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

Diagnosis: Idiopathic Hypersomnia

Treatment: Xywav

The insurer denied coverage for Xywav

The denial is overturned

This case involves an adult male with a history of idiopathic hypersomnia.  He was seen for a multiple sleep latency test.  At the time of the testing, his clinical presentation included hypersomnia with possible narcolepsy and excessive daytime sleepiness.  The impression from testing was positive for the idiopathic hypersomnia, and while there were no sleep onset rapid eye movement (SOREM) naps to qualify as narcolepsy, the test revealed the presence of hypersomnia with a mean sleep latency of 5.50.  The follow-up note noted that the patient reported having hypersomnia for the past several years.  Vital signs were stable with no physical abnormalities noted.  The report reference to a polysomnography study showing mild sleep apnea with respiratory disturbance index (RDI) of 7.1.  A continuous positive airway pressure (CPAP) titration study showed that the patient required CPAP 4 cmh20 (centimeters of water).  The treatment plan at that time was to start the patient on Xywav with continuation of the CPAP and a 2-month follow-up.  

The Food and Drug Administration states that Xywav is indicated for the treatment of cataplexy or excessive daytime sleepiness in young patients and older with narcolepsy and for idiopathic hypersomnia in adults. The records provided for the review noted the patient's history of hypersomnia was confirmed with diagnosis of idiopathic hypersomnia following multiple sleep latency testing.  While there was no sleep log with wrist actigraphy provided, given that the patient had been authorized for the sleep study in general indicates that he had issues with hypersomnia. There was no clear explanation given for how staying in bed for longer periods of time at night would significantly benefit in the patient given that this does not support that remaining in bed for prolonged periods consisted of restful sleep.  Given these findings, the request for Xywav is reasonable and medically necessary.  

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 Xywav is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

The patient is a female with a history of human immunodeficiency virus (HIV), hypertension, diabetes, asthma, schizophrenia, bipolar disorder, and epilepsy. She presented to the emergency room with chest pain radiating to her back that was worse with deep inspiration. The vital signs were notable for a blood pressure 168/110 and a pulse of 108. She was well-appearing and in no acute distress. The remainder of the physical exam was normal. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. Labs were remarkable for an elevated D-dimer level. The computed tomography (CT) chest and abdominal angiogram was negative for pulmonary embolus and revealed no acute pathology. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with aspirin, statin, and her usual home medications. An echocardiogram was non-contributory. The remainder of the stay was clinically uneventful, and she was discharged.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The evaluation of her complaints was straightforward and did not require acute inpatient admission. Therefore, based on the standard of care, and the peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End Stage Renal Disease (ESRD)
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Overturned.

The patient is a female with a history of congestive heart failure (CHF), diabetes mellitus (DM), hypertension (HTN), cerebrovascular accident (CVA), post-traumatic stress disorder (PTSD), right eye blindness, and end stage renal disease (ESRD) on hemodialysis who presented due to worsening nausea, vomiting, abdominal pain, constipation, fatigue and shortness of breath in the setting of missing 5 dialysis sessions.
Her vitals showed that she was afebrile with a pulse of 89, a respiratory rate of 20, a blood pressure of 171/101 and a room air pulse oximetry of 100% (percent). On exam she was not in any acute distress, she had mild crackles in her lower lung fields bilaterally and no edema. Her labs showed a white blood cell (WBC) of 13.7, a hemoglobin of 12.6, a venous potential hydrogen (pH) of 7.14, a potassium of 3.6, a lipase of 571, a creatinine of 9.8, a blood urea nitrogen (BUN) of 95, and a carbon dioxide (CO2) of 11. She was started on intravenous (IV) bicarbonate and was admitted to inpatient medicine. Nephrology was consulted and she underwent urgent hemodialysis. A computed tomography (CT) scan showed no concerning findings. As her last outpatient hemodialysis (HD) session was noted to more than 30 days ago she lost her outpatient dialysis slot and required a new outpatient dialysis spot. She complained of left facial decreased sensation and a stroke code was activated which was negative. She was considered stable for discharge. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The patient presented with nausea, vomiting, and severe metabolic acidosis in setting of missed dialysis treatment. Importantly, the patient had lost their outpatient dialysis spot due to missed treatment and could not be safely discharged until a new outpatient dialysis spot was established. She required urgent hemodialysis on presentation due to her severe metabolic acidosis and then required continued inpatient monitoring and treatment while awaiting a safe discharge plan. The inpatient stay was therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest 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 department complaining of four days of nausea, vomiting, diarrhea and nonexertional left-sided chest pain. His medical history was remarkable for possible acute coronary syndrome. His physical exam was remarkable for epigastric tenderness. An electrocardiogram showed sinus rhythm with "ST changes" in leads III, aVL and V2. The abnormalities were not further described. The patient's serum troponin level was normal. A chest x-ray showed no acute pathology. The patient was treated with intravenous fluid, ondansetron, famotidine and Maalox. He was admitted to the hospital with diagnoses of viral gastroenteritis and possible acute coronary syndrome. His troponin level remained normal. Losartan was prescribed for hypertension. The progress note indicated that myocardial perfusion imaging (MPI) was planned. The patient remained stable. MPI was performed and showed no evidence of ischemia. The patient was discharged. The medical necessity for an inpatient admission is under review.

Based on the documentation provided an inpatient level of care was not medically necessary.

This patient presented with chest pain that was thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable and had normal cardiac biomarkers. While his electrocardiogram was abnormal, the records do not indicate that there were findings that were diagnostic for acute ischemia. The patient did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for his chest pain did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021

American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes. The records provided do not indicate that there was a medical reason for the delay in performing the myocardial perfusion 
The patient was also admitted with a diagnosis of viral gastroenteritis. However, the records do not indicate that he had intractable vomiting or was unable to tolerate oral fluids. The progress notes do not mention continued nausea, vomiting or diarrhea. Thus. based on the medical record documentation, this did not warrant inpatient admission.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Low Back Pain. 
Treatment: Diclofenac Patch. 

The insurer denied coverage for Diclofenac Patch. 

The denial is overturned. 

This is the case of a patient with a history of low back pain, unspecified. Per the Prior Authorization Request form, the patient is unable to take nonsteroidal anti-inflammatory drugs (NSAIDS). Per the appeal letter, treatment with Diclofenac Patch 1.3% (percent) is requested for treatment of muscular, low back pain. Other therapies tried were not tolerated or non-effective. 

The insurer has denied coverage for Diclofenac Patch. In their Final Adverse Determination letter, they write that the drug is covered when the criteria are met: the patient has tried and had an inadequate treatment response or intolerance to the required number of formulary alternatives, or had a documented clinical reason such as expected adverse reaction or contraindication that prevents the patient from trying the alternatives. This was not met. 

Formulary alternatives are diclofenac sodium, diclofenac sodium gel 1% (generic Voltaren Gel), meloxicam tablet, naproxen (except naproxen CR (controlled released) or naproxen suspension). The patient must have tried and failed all of the formulary alternatives, but not more than three. 

The report specifically describes use of the Formulary alternative. Use of Voltaren Gel had been attempted. Use of oral medications was documented. Based upon lack of efficacy, the next step would be the Diclofenac Patch. 

The physician has submitted documentation of formulary medication being ineffective. This is based upon the report made to the physician about its use. 

The formulary drug(s) are expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication. 

The formulary drug is expected to be ineffective. 

The non-formulary drug is expected to be more effective that the formulary alternatives. The carrier's denial of Request for Formulary Exception for Diclofenac Patch is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder-Anemia
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

This case involves a female patient with a history of gastric cancer status post gastrectomy many years before this presentation, who presented to the hospital after outpatient lab testing revealed hemoglobin of 5. The patient has a history of anemia, with limited blood draws in the outpatient setting to prevent further phlebotomy, and therefore did not appear to know her baseline hemoglobin level. The last endoscopic evaluation with esophagogastroduodenoscopy (EGD) and colonoscopy was reportedly normal. The patient denied any visual bleeding episodes. She felt tired and short of breath for prolonged periods of time. She experienced some cramping in the extremities. The patient reported diarrhea after food intake but otherwise no constitutional symptoms. On arrival in the emergency department (ED), the hemoglobin was confirmed at 6.4, and she was given 1 unit of blood. Vital signs appeared stable. On examination, the patient's cardiopulmonary exam was unremarkable. The abdomen was soft and nontender to palpation. The electrolytes and renal function remained stable. The liver function tests (LFTs) were normal as well. The patient was admitted to the hospital with a principal diagnosis of anemia. The fecal occult blood test was negative. The medical team ordered a computed tomography (CT) angiogram of the abdomen and pelvis and established the goal for hemoglobin greater than 7. This suspected the patient is poorly absorbing iron and B12 due to the gastrectomy as the primary cause of the anemia. They also ordered an echocardiogram because the patient was experiencing dyspnea, although the low hemoglobin likely explains the symptoms.
The following day, the patient's hemoglobin was rechecked and was 8 grams per deciliter (g/dL). The CT scan of the abdomen and pelvis showed no active bleeding. The echocardiogram showed a normal ejection fraction with no wall motion abnormalities. The patient was deemed medically stable for discharge. She was prescribed iron tablets and scheduled for an outpatient follow-up to recheck her hemoglobin in 1 week.

No. Inpatient hospitalization is not warranted in this case. There is no clinical indication for admission to an inpatient level of care in the patient with chronic anemia, who required a blood transfusion and was stable. There is no hemodynamic instability. The fecal occult blood test is negative, the patient endorsed no occult bleeding, and the CT angiogram failed to demonstrate an active bleeding source. The patient has undergone gastrectomy and is likely chronically malabsorbing iron, hence the iron deficiency anemia. A lower level of care setting is the perfect setting for this type of presentation, rapid work-up, and subsequent discharge within 24 hours.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Other Hypertrophic Cardiomyopathy. 
Treatment: Camzyos.  

The insurer denied coverage for Camzyos. 

The denial is upheld. 

The patient is an adult who presented for evaluation of lightheadedness and palpitations. The patient's medications include verapamil, Crestor and aspirin. The physical exam was unremarkable. Work up revealed asymmetric septal hypertrophy with maximal septal thickness of 2.9 centimeters (cm). No outflow tract obstruction was noted on echocardiography or cardiac magnetic resonance imaging (MRI). 

This patient presented with newly diagnosed asymmetric septal hypertrophy. Numerous imaging studies were performed including echocardiography and cardiac MRI. Both confirmed no evidence of outflow tract obstruction or gradient. 

Mavacamten (Camzyos) has been shown to be an effective treatment for patients with symptomatic hypertrophic cardiomyopathy (HCM) that have clear evidence of outflow tract obstruction and New York Heart Association (NYHA) class II-III symptomatology (Reference 1). In non-obstructive HCM, mavacamten has also been demonstrated to be effective in improving patient function status and reducing NYHA class in patients with NYHA class II-III functional status (Reference 2). The NYHA definition is "Class II: Symptoms of heart failure with moderate exertion, such as ambulating two blocks or two flights of stairs. Class III: Symptoms of heart failure with minimal exertion, such as ambulating one block or one flight of stairs, but no symptoms at rest." Medical records document that this patient does not meet this definition and is without evidence of outflow tract obstruction. 

No, formulary drugs are available or suggested by the insurer. In conclusion, Camzyos (mavacamten) is not clinically appropriate for the patient's condition. 

The insurer's denial of request for Formulary Exception for Camzyos for treatment of other hypertrophic cardiomyopathy is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute On Chronic Diastolic Heart Failure
Treatment: Inpatient Stay. 
The insurer denied the inpatient stay.  The health plan's determination is overturned.

The patient is a male with a past medical history significant for type II diabetes mellitus, hypertension, hyperlipidemia, non-obstructive coronary artery disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), arthritis, bipolar disorder, and chronic pancreatitis who was brought to the hospital because of shortness of breath. He had been feeling short of breath for several days and was unable to walk 2 blocks without getting short of breath. He also complained of orthopnea and slept in a chair for 4 - 5 days. The patient ran out of supplemental oxygen 2 days before the presentation. He also complained of swelling in the lower extremities as well as a cough associated with white phlegm for 7 days.

The patient was admitted to the hospital with acute CHF (congestive heart failure) exacerbation, acute kidney injury superimposed on chronic kidney disease. 

Upon admission to the hospital, the patient was started on intravenous Lasix. A cardiology consultation was requested. The patient underwent an echocardiogram that demonstrated a normal left ventricular ejection fraction. There was grade 3 severe diastolic dysfunction. A kidney ultrasound was also performed and demonstrated echogenic kidneys bilaterally, consistent with medical renal disease. During the hospital stay, the patient's clinical condition continued to improve and he was transitioned to outpatient care in stable clinical condition.

Due to the severity of the patient's condition, including worsening kidney function in the setting of continued use of diuretics, the requested health service/treatment of inpatient hospital services was medically necessary for this patient. Treatment of acute exacerbation of congestive heart failure necessitated treatment with diuretics, which was very challenging in the setting of worsening kidney failure. The patient required close monitoring of the kidney function and electrolytes and adjustment of diuretic.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Adbry
The insurer denied Adbry.
The determination is upheld.

The patient has atopic dermatitis. He also has a history of asthma and allergic rhinitis. The correspondence from the health plan reports that Dupixent was denied because standard, first-line therapies (oral immunomodulators) and phototherapy. However, the patient was started on samples but had red eyes with a lot of discharge despite use of eye drops. The patient has tried and failed topical triamcinolone, Eucrisa, and tacrolimus. Adbry is now being requested. At issue is the medical necessity of Adbry.

The Adbry is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine,), and/or Phototherapy. Adbry is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with the standard of care based on modern dermatology literature [1-5], the requested Adbry is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity
Treatment: Surgical procedure on the stomach (repeat bariatric surgery) with hospital admission
The insurer denied coverage for surgical procedure on the stomach (repeat bariatric surgery) with hospital admission
The denial is overturned

The indications for revision of bariatric surgery are inadequate weight loss, weight regain, or complications. [1] The National Institutes of Health has indicated that bariatric surgery is appropriate for all patients with a body mass index (BMI) greater than 40, or for patients with a BMI of 35 to 40 with associated comorbid conditions. Obesity-related comorbidities are conditions that are directly caused by obesity or contribute to the severity of the condition. Obesity-related conditions include cardiovascular problems, diabetes mellitus, obstructive sleep apnea, asthma, musculoskeletal conditions, and various reproductive conditions. [2, 3]

Per clinical documentation, the patient has a history of morbid obesity. BMI was 45.04. The patient has failed to lose weight after a previous sleeve gastrectomy. In this situation, the health plan did not act reasonably in their denial of the bariatric surgery. The requested bariatric surgery is medically necessary for this patient.

Clinical documentation notes that the patient previously was scheduled for a revision bariatric procedure. There was difficulty with intubation, and the patient had bronchospasm after extubation. Per Milliman Care Guideline (MCG) guidelines, goal length of stay is one day postoperative. However, an extended stay is warranted in patients with complex comorbidities (i.e. severe sleep apnea) that may require continued inpatient care. Admission would be indicated for this patient.

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 surgical procedure on the stomach (repeat bariatric surgery) with hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Erectile dysfunction
Treatment: Ambulatory surgery, penile prosthesis placement
The insurer denied coverage for ambulatory surgery, penile prosthesis placement
The denial is upheld.

This is a male with history of erectile dysfunction and congestive heart disease. The patient presented to urology for follow up on his erectile dysfunction. The patient has decreased libido and trouble attaining erections. The patient has tried and failed Viagra, Levitra, and Cialis. The physician recommended placement of a penile prothesis for the treatment of his erectile dysfunction. 

The insurer has denied coverage for ambulatory surgery placement of a penile prosthesis as not medically necessary. They stated that records do not show patient had had erectile dysfunction for at least 6 months and the patient has not tried and failed second line treatments, such as vacuum erection device, intracavernosal injections, or intra urethral medications. 

The appeal on behalf of the patient is noted and read in detail. 

Doppler studies showed arterial insufficiency and corpora venous leakage. 

Based on the literature the standard of care in most situations for erectile dysfunction: a patient must fail 1st and 2nd line treatment before implantation of a penile prosthesis is considered. If records show erectile dysfunction has not been present for more than 6 months and patient has not tried any 2nd line therapies, as described earlier, then the implantation of a penile prosthesis would not be medically necessary. If records indicated that the patient has previously tried and failed intracavernosal injection therapy, intraurethral suppository, testosterone supplementation (if he has a documented testosterone serum level x2), then a penile prosthesis implantation would be considered medically necessary. 

Most male patients are not interested in a vacuum erection device. Review of the supporting letter makes no mention of a trial of any of the above noted 2nd line treatments.

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

The insurer's denial of coverage for ambulatory surgery, penile prosthesis implantation is upheld. Medical Necessity is not substantiated.