Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity
Treatment: Mounjaro (Tirzepatide) 
The insurer denied the request for Mounjaro (Tirzepatide).
The health plan's determination is overturned in whole.

The patient is a male who is requesting approval for Mounjaro (Tirzepatide) for the indication of obesity. He has a history of obstructive sleep apnea (OSA), hypertension, gastroesophageal reflux disease (GERD), and dyslipidemia. He has previously tried Metformin, Jardiance, Rybelsus, and Ozempic. He is only taking Zonisamide and Mounjaro currently. He is in a medical weight loss program. The appeal letter was reviewed. The office visits were reviewed; the patient is having less side effects on Mounjaro.

Under review is the request for Mounjaro (Tirzepatide) and whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

It was documented in the appeal letter that the patient has tried and failed Ozempic and Rybelsus. As this appears to be the reason the Mounjaro was denied, this meets the health plan's criteria for coverage. Thus, Mounjaro is approved. It is a well-studied medication that is frequently used for weight loss and is successful.

The health plan's determination is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: shortness of breath
Treatment: Hospital Admission
The insurer denied: Hospital Admission
The denial is: Upheld

The patient is a female born prematurely via cesarean section due to maternal pre-eclampsia who was referred to the emergency department (ED) with two-day history of runny nose, decreased oral intake, and worsening shortness of breath. She was wheezing, taken to urgent care where she was given three albuterol treatments, and subsequently referred to the ED. Vital signs included temperature 98.4 degrees Fahrenheit (F), heart rate 180, and respiratory rate 32. Examination was significant for tachypnea, not ill-appearing, moist mucous membranes, clear rhinorrhea at the nares, subcostal retractions, nasal flaring, clear lungs without wheezing, and non-focal neurologic exam. She was diagnosed with bronchiolitis. Respiratory panel returned positive for rhino-enterovirus and respiratory syncytial virus (RSV). Chest x-ray revealed air-filled prominent loops of bowel with paucity of distal air. On re-evaluation she was still exhibiting nasal flaring with subcostal retractions and tachypnea. She was admitted for further management of acute bronchiolitis. Admission orders included albuterol every three hours, nasal suctioning as needed, intravenous (IV) fluids, vital signs every four hours, and monitoring oxygenation.
Overnight, she had low-grade temperature to 100.7 F, treated with acetaminophen. She required suctioning before feeding because of thick oropharyngeal secretions. She clinically improved with albuterol treatments every three to four hours along with chest physiotherapy. She continued to receive supportive care and albuterol treatments. She was deemed stable for discharge to follow-up with her pediatrician in one to two days.
The subject under review is the medical necessity for an inpatient hospital admission.

Inpatient hospital admission was not medically necessary. This patient was born prematurely presented and had increased work of breathing and congestion and tested positive for both RSV and rhino-enterovirus. She responded well to treatment with albuterol, IV fluids, and suctioning. While it was reasonable to monitor her in the hospital for improvement versus decompensation, she was overall hemodynamically stable with no need for supplemental oxygen and no evidence of impending respiratory failure. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis 
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

Acute cholecystitis is a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes.

Per clinical documentation, this patient presented to the Emergency Department (ED) with epigastric abdominal pain. There was associated nausea without vomiting. Vital signs in the ED were within normal limits. White blood cell count was slightly elevated at 11.0. Alanine aminotransferase (ALT) and aspartate transferase (AST) were elevated to 133 and 184, respectively. An abdominal ultrasound demonstrated a thickened gallbladder wall with adenomyomatosis and hyperemia and mild pericholecystic fluid. A transvaginal ultrasound was done that demonstrated an early intrauterine pregnancy. The Obstetrics/Gynecological service was consulted and recommended surgery without delays. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. Per Milliman Care Guidelines (MCG) criteria, admission is indicated for calculus or obstruction of gallbladder or bile duct and either hemodynamic instability, common bile duct obstruction, severe or persistent vomiting or dehydration, severe pain, or bacteremia. According to clinical documentation, the patient did not meet criteria for inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Therefore, the requested hospital stay should be billed as observation status. Inpatient admission is 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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis 
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

Acute cholecystitis is a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes.

Per clinical documentation, this patient presented to the Emergency Department (ED) with epigastric abdominal pain. There was associated nausea without vomiting. Vital signs in the ED were within normal limits. White blood cell count was slightly elevated at 11.0. Alanine aminotransferase (ALT) and aspartate transferase (AST) were elevated to 133 and 184, respectively. An abdominal ultrasound demonstrated a thickened gallbladder wall with adenomyomatosis and hyperemia and mild pericholecystic fluid. A transvaginal ultrasound was done that demonstrated an early intrauterine pregnancy. The Obstetrics/Gynecological service was consulted and recommended surgery without delays. The patient was taken to the operating room for a laparoscopic cholecystectomy. There were no reported complications. Per Milliman Care Guidelines (MCG) criteria, admission is indicated for calculus or obstruction of gallbladder or bile duct and either hemodynamic instability, common bile duct obstruction, severe or persistent vomiting or dehydration, severe pain, or bacteremia. According to clinical documentation, the patient did not meet criteria for inpatient admission. Peer-reviewed literature indicates that laparoscopic cholecystectomy can successfully be performed as an outpatient procedure. Therefore, the requested hospital stay should be billed as observation status. Inpatient admission is 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 inpatient admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Frontal fibrosing alopecia
Treatment: Xeljanz 10 milligrams (mg) tablet
The insurer denied coverage for the Xeljanz 10 mg tablet.
The denial is upheld.

The patient is an adult with a diagnosis of frontal fibrosing alopecia (FFA). The patient has failed therapy with topical minoxidil and oral finasteride 5 milligrams (mg) every day (qd). The patient has a past medical history significant for myotonic dystrophy, diabetes, atrial flutter with cardioversion. The documentation provided does not indicate that the patient has failed intralesional Kenalog, hydroxychloroquine, or methotrexate. The request is for Xeljanz for the treatment of FFA.

Based on the submitted documentation, Xeljanz is not medically necessary for the treatment of FFA in this patient. The patient has failed only topical minoxidil and high dose oral finasteride. There is no documentation of a trial of intralesional Kenalog or hydroxychloroquine-medications commonly used for the treatment of FFA which do not require significant laboratory monitoring compared to Xeljanz. Xeljanz is not Food and Drug Administration (FDA) approved for FFA. Although Xeljanz may be a therapeutic option, it has significantly more potential side effects compared to alternatives commonly used in the treatment of FFA. As such, Xeljanz would not appear to be the best therapeutic option for the treatment of FFA in this patient at this time since the adverse risks are likely to be higher than one would reasonably expect compared to available alternatives which are standard of care for the treatment of FFA. The use of Xeljanz may ultimately be beneficial after a trial of standard therapeutic options. 

In summary, the denial of Xeljanz 10 milligrams (mg) tablet and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Frontal fibrosing alopecia
Treatment: Xeljanz 10 milligrams (mg) tablet
The insurer denied coverage for the Xeljanz 10 mg tablet.
The denial is upheld.

The patient is an adult with frontal fibrosing alopecia (FFA). The patient has tried and failed minoxidil and finasteride. The prescriber is a dermatologist. The medication under review is Xeljanz 10 milligrams (mg) tablet.

Scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. There is a lack of support for the use of Xeljanz for the treatment of frontal fibrosing alopecia, at this time.

Per the Food and Drug Administration (FDA) approved Package Insert, Xeljanz is not FDA approved for the treatment of frontal fibrosing alopecia (FFA). 

This patient is not a good candidate for Xeljanz 10 milligrams (mg) tablet. 

Xeljanz 10 milligram (mg) tablet is not the best available treatment for this patient at this time. 

The requested service is not considered appropriate based on the current peer-reviewed literature. There is no documentation provided that the patient has failed the standard of care treatments, such as isotretinoin. The patient has a rare, scarring hair disease for which limited treatments are available. The use of Xeljanz is not determined to be appropriate, in this case. 

Rakowska et al. (2017) noted that "the primary treatment goal was achieved by 76% (23/29) of patients treated with isotretinoin, 73% (8/11) of patients treated with acitretin, and 43% (6/14) of patients treated with finasteride. The secondary treatment goal was achieved by 72% (21/29) of patients treated with isotretinoin, 73% (8/11) of patients treated with acitretin, and 43% (6/14) of patients treated with finasteride. Thus, the administration of systemic retinoids may be beneficial for the stabilization of frontal hairline in patients with FFA." 

Mahmoudi et al. (2022) wrote that "frontal fibrosing alopecia (FFA) is a scarring alopecia with no promising treatment. Frontotemporal hairline (p values for frontal&lt;.001; R lateral: 0.03; L Lateral: 0.02), total scalp margins, total additional features' scores, and total combined (p value&lt;.001 for all) improved more in the isotretinoin group than in the control group."

There is no documentation provided that the patient has tried and failed the generic treatment isotretinoin which would then require alternative therapies, such as Xeljanz. 

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of Xeljanz 10 milligrams (mg) tablet and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
This is the case of an adult patient who presented to the emergency department (ED). The patient was afebrile with stable vital signs. The patient complained of abdominal pain upon waking up this morning. As per the ED provider note on the patient complained of sharp right upper quadrant (RUQ) pain radiating to the back with nausea. She denied fever. Exam revealed the abdomen to be soft, non-distended, without rebound or guarding. There was RUQ tenderness. Labs included normal amylase, white blood cell count (WBC) 11.1, alkaline phosphatase (ALP) 59, Aspartate transferase (AST) 29, alanine transaminase (ALT) 42, bilirubin total 0.3. Diagnostic sonogram revealed cholelithiasis without evidence of gallbladder wall thickening or pericholecystic fluid. Occasional mobile gallstones were identified in the region of the gallbladder neck. Murphy's sign was negative. Common bile duct (CBD) was mildly dilated at 7 millimeters (mm). There was no intrahepatic biliary ductal dilation. The assessment was cholelithiasis.

The patient was admitted and as per the history and physical (H and P) the patient reported intermittent pain associated with nausea without emesis. Labs were reviewed. The assessment was cholelithiasis with the plan to send to the OR in the morning for laparoscopic cholecystectomy. The plan was also for follow-up Magnetic resonance cholangiopancreatography (MRCP) due to dilated CBD. The patient was made nothing by mouth (NPO) and given intravenous (IV) Zosyn.

The patient was taken to the operating room for a laparoscopic cholecystectomy. Surgery was uneventful. Pathology revealed chronic cholecystitis and cholelithiasis.

Progress notes indicated no acute events overnight. The pain was well controlled. The plan was to advance the diet and possible discharge if labs normal.

Based upon the records, the inpatient admission was not justified as this patient could have been managed in an ambulatory/observation setting as she had an uneventful laparoscopic cholecystectomy for cholelithiasis. She did not have acute cholangitis and probably only had biliary colic. She did not have a significantly elevated WBC and she did not have a fever. She did not have elevated liver function tests. She did have a cholecystectomy, but this could have been done in an ambulatory/observation setting without an acute inpatient admission. 

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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Patent foramen ovale (PFO).
Treatment:  Cardiology service(s), procedure to close a hole in the heart.

The insurer denied coverage for cardiology service(s), procedure to close a hole in the heart.  The denial is overturned.

The is a patient with multiple cryptogenic strokes over the course of four years. There was no atrial fibrillation or other etiology for the strokes reported. The patient was diagnosed with a patent foramen ovale (PFO). PFO closure is under review. Complete neurovascular imaging revealed no etiology to explain the strokes.

The procedure to close a hole in the heart is considered medically necessary for this patient.

PFO closure has been considered as an alternate treatment to medical therapy (antithrombotic, antiplatelet) for individuals with a cryptogenic stroke and associated PFO. In the past, there had been essentially observational studies and meta-analyses, which did not demonstrate definitively that PFO closure improved outcomes above medical therapy. 

Mas, et.al. (2017) recently completed a large multinational randomized trial (total of 660 patients with a cryptogenic cerebrovascular accident (CVA) and PFO followed for at least 24 months post cerebrovascular accident (CVA), median follow up 3.2 years) of PFO closure and antiplatelet therapy versus antiplatelet therapy alone. There was a recurrent CVA/transient ischemic attack (TIA) in 1.4% of the PFO group versus 5.4% in the control (medication only) group. The decreased recurrence of a neurologic event was statistically significant for the PFO group (p 0.002). 

This study demonstrated that in this setting of a cryptogenic CVA, PFO closure with antiplatelet therapy, compared to antiplatelet therapy alone, is associated with decreased future occurrence of a CVA. 

Therefore, the request for PFO closure is considered medically necessary in this case.

Per Carroll, J. L., et al., (2017), "Among adults who had had a cryptogenic ischemic stroke, closure of a PFO was associated with a lower rate of recurrent ischemic strokes than medical therapy alone during extended follow-up."

Per Sndergaard, L., et al., (2017), "Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone."                                                         

Based on the additional data provided, 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 cardiology service(s) is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Rosacea. 
Treatment: Azelaic Acid 15% Gel. 

The insurer denied Pharmacy/Prescription Drugs- Azelaic Acid 15% Gel. 
The determination is upheld. 

This patient has a past medical history of rosacea. The patient has used topical metronidazole cream since beginning of last year but this medication is no longer working. At issue is the requested non-formulary medication, Azelaic Acid 15% Gel. 

The patient has no documented treatment failure with doxycycline. There is no evidence that doxycycline would be any less effective than the non-formulary medication. The patient does not have a documented true medical contraindication to oral doxycycline. 

Oral antibiotics are a mainstay of treatment for rosacea, especially the tetracycline derivatives, doxycycline, and minocycline. Current medical literature [2-8] notes that oral medications for treatment of rosacea are typically of a greater potency than topical agents, and this would include the topical agent azelaic acid as well as the topical agent metronidazole. Doxycycline is normally highly effective, with a low incidence of adverse effects (particularly if taken with food) and would be much more likely than not to be of greater efficacy than the requested azelaic acid gel.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Migraine.
Treatment:  Formulary exception for Nurtec ODT (oral disintegrating tablet) 75mg (milligrams).

The insurer denied Formulary exception for Nurtec ODT 75mg.  The denial is upheld.

The patient is an adult female with migraine headache disorder. She has tried and failed sumatriptan, eletripan and Fioricet for abortive therapy. The provider is requesting Nurtec. The requested medication was denied coverage by the health plan, as the patient has not tried and failed or does not have a contraindication to the preferred medication, Ubrelvy.

The health plan should not cover the formulary exception for Nurtec.

There is no documented reason the patient cannot be treated with Ubrelvy. Ubrelvy is FDA- (United States Food and Drug Administration) approved for the acute treatment of migraine headaches and is considered to be a standard-of-care abortive agent (Dodick et al., 2019). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Nurtec relative to Ubrelvy.

Therefore, given the above, the health plan should not cover the formulary exception for Nurtec.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Appendicitis.
Treatment:  Inpatient Hospital Stay.

The health plan denied inpatient hospital stay.  The determination is upheld.

The patient is an adult male, who presented with 1 day of abdominal pain and constipation. He was found to have acute appendicitis on computed tomography (CT). He was taken to the operating room (OR) for an uneventful laparoscopic appendectomy. Incidentally, he tested positive for COVID-19 and cannabis in his urine. The patient was discharged after 1 day; there were no postoperative notes found in the chart.

At issue is the medical necessity of the inpatient stay.

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

The inpatient stay is not medically necessary for this patient. A recent study showed that nearly a quarter of patients with non-perforated appendicitis undergoing laparoscopic appendectomy are discharged the same day. The risk of 30-day readmission is similar compared to those with a longer index hospital stay. Interestingly, the risk of superficial surgical site infection is lower[1].

Another study found that same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis is safe without an increased risk of readmission, complications, or unplanned hospital visits. Hence, same-day discharge may be further encouraged in selected patients[2].

Finally, another study in pediatric patients found that there is a significant financial benefit when patients are discharged early[3]. Therefore, the inpatient stay was not medically necessary.