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

Diagnosis: Tingling and Numbness and High Blood Pressure
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female who presented to the emergency room with complaints of dizziness, left facial paresthesia, headache and facial droop. The patient's blood pressures were over 200/100. Although the workup eventually was negative for a stroke, the patient was admitted for hypertensive emergency which is a critically ill state that requires frequent neurological checks, blood pressure monitoring and gradual decrease in blood pressure that often takes a few days to achieve.

The proposed treatment was medically necessary.
Hypertensive emergency is a critically ill state that requires frequent neurological checks, blood pressure monitoring and gradual decrease in blood pressure that often takes a few days to achieve. Furthermore, it requires intravenous antihypertensive medications. Close monitoring and intravenous antihypertensive medications could not be done in the outpatient setting and requires at least two midnights so observation status would not have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus
Treatment: Hospital admission
The insurer denied coverage for hospital admission.
The denial is overturned.

The patient is a female with a history of asthma who had shortness of breath, fever, cough and wheezing for two days. There is a history of a previous visit to the ER (emergency room) for asthma. The child had been treated with albuterol at home with no improvement in her difficulty breathing so the mother brought her to the ER for further treatment.

In the ER, she was noted to have moderate respiratory distress with retractions and increased work of breathing, on physical exam, she was noted to have tachypnea, coarse breath sounds and subcostal retractions. She also was described as having difficulty speaking. Her pulse oximeter was 94% (percent). A respiratory viral panel was positive for rhino/enterovirus. She was treated with IV (intravenous) fluids, dexamethasone magnesium sulfate and multiple inhalation treatments with DuoNeb. When she did not improve with treatment in the ER, the decision was made to admit to her to the hospital with a diagnosis of status asthmaticus, for ongoing treatment with albuterol every 2 hours and atrovent every 6 hours. 

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The Denial is overturned.

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. She has a history of previous ER visits for asthma, and she did not improve with albuterol at home. Despite appropriate treatment in the ER, there was clinical evidence of persistent wheezing and increased work of breathing. It was appropriate and consistent with the standard of care to admit her to the hospital for ongoing treatment with albuterol every 2 hours. She was not stable enough to be sent home.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: fall
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

This patient is man who presented following a fall from a ladder. There was no loss of consciousness. His past medical history is notable for testicular cancer and right bundle branch block. He complained of right elbow and right ankle pain and was unable to walk post injury. Vital signs were normal in the emergency department (ED). Following a complete trauma assessment, the identified injuries included a right ankle trimalleolar fracture and a distal humerus fracture. The orthopedic surgery service was consulted and the patient underwent closed treatment of the right ankle fracture and application of a right elbow splint. The injuries were determined to be too edematous for surgical treatment and outpatient orthopedic follow up was arranged.

The inpatient hospital admission was not medically necessary. The care and treatment provided could have been rendered at a lower level of care. This would have permitted evaluation, imaging, and nonsurgical treatment of the ankle and elbow fractures and overnight monitoring.
This patient presented to the ED following fall from the 4th rung of a ladder. He was clinically and hemodynamically stable at the time of ED presentation. His evaluation and clinical work up identified a right ankle trimalleolar fracture and a distal right humerus fracture. The patient did require acute surgical intervention for the orthopedic injury and underwent closed reduction of the ankle fracture and splinting of the elbow injury. Definitive surgical treatment was deferred until the edema reduced.
A lower level of care would allow for provision of intravenous (IV) fluid, IV pain medication, orthopedic treatment, and overnight monitoring. He remained hemodynamically stable without aberration of vital signs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Muscular Dystrophy
Treatment: Emflaza
The insurer denied Emflaza.
The denial is overturned.

The patient is a male who was diagnosed with Duchenne muscular dystrophy (DMD) when he was 5 years 1 month old. His creatine phosphokinase level was 25807 units per liter (U/L). The patient walked independently at 20-22 months. Genetic testing indicated an out of frame duplication of exon 21 in the dystrophin gene.

The health plan has determined that Emflaza is not medically necessary, recommending substitution with prednisone. His treating neuromuscular specialist wrote appeal letters, stating that the patient needs to stay on Emflaza given his previous history of excessive weight gain when on prednisone, and the development of insulin resistance. She also described that Emflaza should delay the onset of cardiomyopathy, preserve his pulmonary function, and decrease the risk of scoliosis.

The subject under review is the medical necessity of Emflaza for this patient.

The health plan's determination is overturned. 

The requested treatment of Emflaza is medically necessary for this patient. The medical literature supports the continued use of Emflaza (deflazacort) as being more effective in the treatment of Duchenne muscular dystrophy, with the likelihood of fewer side effects. In addition, deflazacort has shown significant decrease in functional decline compared with prednisone and is associated with a lower risk of scoliosis, greater percentage lean body mass, and lower weight. The patient had excessive weight gain when on prednisone and developed insulin resistance. Placing him back on prednisone is highly likely to result in additional weight gain and may exacerbate his insulin resistance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infertility
Treatment: Controlled ovarian situation (clomid or letrozole) with intrauterine insemination (IUI)
The insurer denied coverage for controlled ovarian situation (clomid or letrozole) with intrauterine insemination (IUI)
The denial is overturned.

This is a patient with a history of infertility. She presented to the Reproductive Endocrinologist's office for a second treatment of ovulation induction with oral medications and intrauterine insemination (IUI). The patient's IUI cycles had failed, and she was requesting coverage for an additional IUI cycle with oral medication. 

The insurer has denied coverage for controlled ovarian situation (clomid or letrozole) with intrauterine insemination (IUI), as not medically necessary. In a Final Adverse Determination letter, they stated that the patient has unexplained infertility. The patient was treated with two cycles of clomid/Femara and timed intercourse by the Gynecologist. The patient was approved for a cycle of IUI with Femara with an infertility specialist. The physician plans to do a fourth cycle of ovarian stimulating medication with the IUI. The requested treatment is not indicated for unexplained infertility beyond three cycles. 

This patient has a diagnosis of unexplained infertility. She has undergone 1 cycle of induction of ovulation and intrauterine insemination.
According to ASRM (American Society for Reproductive Medicine), "It is recommended that letrozole with IUI treatments be considered as a regimen for couples with unexplained infertility. There is compelling evidence that a strategy of 3 cycles of clomiphene citrate or Letrozole IUI for unexplained infertility and if it fails, the next step is to be followed immediately by IVF (in-vitro fertilization)".
This patient has undergone 1 cycle of insemination. Based on the current evidence, additional cycles of Letrozole and IUI are medically necessary.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

Controlled ovarian situation (clomid or letrozole) with intrauterine insemination (IUI) is considered medically necessary for this patient

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 controlled ovarian situation (clomid or letrozole) with intrauterine insemination IUI services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized muscle weakness.
Treatment: Continued stay in skilled nursing facility.
The insurer denied continued stay in skilled nursing facility.  The denial is upheld.

The patient is a male with a significant history of hypertension, seizures, human immunodeficiency virus (HIV) and generalized muscle weakness was admitted to the skilled nursing facility (SNF) for skilled physical therapy to improve functional mobility status after recent hospitalization for knee debridement with revision. After the requested date of service , the patient had demonstrated an appropriate therapeutic response to treatment with physical therapy and was appropriate for discharge with home care. He no longer required the skilled services required at a SNF level of care and per the physical therapy notes was appropriate to be discharged home for continued care. The subject under review is the medical necessity for continued stay in a skilled nursing facility.

The health plan's determination is upheld.

The requested treatment of continued stay in a Skilled nursing facility for the requested date of service forward was not medically necessary for this patient. This patient was admitted to the skilled nursing facility (SNF) for skilled physical therapy to improve functional mobility status after recent hospitalization for knee debridement with revision. After the requested date of service, the patient had demonstrated an appropriate therapeutic response to treatment with physical therapy and was appropriate for discharge with home care. He no longer required the skilled services required at a SNF level of care and per the physical therapy notes was appropriate to be discharged home for continued care. Based on the assessments, the home environment would be considered safe and no longer requires skilled services, particularly continued physical therapy at a SNF level of care. Therefore, the requested health service/treatment of continued stay in a Skilled nursing facility was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High Blood Glucose
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a male. The patient has a history of hypertension, chronic neck/back
pain. He presented with generalized weakness, dizziness, difficulty walking for the
prior week. The patient started gabapentin for his neck pain one week prior. He
started feeling thirsty. Serum blood glucose was 1481.

The patient was admitted to the intensive care unit for insulin infusion. The patient
had hyperosmolar state. Sodium was 125, bicarbonate was 21, osmolality was 368,
lactate was 2.42, ketones were 15. Blood gas showed an arterial pH (potential of hydrogen) of 7.33. The
patient had an appropriate decline in glucoses. The patient was started on Lantus
and Novolog. He was transitioned to subcutaneous insulin once the glucoses
normalized. The patient received diabetes education.

Yes, the Inpatient admission was medically necessary.
Acute inpatient admission for patients with symptomatic diabetes is necessary
when the patient has evidence of ketoacidosis or a hyperosmolar state [1, 2, 3, 4, 5,
6]. Observation is generally sufficient for patients with ketosis or vomiting that
resolves after hydration [7, 8, 9].

The patient had new onset symptomatic diabetes with hyperosmolar state.
Admission for an insulin infusion to slowly normalize the glucoses followed by
conversion from an insulin infusion to subcutaneous insulin and educating the
patient is consistent with generally accepted standards of medical practice. The
requested hospitalization was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the
best interest of the patient, as the request is medically necessary as described
above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High Blood Glucose
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a male. The patient has a history of hypertension, chronic neck/back pain. He presented with generalized weakness, dizziness, difficulty walking for the prior week. The patient started gabapentin for his neck pain one week prior. He started feeling thirsty. Serum blood glucose was 1481.

The patient was admitted to the intensive care unit for insulin infusion. The patient had hyperosmolar state. Sodium was 125, bicarbonate was 21, osmolality was 368, lactate was 2.42, ketones were 15. Blood gas showed an arterial pH of 7.33. The patient had an appropriate decline in glucoses. The patient was started on Lantus and Novolog. He was transitioned to subcutaneous insulin once the glucoses normalized. The patient received diabetes education.

Yes, the Inpatient admission was medically necessary.
Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state [1, 2, 3, 4, 5, 6]. Observation is generally sufficient for patients with ketosis or vomiting that resolves after hydration [7, 8, 9].

The patient had new onset symptomatic diabetes with hyperosmolar state. Admission for an insulin infusion to slowly normalize the glucoses followed by conversion from an insulin infusion to subcutaneous insulin and educating the patient is consistent with generally accepted standards of medical practice. The requested hospitalization was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, as the request is medically necessary as described above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD (chronicvobstructive pulmonary disease) exacerbation
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a male with CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease) on home O2 (oxygen), HTN (hypertension), DM (diabetes mellitus), Rheumatoid arthritis induced pulmonary fibrosis on prednisone, plaquanil, and embrel.

The patient presented to the ER (emergency room) with SOB (shortness of breath). The patient was found to have influenza infection and was admitted to hospital for COPD (chronicvobstructive pulmonary disease) exacerbation. The patient was seen by cardiology, pulmonology and rheumatology. The patient was treated with IV (intravenous) steroids, supplemental oxygen, Tamiflu and nebulization.

Coverage for the hospitalization is denied by the health plan due to lack of medical necessity. This denial is being appealed.

No, the Inpatient Hospital Admission was not medically necessary.
The patient was admitted for the management of COPD (chronic obstructive pulmonary disease) exacerbation. The patient was hemodynamically stable. The patient's symptoms improved with ER (emergency room) care. The patient's oxygen level was above 90%. The patient was able to tolerate oral diet and oral medications. Given the patient's signs and symptoms, it would have been reasonable to expect significant improvement within 24 hours, as is what happened with the patient. The patient's treatment course would not have been expected to require treatments or interventions that could not have been provided at a lower level of care. No treatment was provided or was reasonably expected to be provided that required an acute inpatient level of care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Given the patient's signs and symptoms, it would have been reasonable to expect significant improvement within 24 hours, as is what happened with the patient. The patient's treatment course would not have been expected to require treatments or interventions that could not have been provided at a lower level of care. No treatment was provided or was reasonably expected to be provided that required an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine.
Treatment: Nurtec.
The insurer denied Nurtec. 
The health plan's determination is overturned. 

The patient is a female with a history of migraine headaches. Her medical history is also notable for chronic low back pain and anxiety. With regards to her migraines, she had an anaphylactic reaction to sumatriptan. She has since been using Fioricet (Butalbital / Acetaminophen / Caffeine) for acute treatment of her migraines. Prior preventative medications were said to have included topiramate, amitriptyline, nortriptyline and propranolol. At the time of a recent follow-up visit the patient was prescribed Nurtec. 

Nurtec is medically necessary for this patient. In this case, the patient has a history of migraine headaches and Nurtec has been prescribed for the acute treatment of her migraines (an indication for which the medication is Food and Drug Administration (FDA) approved for use). The patient was noted to have had an intolerance to triptans based on the documented anaphylactic response to sumatriptan.
According to the current guidance from the American Headache Society on the use of CGRP (Calcitonin gene-related peptide) drugs, the use of a gepant (for the acute treatment of migraine) is indicated for patient with "Contraindications to or inability to tolerate triptans".
In this setting, the use of Nurtec would be clinically appropriate and consistent with the standards of practice/care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glioblastoma.
Treatment: Home health care / Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift). 
The insurer denied Home Care / Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift). 
The health plan's determination is overturned. 

The patient is a male with a past medical history of glioblastoma, seizures, gastroesophageal reflux disease (GERD), BPH (Benign prostatic hyperplasia), hypertension, urinary incontinence, idiopathic pulmonary fibrosis, alcoholism, atrial flutter, and hepatitis C who was diagnosed with glioblastoma with subsequent resection. There was a request for PCS (personal care services).

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift) is medically necessary for this patient.
There is documentation from the patient's neurologist of a need for frequent turning and repositioning. Since the last assessment, the patient has had a significant decline in functional status. The assessment also underestimated the patient's care needs with multiple tasks as there was noted "improvement" in assistance needs with several tasks when compared to the previous assessment despite the patient's decline in functional status with the progression of his cancer. Furthermore, the patient has 24-hour care needs and therefore the plan should not have utilized a task-based assessment to calculate PCS services. There is documentation of the patient's urinary incontinence and therefore the patient would have unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient requires frequent turning and repositioning at least every 2 hours and the patient is not able to perform these tasks independently per the neurology note. The requested increase in PCS services is not solely for safety and supervision but to assist the patient with the safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's ADL care needs would not allow a PCS to obtain at least 5 hours of uninterrupted sleep. The patient has a terminal condition with a predictive decline in functional status for which he would require increased assistance with all ADLs/IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift) is medically necessary. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glioblastoma
Treatment: Xpovio
The insurer denied: Xpovio
The denial is: Upheld

The patient is a male with glioblastoma, Isocitrate dehydrogenase (IDH) wild type. The patient has previously undergone resection followed by adjuvant temozolamide+radiation. The patient has progressed and underwent re-excision. Selinexor (Xpovio) has been recommended.
The subject under review is the medical necessity for Xpovio for this patient.

The health plan's determination is upheld.

The use of selinexor (Xpovio) in this clinical scenario remains the subject of ongoing investigation in a number of trials including, but not limited to, National Clinical Trial (NCT) 04421378 and NCT05432804. Lacking meaningful outcomes data, neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate recommend the use of this agent in this clinical scenario. Because this agent is unproven and not a standard of care, medical necessity cannot be established.