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

Diagnosis: Leg weakness
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.

 
The patient was seen in the emergency department with complaints of left-sided chest pain that started 1 hour prior without radiation. The patient also reported a 2-week history of feeling unsteady in the bilateral legs as well as urinary retention and difficulty moving bowels. Past medical history was significant for Guillain- Barre syndrome. The patient also had a history of a stroke. The patient reported the main cause of presentation was willingness to go on subacute rehab (SAR).  It was noted the patient did not want to be placed on SAR where he was located so he left against medical advice (AMA) and came to current facility. The patient was admitted for diagnosis of leg weakness. It was noted that his chest pain was not resolved. It was also reported the patient had a longstanding issue with neurological conditions and would likely need admission for SAR placement.  

The patient received treatment and magnetic resonance imaging (MRI). The patient left against medical advice and without completion of the physician's evaluation and monitoring. The patient pulled out his intravenous (IV) access and left the hospital. It was noted that the patient required an inpatient admission for urgent evaluation given a new onset of weakness.  

Milliman Care Guidelines (MCG) recommends hospital admission for ataxia, weakness that is progressive or severe, and/or Guillain-Barre syndrome amongst other neurological conditions. In this case, the patient presented with a 2-week history of feeling unsteady in the bilateral legs. The patient had a history of Guillain-Barre syndrome as well as a stroke. It was noted that the patient left AMA at another facility as he wanted to go on subacute rehab at a different location. It was also reported the patient had longstanding issue with neurological conditions and would likely need admission for SAR placement. Given the findings, there was a history of neurological issues with plan for rehab placement. There is a lack of findings to support inpatient admission versus observation status. 

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

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

Diagnosis: Flank Pain
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 room (ER) with flank pain. His past medical history is significant for supraventricular tachycardia (SVT) and pre-diabetes. The patient's associated symptoms included hematuria. He was afebrile and hemodynamically stable on presentation. The review of systems and physical examination were normal. Lab results were grossly normal other than a white blood cell count (WBC) of 16.6. A computed tomography (CT) scan showed moderate left hydroureteronephrosis due to an 8-millimeter (mm) left proximal ureteral stone. He was admitted to the inpatient service and underwent cystoscopy with stent placement. The patient had an uneventful hospital course and was discharged. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. A majority of patients who present with renal colic can be discharged within 24-48 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. The procedure was not done on an emergent basis (done the next day). The procedure performed is considered a minimally invasive outpatient procedure and as such in the absence of a "high risk surgical patient" does not warrant acute inpatient care. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. Observation for this patient's clinical presentation and postoperative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient hospital.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This case involves a woman who presented to the emergency department (ED) with complaints of chest pain. She reported left-sided persistent sharp non-radiating chest pain for three weeks. Outpatient assessment by cardiology reportedly yielded an abnormal stress test, and she was referred to the ED. Vital signs on arrival were stable, including normal temperature, heart rate of 102, respirations of 18, and blood pressure of 146/88. The patient denied any chest pain at arrival and no shortness of breath. There were no cardiopulmonary abnormalities, and the rest of the exam was completely benign.

Based on the provided documentation, the inpatient hospital admission was not medically necessary. The patient did not have acute coronary syndrome. She had a false positive abnormal stress test and required a confirmatory test with a left and right heart catheterization. The results of the invasive study were unremarkable. Performing a heart catheterization is not exclusive to inpatient care and can be accomplished as an outpatient. No severe abnormalities were found to warrant the patient to remain in the hospital in an inpatient status, such as the deployment of drug-eluting stents and treatment with continuous parenteral anticoagulation. Observation is appropriate for evaluating this young patient with no cardiovascular risk factors.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dissociation of the polyethylene liner from the femoral head in the right hip
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission
The denial is overturned.
 
The medical record shows a post-surgical complication of late dislocation. She presented to the hospital with a semi emergent condition. A dissociation of liner from socket requires urgent management. She had a hip replacement with a "dual mobility liner". A dislocation occurring with this type of device has a worse prognosis as it is quite unusual. There is an increased chance of redislocation. 

She underwent a revision procedure on a semi emergent basis. The operation was performed the following day after admission. She could not have had the operation the same day. Her revision surgery was complex with high risk for ongoing instability. Based upon her entire clinical history the admission would be warranted and necessary. These services could not have been completed at a lower level of care. 

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

The medical necessity for full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This female infant presented with a fever and fussiness. She was well until 2 days prior to presentation when she developed a cough. She then developed a fever on the day of presentation. She received acetaminophen at home but continued to feel warm, so she was brought to the emergency department for care.
Upon presentation in the emergency department, her temperature was 39.7 degrees Celsius (C) and her heart rate was 180 beats per minute (bpm). A sepsis evaluation revealed leukopenia with an elevated C-reactive protein (CRP) of 1.90 and a urinalysis positive for nitrites. There were also many bacteria noted in the urine. The urine was sent for culture, and she was started on ceftriaxone and intravenous fluids for presumed pyelonephritis.
In the hospital, she was noted to be mildly irritable with a temperature of 38.1 degrees Celsius (C). She was continued on intravenous ceftriaxone, was given intravenous fluids, and was placed on continuous pulse oximetry monitoring. The viral panel was negative. A renal ultrasound was obtained which revealed minimal fullness of the left renal collecting system. She continued to have fevers during the hospitalization. She improved, was tolerating oral intake well, and was felt to be stable for discharge to home with continued treatment and follow up as an outpatient.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was medically necessary for this patient.
This is a very young infant who presented with a high fever and tachycardia, consistent with systemic inflammatory response syndrome. She was found to have bacteria in her urine and elevated inflammatory markers. She, therefore, required hospital admission for prompt administration of parenteral antibiotic therapies as well as intravenous fluids to maintain her hydration status in the context of a urinary infection as well as increased insensible fluid losses from fever. The decision making at the time of admission for this patient was consistent with her young age, the presence of a high fever, tachycardia, and bacteria in her urine, and the need for prompt and intensive parenteral treatments along with close monitoring for potential deterioration of her clinical status.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 26th Edition, Urinary Tract Infection (UTI), Pediatric; hospital admission is indicated for patients with a UTI who have persistent worsening of clinical findings despite observation care, including signs or symptoms of pyelonephritis. This patient was very young and continued to have high fevers and tachycardia (signs of systemic infection) in the emergency department. She required hospital admission for ongoing treatment with parenteral antibiotics, intravenous fluids to protect her kidneys, and close monitoring with additional treatments as needed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease. 
Treatment: Drug assay testing for Humira. 

The insurer denied coverage for drug assay testing for Humira. 

The denial is overturned. 

The patient has Crohn's colitis. She has been treated with Humira. She had previously failed treatment with Remicade. Her symptoms were under control with the Humira. Her physician has advised that she would benefit from therapeutic drug monitoring. An adalimumab (Humira) trough level was obtained and was 5.3. 

Clinical Gastroenterology and Hepatology 2019; 17:1656-1688 has an article titled "Appropriate Therapeutic Monitoring of Biologic Agents for Patients with Inflammatory Bowel Disease." The conclusion states that consensus was achieved towards the utility of therapeutic drug monitoring of biologics in IBD, particularly anti-tumor necrosis factor (TNF) therapy. For anti-TNF therapies, proactive therapeutic drug monitoring was found to be appropriate after induction and at least once during maintenance therapy. 

The physician has provided a copy of an article from Gastroenterology 2019;157:985-996 titled "Proactive Monitoring of Adalimumab Trough Concentration Associated With Increased Clinical Remission in Children With Crohn's Disease Compared With Reactive Monitoring." The conclusion was that proactive monitoring of adalimumab trough levels in pediatric patients with Crohn's disease resulted in significantly higher corticosteroid-free clinical remission as compared to reactive monitoring. 

This patient has Crohn's disease and has been treated with Humira after failing Remicade. The physician wanted to optimize treatment with the adalimumab by obtaining therapeutic drug monitoring. This testing is well supported in the medical literature for irritable bowel disease (IBD) patients on TNF blockers. Doing therapeutic drug monitoring is medically necessary. 

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

The medical necessity for drug assay testing for Humira is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Amyotrophic Lateral Sclerosis. 
Treatment: Methylcobalamin. 

The insurer denied methylcobalamin. The health plan's determination is overturned. 

The patient is a female with amyotrophic lateral sclerosis (ALS). Treatment with methylcobalamin is the subject of this review. The drug was denied by the health plan. 

The non-formulary drug is clinically appropriate for this patient's condition.
Compounded methylcobalamin is requested based on results from a phase II/III study showing that ultra-high-dose methylcobalamin did not show significant efficacy in the entire cohort studies, but did slow progression of ALS symptoms if started early. There are no available formulary alternatives, as the synthetic vitamin B12, which is cyanocobalamin, does not show the same results in clinic studies. Thus, traditional oral and injectable medications would be ineffective. As such, there is reasonable evidence to continue injections with compounded methylcobalamin. The patient has a rare disease that is usually terminal within several years. The efficacy of this therapy has been demonstrated in two randomized controlled trials.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Vitiligo
Treatment: Opzelura 1.5% (percent) Cream
The insurer denied Opzelura 1.5% Cream.
The denial is Upheld.

The patient is an adult female with vitiligo, treated with topical steroids and Protopic. The Provider is requesting Opzelura cream. The health plan requires use of formulary topical steroids. According to the limited documentation, the vitiligo involves the face.

The health plan should not cover the proposed treatment.

The formulary agents are not appropriate for the face with the exception of Alclometasone and Desonide. The other formulary agents would have adverse effects as they are too potent for the face and would cause atrophy. Alclometasone and Desonide would be appropriate therapies. It is not documented whether the patient has tried these. Therefore, a trial of these would be appropriate before Opzelura is considered medically appropriate.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Idiopathic Constipation. 
Treatment: Formulary exception for Motegrity. 

The insurer denied: Formulary exception for Motegrity. 
The denial is upheld. 

The patient is an adult female with chronic idiopathic constipation and chronic nausea. She has failed Linzess and Trulance. Her provider states that the patient cannot take lubiprostone due to chronic nausea. The provider is requesting treatment with Motegrity. 

The health plan should not cover the Formulary exception for Motegrity. 

The patient has failed two preferred formulary agents, Linzess and Trulance. The patient has not documented to have failed the third preferred agent, Lubiprostone. There is no evidence that the preferred formulary agent Lubiprostone would be ineffective. There is no literature to support that Motegrity is more effective than Lubiprostone for the treatment of chronic idiopathic constipation. While 11-31% of patients treated with Lubiprostone develop nausea, 69-89% of patients treated with 
Lubiprostone do not develop nausea. Therefore, the health plan should not cover the formulary exception for Motegrity, unless the patient fails Lubiprostone, or the patient develops nausea or other side effects with Lubiprostone.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Kyphoplasty. 

The insurer denied: Kyphoplasty. 
The denial is upheld. 

The patient is an adult male. He presented with back pain after a fall. Initial images showed moderate L3 compression fracture. MRI (magnetic resonance imaging) showed compression fracture and disc bulge with spinal stenosis. Subsequent treatment included medications. Kyphoplasty was done with improvement in pain. 

The Kyphoplasty is not medically necessary. 

The patient had an uncomplicated compression fracture without a documented trial of conservative treatments. No complicating factors were identified. The appeal letter justifies the procedure based on the presence of pain despite conservative treatment, however a comprehensive course was not documented. The provider also reports a risk of further stenosis from L3 compression, which is not supported by the medical literature. 

The medical literature has called into question the efficacy and necessity of kyphoplasty for routine management of vertebral compression fractures. Several studies have shown such treatments to be no better than standard non-interventional treatments in large randomized clinical trials. There were no documented factors to identify that conservative treatment would have been insufficient or inappropriate for this patient. The use of such a procedure is therefore considered not medically necessary in this patient's case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental/orthodontic problems - Class II Division 1 malocclusion with maxillary and mandibular crowding
Treatment: Braces/monthly visits
The insurer denied braces/monthly visits. The health plan's determination is overturned. 

The patient in question is a young male with a Class II Division 1 malocclusion with maxillary and mandibular crowding. He has 8 millimeter (mm) overjet and 6 mm overbite. 

Braces and monthly visits are medically necessary for this patient.
Teeth # (number) 8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. This patient, like fifteen percent of the population, exhibits an Angle's Class II bite Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+ (plus) millimeter (mm) overjet, which this patient has. For these reasons, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult female who presented to the hospital complaining of nausea and vomiting for one week.  On arrival she was noted to be hypertensive, and the patient reported that she was unable to take her antihypertensive medications. Past medical history was significant for hypertension, diabetes mellitus, gastroparesis, peripheral and vascular disease status post metatarsal amputation. Blood Pressure on arrival was 213/136 millimeters of mercury (mmHg) and pulse was 94 beats per minute.  Physical examination was unremarkable.  12 lead electrocardiogram revealed normal sinus rhythm without ST or T wave abnormalities.  Serum blood testing demonstrated no elevation in troponin (0.079ng/ml) and a creatinine of 1.4 mg/dl.  The patient was treated with nifedipine and labetalol and admitted to the hospital for further treatment.  Blood Pressure was immediately controlled, and the patient was released on oral medications the following day. 

Hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1)  In this patient, target organ damage was not present. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) This patient was unable to take medications due to nausea and vomiting.  Following treatment for nausea, the Blood Pressure was immediately controlled with re-initiation of oral antihypertensive medications.  In conclusion acute inpatient admission was not medically necessary. 

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: Dementia, atrial fibrillation, congestive heart failure, insulin dependent diabetes, chronic urinary tract infections, and osteoarthritis

Treatment: Level 2 personal care services, per 15 minutes, increase to 24 hours per day (split shift)

The insurer denied coverage for Level 2 personal care services, per 15 minutes, increase to 24 hours per day (split shift)

The denial is overturned

The patient has a diagnosis of vascular dementia. The patient has been at home and has arthritis and other comorbidities. The patient lives alone. The request is for 24-hour care. It is noted that the patient has bed sores and frequent urination issues. It is noted the patient's daughter is involved with care. The request is for Level 2 personal care services, per 15 minutes, increase to 24 hours per day (split shift). A letter from the treating provider noted that when the patient is able to verbalize need for bowel or bladder movement the patient needs a Hoyer lift to get to the commode.  This cannot be done without an aide. The treating provider also noted that the medication the patient needs results in frequent urination, every 2 hours. The treating provider also confirmed the presence of skin breakdown and the need to avoid further injury.

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

The medical necessity for Level 2 personal care services, per 15 minutes, increase to 24 hours per day (split shift) is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Endocrine/Metabolic/Nutritional
Pharmacy/Prescription Drugs

Diagnosis: Obesity
Treatment: Wegovy

The health plan has denied: Wegovy
The determination is: Overturned

The patient is a female being prescribed Wegovy for the treatment of obesity. Coverage for this medication was denied by the health plan, and this denial is the subject under review.
The health plan requires a trial of two preferred formulary medications before considering the requested medication. Formulary alternatives include phentermine, benzphetamine, diethylpropion, and phendimetrazine.
The prescribing physician provided an office visit note for review. The note states that since being diagnosed with multiple sclerosis, the patient has gained 15 pounds of weight despite multiple attempts at weight loss. She has attempted the keto diet, Weight Watchers, and a high-protein diet. She was previously treated with more than six months of phentermine and diethylpropion. These were not successful trials, and she had side effects of palpitations. The patient's current body mass index (BMI) is 31.3.
The health plan's determination is overturned in whole.
The formulary alternatives phentermine and diethylpropion have been tried and have been ineffective. The patient has also had the adverse effects of palpitations.
The plan document states that for a non-formulary medication to be approved, there must be a trial of two formulary alternatives. The mechanism of action of the formulary drugs is of the stimulant class; the patient has had an adequate trial (greater than 6 months, per the notes) without adequate response. It is therefore allowable under the plan document to attempt alternative therapy with Wegovy.