG). The patient remained medically stable while undergoing workup. 

The requested health service was not medically necessary.

Most causes of syncope are benign. Studies have not proven that inpatient admission of asymptomatic patients after syncope affects outcomes. There are no standard criteria for diagnosing undifferentiated syncope. Inpatient admission should be reserved for patients identified to be at immediate risk. Outpatient management can be used for patients who are at low risk for a cardiac etiology. The evaluation showed the patient to be hemodynamically stable. He did not have a fever or leukocytosis. The electrocardiogram was unremarkable for arrhythmia or acute changes. Imaging was unremarkable. The patient was admitted for a workup that could have been performed on an ambulatory level of care. Based on the patient's severity of illness, acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus
Treatment: Mounjaro
The insurer denied Mounjaro.
The determination is upheld.

This is a female patient diagnosed with type 2 diabetes mellitus (T2DM). This request is for Mounjaro. She states that she started metformin and then tried Ozempic and with both, she suffered adverse side effects. She failed metformin due to stomach cramping and almost daily diarrhea. She paid a subscription for Weight Watchers. She is using Mounjaro and doing well; her glycated hemoglobin (A1C) was 4.7 percent (%). Her A1C was 7.9 %.  She has obesity, anxiety and depression. She has been on Ozempic and her sugars improved and her weight is down but she had terrible gastrointestinal (GI) side effects, nausea and an upset stomach. It was not reported in this visit note that she has T2DM. At issue is the medical necessity of Mounjaro.

The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss (1-3).
There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 receptor agonists as a first line agent. There is no preference for the requested medication over GLP-1 receptor agonists(4). The patient failed Ozempic. The patient can try one more formulary alternative. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.