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

Diagnosis: Duodenal Ulcer without bleeding

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient was having black stool and was referred to the hospital for a hemoglobin of 6.0. She reported shortness of breath (SOB) and chest tightness on exertion. She was afebrile and the vital signs were stable. The abdominal exam was benign. The hemoglobin was 7.8. The stool occult blood was negative. Proton-pump inhibitor (PPI) therapy was given. An endoscopy revealed a duodenal ulcer without bleeding. A colonoscopy was negative except for hemorrhoids. The hemoglobin remained stable.

Clinical indications for admission for Anemia (M-35) include hemodynamic instability, active bleeding, altered mental status, recurrent syncope, cardiac arrhythmias, severe thrombocytopenia, acute renal failure, and symptoms of cardiac ischemia that persist after observation care. The patient did not have these conditions.

This patient was having black stool, but the bleeding had stopped by the time that she arrived in the hospital. The stool occult blood was reported to be negative. The hemoglobin remained stable. The endoscopy revealed an ulcer, but it was not bleeding and there were no high-risk endoscopic features. The hemoglobin had risen to 7.8 on the day of admission. The cardiologist did not find any active cardiac problems. She required PPI therapy and an endoscopy, but was stable to have had it done with observation status. She did not meet Milliman Care Guideline (MCG) criteria for admission for anemia. 

The health care plan acted reasonably and with sound medical judgement. An inpatient medical stay was not medically necessary.

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis. 
Treatment: Hospital Admission. 

The insurer is denied coverage for hospital admission. 

The denial is upheld. 

This female patient has a history of gastric ulcers, scleroderma, and gastroesophageal reflux disease (GERD). 

This patient was found to have cholelithiasis and ductal dilatation. General Surgery service was consulted. Based on the patient's findings, there was a suspicion of choledocholithiasis for which an magnetic resonance cholangiopancreatography was appropriately obtained on the day of presentation to the hospital. Her pain was managed, and she was on antibiotics. Her liver enzymes were not consistent with choledocholithiasis, and the patient did not exhibit clinical signs of cholangitis or sepsis. She was taken to the Operating Room on for laparoscopic cholecystectomy and eventually discharged on the same day of surgery. 

Due to the need for further workup to rule out choledocholithiasis in a stable patient, it would have been feasible, safe, and practical to admit the patient as observation status and not inpatient and proceed with early cholecystectomy. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dehydration

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld. 

This was a male patient with no significant past medical history.

The fact that his serum bicarbonate was normal would suggest that stool losses were modest. A minimally elevated C-reactive protein (CRP) and unremarkable complete blood count would suggest that a significant bacterial process was not present. After a brief period of hydration and observation, this patient could have been safely discharged with outpatient follow-up and parental reassurance. He actually received no acute care after admission to merit admission at that level. His heart rate (HR) at admission to the inpatient service (123) was the same at discharge (126). The child certainly was never severely dehydrated as stated in the appeal. The brevity of his admission also speaks to the likely inaccurate report of 3-4 weeks of ongoing diarrhea and vomiting.

The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatitis

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission.

The denial is overturned. 

This male patient has a history of diabetes, hypertension (HTN), hyperlipidemia, neuropathy, vertigo, methadone maintenance and pancreatitis.

The patient had a history of pancreatitis and presented with epigastric pain. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. A computed tomography (CT) scan revealed mild peripancreatic fat stranding, and a calcification in the tail of the pancreas. There was a lipase level of 591 with a reference range of under 60.
 
Clinical indications for admission for Pancreatitis (M-250) include having acute pancreatitis as manifested by 2 or more of the following: epigastric pain, serum lipase greater than 3 times the upper limit of normal, and characteristic findings from abdominal imaging. 

This patient had all 3 indications. There was epigastric pain, lipase greater than 3 times the upper limit of normal, and inflammation around the pancreas on the CT scan.

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

The carrier's denial of coverage for the inpatient admission is overturned. The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Gastrointestinal Reflux Disease (GERD). 

Treatment: Omeprazole-Sodium Bicarbonate. 

The insurer is denied coverage for Omeprazole-Sodium Bicarbonate. 

The denial is upheld. 

The patient has required percutaneous endoscopic gastrostomy (PEG) feedings for his entire life. An endoscopy revealed reflux esophagitis. The physician writes that other formulations have been tried and failed. There is no specific documentation submitted as to which medications failed and if there were any specific side effects. 

The American College of Gastroenterology has published Guidelines for the Diagnosis and Management of Gastroesophaeal Reflux Disease (GERD). The guideline states that proton pump inhibitor (PPI) therapy has been associated with superior healing rates and decreased relapse rates compared to H2 (Histamine-2) blockers and placebo for patients with erosive esophagitis. However, the article also states that meta-analysis has failed to show a significant difference in efficacy for symptom relief between PPI. It is noted that Omeprazole-Sodium Bicarbonate is more effective in the first 4 hours of sleep. However, it has not been shown that this leads to any superior clinical outcomes. 

This patient requires PPI therapy for erosive esophagitis. However, it has not been proven that one PPI is superior to others in the treatment of GERD. The other formulary PPI alternatives are not likely to cause an adverse reaction. The chart does not detail which other PPI have been tried and failed. The Omperazole-Sodium Bicarbonate has not been shown to be more effective in the treatment of GERD as compared to other PPI. 

The insurer's denial of formulary exception for Omeprazole-Sodium Bicarbonate is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hereditary Angioedema. 
Treatment: Firazyr (icatibant), Pre-service. 

The insurer denied the Firazyr (icatibant), Pre-service. 
The denial is overturned. 

The patient is a female with a history of hereditary angioedema.  The patient was previously on Takhzyro and was not able to continue injections due to weight gain.  She is appealing the continuation of Firazyr for on-demand treatment. 

Yes, the proposed treatment is medically necessary. 

Hereditary angioedema (HAE) is a rare disorder characterized by recurrent episodes of angioedema without urticaria, which most often affects the skin or mucosal tissues of the upper respiratory and gastrointestinal tracts. The most common forms of hereditary angioedema (types I and II) are caused by deficiency or dysfunction in C1 inhibitor (C1-INH).   Firazyr is a synthetic bradykinin B2-receptor antagonist approved for patients 18 years of age and older for acute treatment of hereditary angioedema attacks in patients with hereditary C1 inhibitor (C1-INH) deficiency. 

The FAST-1 and FAST-2 trials were randomized, multicenter, phase III trials, in which 130 adults with C1 inhibitor (C1-INH) deficiency were treated with Firazyr for laryngeal, gastrointestinal, or cutaneous attacks of moderate-to-severe intensity. In a pooled analysis of the two trials, significantly more patients on Firazyr had symptom relief within four hours compared with placebo. In a third trial, FAST-3, 83 patients were randomly assigned to receive Firazyr, which significantly reduced median times to 50 percent reduction in symptom severity, onset of primary symptom relief, or near-complete symptom relief (eight versus 36 hours) and provided a shorter time to initial symptom relief. A phase III study involved 32 children and adolescents with hereditary angioedema, ranging in age from two to 18, who were treated with 0.4 milligrams per kilogram of Firazyr. Among 11 children and 11 adolescents treated for attacks, the median time to symptom relief was one hour. Adverse events occurred in nine subjects, were mild or moderate, and consisted predominantly of injection site reactions and gastrointestinal complaints.  Therefore, the use of Firazyr for acute symptoms for hereditary angioedema attacks is efficacious. 

The progress notes have shown that the patient is having fewer attacks, and not using Firazyr as often as when she has dental surgeries.  Therefore, the continuation criteria are met for the approval for Firazyr.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Urinary incontinence. 
Treatment: Formulary exception for Toviaz. 

The insurer denied the Formulary exception for Toviaz. 
The denial is upheld. 

The patient is a female with history of mixed urinary incontinence, status post hysterectomy with nocturia seven to eight times per night and urinary frequency. The patient is reported to have tried BOTOX 100 units (U), first time not covered by insurance. The patient tried and failed myrbetriq, 25 milligrams (mg) and Toviaz, eight milligrams daily. 

The appeal in this case is regarding denial of continuation of Toviaz eight milligrams daily. Prior notes indicate that the patient was continued on toviaz eight milligrams to ease her symptoms. The patient was denied coverage for Toviaz, as the patient has not tried and failed all preferred medications which include oxybutynin, trospium, tolterodine, darifenacin and solifenacin. 

No, the health plan should not cover the formulary exception for Toviaz. 

The patient has not been demonstrated to have failed the available formulary alternatives. There is lack of documentation provided to support that the patient has failed monotherapy with one or more of the formulary anticholinergics. The patient has not been documented to have experienced adverse effects or contraindications to the formulary alternatives. 

The AUA (American Urological Association) guidelines support the use of an alternative antimuscarinic agent if one agent fails. "If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one antimuscarinic medication, then a dose modification or a different anti-muscarinic medication or a 3-adrenoceptor agonist may be tried."  The AUA (American Urological Association) guidelines note with respect to efficacy, "Due to the similar efficacy observed for all oral antimuscarinic medications, the choice of medication for a particular patient depends on the patient's history of anti-muscarinic use, information regarding adverse events experienced in the past, the impact on the patient of adverse events, patient preferences, comorbidities, use of other medications and the availability of and resources to acquire specific medications. In addition, although there was no evidence of differential efficacy across medications, both qualitative analysis and meta-analysis of all randomized trial arms revealed different adverse event profiles for dry mouth and constipation. This information may be relevant if a patient is particularly sensitive to one of these adverse events." 

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

Diagnosis: Crohn's Disease. 
Treatment: Stelara. 

The insurer denied the Stelara. 
The denial is overturned. 

The patient is a male with moderate to severe Crohn's. He has failed Pentasa, budesonide and Humira. His provider is requesting treatment with Stelara. Stelara was denied, as the patient has not tried and failed Renflexis, Inflectra, Avsola or Entyvio. 

Yes, the requested Stelara is medically necessary. 

Stelara is a safe and effective treatment for moderate to severe Crohn's. It is supported by medical literature and ACG (American College of Gastroenterology) guidelines as both first-line biologic treatment, as well as in patients with moderate to severe Crohn's who have failed anti-TNFs (tumor necrosis factor). 

The provider's argument in the appeal letter that Stelara is more effective than Entyvio in a patient such as this who has failed Humira is reasonable. 

As this patient has tried and failed Humira, an anti-TNF (tumor necrosis factor), the use of Stelara is clinically appropriate, accepted standard of medical care, and is medically necessary in this patient. 

As above, as Stelara is medically necessary, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease.
Treatment: J1745 - Remicade.
The insurer denied the J1745 - Remicade.
The denial is overturned.

The patient is a male newly diagnosed with Crohn's disease and under the care of Pediatric GI (gastroenterology). The patient presented to the ED (emergency department) with progressively worsening abdominal pain and decreased oral intake. He was admitted overnight for hydration. CT (computed tomography) Scan revealed enteritis of the terminal ileum to splenic flexure.  EGD (esophagogastroduodenoscopy) and colonoscopy revealed Crohn's ileitis and colitis with upper tract disease.  The patient had lost 10 pounds over the preceding 2 weeks, experiencing severe abdominal pain and vomiting. He had not been able to attend school and was readmitted to the hospital with labs that are consistent with inflammation.  PCDAI (Pediatric Crohn's Disease Activity Index) score was consistent with moderate to severe Crohn's disease.

TB (tuberculosis) testing (PPD [purified protein derivative] placed and read two days later was negative.  Hepatitis B surface antigen was negative.

Yes, the requested treatment with Remicade is medically necessary.
Infliximab (Remicade) is a chimeric monoclonal antibody (75% human, 25% murine) that inhibits the tumor necrosis factor-alpha (TNF-alpha). Remicade is FDA (United States Food and Drug Administration)-approved for the treatment moderate to severe Crohn's disease. The drug is approved for the treatment of both induction of remission and maintenance of disease. Other anti-TNF (tumor necrosis factor) inhibitors used for treatment of Crohn's disease are Humira and Cimzia.

The conventional agents such as systemic corticosteroids (e.g., budesonide), immunomodulators (e.g., azathioprine, 6-mercaptopurine, methotrexate), aminosalicylates (e.g., mesalamine, sulfasalazine) would be inappropriate for this patient. Steroids cannot be used long-term, and mesalamines do not have a role in Crohn's disease. In addition, immune modulators takes months to take effect.

Additionally, without adequate treatment, this patient may have growth failure and complications of inflammatory bowel disease such as fistula, stricture, abscess, and the need for surgery. In pediatric patients, periods of active disease may result in growth retardation.

The available literature suggests that early IFX (Infliximab) treatment is also more effective when administered earlier in the disease course (Walters TD et al and Kang B et al).

Increasing evidence in adults and children has shown treatment failure may be due in part to low infliximab exposure, and emerging evidence has shown that pediatric patients may benefit from an escalated dose at 10 mg / kg (milligrams per kilogram).

Therefore, given the above, the requested Remicade is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shaking.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented to the emergency ward with the complaint of whole body shaking. She reported two previous episodes. There was no loss of consciousness. At presentation, her neurological examination was normal. She was admitted for further evaluation.

No, the Inpatient admission was not medically necessary.
The patient presented with a third episode of whole body shaking without loss of consciousness. The documented neurological examination was normal. The events, as described, lack the emblematic features or seizure (e.g., post ictal state, loss of consciousness, incontinence) and were most likely non-epileptic events (Asadi-Pooya). The monitoring, treatment, psychiatry and neurology assessments and diagnostic test could have safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Patella Tendon Rupture

Treatment acute inpatient level of care

The insurer denied coverage for acute inpatient level of care.

The denial is upheld.

This is the case of a patient with a history of hypertension and hyperlipidemia. The patient presented to the emergency department (ED) for evaluation of left knee pain following a fall off a ladder. He was unable to bear weight on the left lower extremity. Orthopedics was consulted and the patient was admitted to Orthopedic Surgery for management of left patella tendon rupture. He was made NPO (nothing by mouth) after midnight, and underwent repair of ruptured patellar tendon without complication. The patient received intravenous (IV) antibiotics and pain medication and was discharged home on full weight-bearing status.

The records show the man sustained an isolated patella tendon rupture. 

The injury would be classified under musculoskeletal disease. The Milliman Care Guidelines (MCG) state: "Musculoskeletal disease condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate." 

The records show his operative management and post-surgical course was non complicated. His vital signs were stable. There were no problems with his wound. He was able to tolerate oral pain medications. There were no restrictions to using crutches. He did not require treatment for other underlying medical conditions. He did not require additional imaging. 

These findings are consistent for Observation type level of service. The MCG have not been fulfilled for the acute inpatient level of care. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The acute inpatient level of care is not considered medically necessary for this patient.

The insurer's denial of coverage for the acute inpatient level of care is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Distal Ureteral Stone and Acute Kidney Injury (AKI).

Treatment full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

This patient has no significant past medical history. The patient presented to emergency department with complaint of left flank pain, emesis. The patient found to have a small left distal ureteral stone and acute kidney injury (AKI). Pain resolved in emergency department, but serum Creatinine noted to increase. Patient given 3 liters of intravenous fluids, admitted, taken to operation room that day for cystoscopy and left stent placement. Creatinine improved after stent insertion; patient voided, good pain control, hemodynamically stable. The patient discharged home on oral antibiotic. 

The insurer has denied coverage for the full hospital admission as not medically necessary. They noted the patient's presentation and the procedure that was done. They stated that there were no severe problems warranting a full hospital admission. 

The patient did not meet Milliman Care Guideline Renal Colic and Kidney Stones and Urologic Surgery or Procedure parameters for inpatient admission.

The healthcare plan acted reasonably and with sound medical judgement and in the interest of the patient. The full hospital admission was not considered medically necessary.

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.