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

Diagnosis: Bronchiolitis
Treatment: Inpatient hospital admission 
The insurer denied coverage for an inpatient hospital admission. 
The denial is overturned.

This is a female with a history of vocal cord paralysis and hemihypertrophy who had been sick for three days with a fever and a cough. She developed difficulty breathing and a decrease in her oral intake of liquids. Her mother was concerned about her rapid rate of breathing and persistent fever, so she decided to take her to the emergency room (ER) for treatment.

In the ER she was noted to be dehydrated and she was given 2 intravenous (IV) boluses of normal saline. Her pulse oximeter reading was 93% (percent) and she was started on oxygen supplementation. On physical exam she was febrile to 103 degrees and was noted to have intercostal retractions, wheezing on the right lung and rhonchi bilaterally. She was treated with 3 doses of albuterol with no improvement in her increased work of breathing and abdominal retractions. A chest x-ray was normal. A respiratory viral panel was positive for RSV (Respiratory syncytial virus) and enterovirus. Her venous blood gas was abnormal with a pH (potential for hydrogen) of 7.33 and a pCO2 (partial pressure of carbon dioxide) of 40. Her lactic acid level was elevated at 5.2 demonstrating evidence of metabolic acidosis. Her urine specific gravity was high at 1030 confirming dehydration. Despite treatment with oxygen, she continued to have hypoxemia and increased work of breathing and she was switched to high flow oxygen at 20 liters per minute with an FIO2 (fraction of inspired oxygen) of 40%. Upon repeat examination after treatment in the ER, she was noted to have a persistent increased work of breathing with abdominal retractions, wheezing on the left lung and rhonchi bilaterally. The decision was made to admit the child to the PICU (pediatric intensive care unit) with a diagnosis of bronchiolitis and dehydration for continued treatment with IV fluids, albuterol treatments and high flow oxygen.

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

The patient was treated appropriately in the ER for hypoxemia and clinical and lab evidence of dehydration. She was treated with two IV boluses of normal saline, 3 treatments with nebulized albuterol and high flow oxygen at 40% but continued to have an increased work of breathing and rhonchi and wheezing upon chest examination. When she did not respond to treatment in the ER, it was appropriate and consistent with the standard of care to admit the infant to the PICU with a diagnosis of bronchiolitis for ongoing oxygen supplementation and IV fluids. She was not stable enough to be safely discharged. 

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

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Diffuse eosinophilic fasciitis.
Treatment: Xeljanz.
The insurer denied coverage for Xeljanz.
The denial is overturned. 

The patient is a female with a diagnosis of eosinophilic fasciitis. The patient has failed therapy with methotrexate, prednisone for > 6 months, mycophenolate (high dose), and mepolizumab. The requested medication is Xeljanz.

The scientific literature supports an improvement in health with the use of Xeljanz to treat eosinophilic fasciitis. Xeljanz is not Food and Drug Administration (FDA) approved for eosinophilic fasciitis. There are currently no FDA approved treatments for this condition. The patient appears to be a good candidate for Xeljanz and has failed numerous traditional medications. Xeljanz would appear to be the best treatment option for this patient based on the information provided. The risks associated with Xeljanz are not significantly greater than those associated with the patient's current regimen. Xeljanz is likely to be more beneficial than the standard treatments for this patient and is approved.

The carrier's denial of Xeljanz should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure
Treatment: Inpatient hospital admission 
The insurer denied coverage for an inpatient hospital admission. 
The denial is overturned.

The patient is a female with no significant past medical or surgical history. She presented to the hospital status post seizure. Per her daughter's report, she became unresponsive for approximately 15 minutes. She arrived via EMS (emergency medical services) and regained consciousness shortly after EMS arrival. She underwent a CT (computed tomography) of the brain that showed a left frontal lobe 3 cm (centimeters) mass with edema and a 5 mm (millimeters) midline shift. She was transferred for neurosurgical treatment. On arrival she was moderately confused. Her chief complaint was nausea and dizziness. Her vital signs were within normal limits. She was admitted for a diagnoses of meningioma, brain mass, and a new onset seizure. The indication for admission was surgical resection of the tumor. The hospital course stated that she underwent an MRI (magnetic resonance imaging) of the brain for preoperative planning. Neurosurgery notes that she was at baseline. The plan was to admit, perform an MRI of the brain with/without contrast, start steroids after brain MRI, perform a medical clearance for a craniotomy with brain tumor resection, perform a neurology consult for seizure management, and initiate GI (gastrointestinal)/DVT (deep vein thrombosis) prophylaxis. Neurology and Internal Medicine were consulted. The MRI noted an extra axial mass along the left frontal lobe, likely a meningioma. Her exam was normal. The patient later changed her mind and refused surgery. She left against medical advice. Her discharge medication list included Keppra and a Medrol dose pak. 

The patient was transferred from another hospital and was admitted to undergo a surgical resection for her brain tumor. She was status post seizure and was confused in the emergency room. She had edema with a midline shift which makes her a high-risk patient. She was started on Keppra and corticosteroids. The patient could not have been monitored at an observational level of care prior to surgery. Per InterQual, resection of brain tumor is inpatient. [2] The inpatient hospital stay meets general guidelines as noted above.

Surgical resection is the primary treatment choice for symptomatic meningiomas. The purpose of the operation is to relieve symptoms caused by the tumor, change the natural course of the tumor, and improve quality of life. The tumor should be removed surgically in patients with obvious mass effect and increased intracranial pressure. The factors that affect the surgical strategy are as follows: (1) surgical benefits; (2) surgical risks; (3) biological characteristics of tumor; (4) tumor mass effect or clinical symptoms; (5) subjective wishes of patients. [3]

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

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

Diagnosis: Orthopedic/Musculoskeletal/Other/Chronic Arm Nerve Pain.
Treatment: Outpatient Procedure - Peripheral nerve stimulator implant as not medically necessary.
The health plan denied the requested Outpatient Procedure - Peripheral nerve stimulator implant as not medically necessary.

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

The patient is a male with a history of chronic arm pain. The notes indicate that he has been treated with prior surgeries, home exercises, nerve blocks, ketamine infusions, pulsed radiofrequency (RF), Amitriptyline, Gabapentin, and nonsteroidal anti-inflammatory drugs (NSAIDs).
At issue is the medical necessity for the requested health service/treatment of the outpatient procedure - peripheral nerve stimulator implant.

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

No. The requested health service/treatment of an Outpatient Procedure - Peripheral nerve stimulator implant is not medically necessary for this patient.
Peripheral nerve stimulation (PNS) targets the nerve(s) that transmit pain signals to the brain. PNS involves a tiny implant, a wire about the thickness of a human hair, or a group of electrodes about the size of a standard paperclip that delivers electrical impulses, similar to a pacemaker, to the nerve.
The greatest need to further improve this bioelectronic therapy is in researching outcomes to help us better understand the proper use and patient selection. While several proof-of-concept studies have been published highlighting its use in various types of surgeries, large-high-quality randomized controlled trials are still needed to support the efficacy of this treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic pain
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female with infertility and progressive pelvic pain. She underwent an abdominal myomectomy for worsening pain.

The patient underwent an open procedure and had 31 fibroids removed, the largest measuring 12 centimeters. She had 800cc (cubic centimeters) of blood loss during the procedure and was given 2 units of packed red blood cells during the procedure. She was transferred to recovery. She had stable vital signs. She had a Foley catheter in place. She was given an IV (intravenous) with fluids, cefazolin every 8 hours, pain medication, anti-nausea medication, and serial blood counts. She was evaluated later that day and was stable. Her urine output was good and her Foley was removed. She was ambulating with assistance.

The patient's post-operative blood level was 11.2 then 10.6. She did not have any active bleeding. By the next day, she was tolerating food, ambulating, passing gas, voiding on her own, and her pain was controlled. She was deemed stable for discharge. She was discharged home later that day.

No, the inpatient hospital admission was not medically necessary.

An outpatient observation bed is an alternate level of healthcare compromising short stay encounters for patients who require close nursing observation or medical management. It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient.

The patient in question was taken to the operating room and underwent an uncomplicated procedure for a multi-fibroid uterus. She had an abdominal myomectomy with the removal of 31 fibroids. She received 2 units of blood intraoperatively. After surgery, she was not ready for discharge the same day due to her surgery. She required observation and nursing care to assist with her ambulation and medical management of her pain and ensure she did not have any surgical complications. This could have been done at a lower level of care status. There was not any care provided that required an inpatient level of care.

By postoperative day 1, the patient was ready for discharge requiring less than a 24-hour stay. She remained hemodynamically stable throughout the hospitalization. She did not have any severe anemia post-surgery. There were no complications.

Therefore, the patient did not require an acute inpatient stay. This was not medically necessary as the inpatient stay is more intensive than an alternative level of care that still provided the same safety and outcome.

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

The plan appropriately denied an inpatient hospital admission, given the information provided. The same care could have been provided with the same safety for the patient at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Newborn sepsis.
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is overturned.

The patient was a premature female born via Cesarean-section for breech presentation. Her birth was uneventful with Apgars of 9 at 1 and 5 minutes. After delivery, the patient was tachypneic with no proven need for oxygen. During pregnancy, her mother was documented to have persistent leakage of amniotic fluid. The diagnosis of premature prolonged rupture of membranes and accordingly the diagnosis of newborn sepsis was entertained. A CBC (complete blood count) and blood culture was drawn and with the history of tachypnea and prolonged rupture, antibiotics were started for the duration of 48 hours awaiting the results of the blood culture. 

The patient was admitted to the neonatal intensive care unit (NICU) for observation and intravenous antibiotics pending the results of the blood culture. By the newborn care standards of the American Academy of Pediatrics (AAP), this is Level II care for intravenous medication and observation pending the results of blood culture drawn in the setting of a premature infant with prolonged rupture of membranes. The suggestion that antibiotics did not need to be initiated would not be reasonable nor sound medical judgment. It would not be safe and in the best interest of the patient to withhold antibiotics pending the results of the blood culture.

The continued admission to the NICU was medically necessary, as the patient was being prepared for discharge. 

The NICU admission is medically necessary. NICU care is appropriate due to the need for intravenous antibiotics pending the results of the blood culture.

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

Diagnosis: Rhinosinusitis. 
Treatment: Dupixent SC (subcutaneous) Injection. 

The insurer denied the Dupixent SC (subcutaneous) Injection. 
The denial is upheld. 

The patient is a male with nasal polyposis. The patient had surgery earlier this year. The most recent exam did not show polyp return. Dupixent is topic of this review. 

No, the requested Dupixent is not medically necessary. 

There is no documentation of nasal polyps. The patient had sinus surgery two months prior. 

Dupixent is not used as a preventative medication. The current studies analyzing Dupixent effectiveness look at patients with active polyp disease. Prescribing Dupixent for a patient without active polyp disease is not consistent with medical literature or standard of care. 

Therefore, given the above, the requested Dupixent is not medically necessary. 

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

The health plan acted reasonably in its denial. The patient does not have active polyp disease. Dupixent is not FDA (United States Food and Drug Administration)-approved for the prevention of nasal polyps after surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent SOPN (Solution Pen-Injector) 300MG (milligrams)/2ML (milliliters)
The insurer denied the Dupixent SOPN 300MG/2ML.
The denial is upheld.

The patient is a female with atopic dermatitis, treated with multiple topical steroids.  The provider is requesting Dupixent.  The health plan requires use of Protopic and Opzelura.  The patient has already responded favorably to Dupixent.  She presented reporting her rash had been present for months with no prior treatment and is located on the eyelid and hand.

No, the proposed treatment with Dupixent is not medically necessary.

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

This patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis, including topical calcineurin inhibitors such as Protopic.  Given that the rash has only been present for roughly a year and is limited to small areas, patch testing is recommended to rule out contact dermatitis.  Therefore, the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ataxia-Telangiectasia and Hypogammaglobulinemia
Treatment: Hizentra
The insurer denied Hizentra.
The health plan's determination is overturned. 

This is a female patient. She has Ataxia-Telangiectasia and Hypogammaglobulinemia. Immunoglobulin G (IgG) is 192, Immunoglobulin A (IgA) is 6 and she has poor vaccine responses. She has had decreased infections on therapy, per the appeal letter.

Hizentra is medically necessary for this patient.

Management of unspecified hypogammaglobulinemia should adhere to the general principles presented for antibody deficiency. If other treatments (eg [for example], antibiotic prophylaxis) fail and a trial of IgG therapy is undertaken, the continuation of such therapy must be based on the objective clinical response.

In this case, the patient has profound hypogammaglobulinemia. She has benefited from therapy and the continuation of Hizentra would be standard of care. The continued of Hizentra in this case is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Knee pain, hip pain, back pain
Treatment: Oxycontin
The insurer denied the Oxycontin.
The determination is upheld.


The patient has a history of diabetes, back pain, right knee pain, and right hip pain. He is requesting coverage for brand name Oxycontin. A prior authorization form was completed indicating that the patient tried and failed oxycodone, fentanyl, morphine, tramadol, Lyrica, and gabapentin. A medical note documented that the patient was being treated with oxycodone and Advil. Notes document the same treatment. There is no documentation in the medical notes supplied that provides a history of failing all of the above listed formulary alternatives.
At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug Oxycontin, or would have adverse effects.

There is no evidence that the patient tried and failed all of the formulary drugs, or that they would not be as effective as brand name Oxycontin, or would have worse side effects.
There is very scant evidence that the patient tried and failed oxycodone (presumably a generic version), fentanyl, and morphine. There is no evidence in the records provided that the patient tried and failed hydrocodone, hydromorphone, methadone, or tapentadol (Nucynta). All opioids have the same side effect profile, and in general there is no credible evidence that Oxycontin would have less adverse effects that the formulary alternative. Therefore, based on the standard of care, plan language, and the peer reviewed literature cited in the references, criteria for a formulary exception for brand name Oxycontin has not been met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis.
Treatment: Dupixent.
The insurer denied Dupixent. 
The health plan's determination is upheld. 

This is a female patient. She has CRS (chronic rhinosinusitis) with NP (nasal polyps). 

Dupixent is not medically necessary for this patient. 
The current standard of care for the treatment of CRS with NP includes the use of systemic corticosteroids as needed for acute symptom management and maintenance therapy with intransasal corticosteroids. Sinus surgery to remove nasal polyps is another treatment option that can be considered when pharmacologic therapies have failed. Relapse after surgery is common, however, and revision surgery is often required. In the trials for Dupixent that led to its approval for CRS with NP, the co-primary efficacy endpoints were the change from baseline in the nasal polyps score (NPS) and the nasal congestion/obstruction (NC) score. For NPS, polyps on each side of the nose were graded on a categorical scale. The total score was the sum of the right and left scores. NC was rated daily by the subjects on a 0 to 3 categorical severity scale. Amongst the secondary endpoints, the sinus computed tomography (CT) scan score evaluated the opacification of each sinus using a 0 to 2 scale. Loss of smell was scored reflectively by the patient every morning on a 0-3 scale. The 22-item sino-nasal outcome test (SNOT-22) includes 22 items assessing symptoms and symptom impact associated with CRS with NP with each item scored from 0 (no problem) to 5 (problem as bad as it can be) with a global score ranging from 0 to 110. Additionally, therapy significantly improved endoscopic nasal polyp scores and patient-reported nasal congestion symptoms compared with placebo; it also significantly reduced loss of smell, reduced the proportion of patients requiring systemic corticosteroids, and reduced the proportion of patients requiring surgery.
While this patient appears to be stable on Dupixent for CRS, there are no updated notes to show the patient's response. The most recent notes were from months ago. There are no current/updated patient records provided to show how the patient is progressing or current status. Continuation of Dupixent would only be SOC (standard of care) if there is continued benefit. Therefore, at this time Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder.
Treatment: Surgical Services (All). 
The insurer denied procedure on the testis in a hospital setting. The denial is upheld. 

The patient is a male with right testicular pain. He had been diagnosed with retractile testicle, intermittent torsion and was recommended to undergo testicular fixation by his provider. The procedure was performed in a hospital setting.
At issue is the medical necessity of Procedures on the Testis in a hospital setting.

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

The requested health service/treatment of Procedures on the Testis in a hospital setting was not medically necessary for this patient.
The patient had chronic, recurrent pain associated with a demonstrable physical abnormality and the procedure was appropriate. However, the patient is an otherwise healthy man with controlled hypertension. He did not require in-hospital monitoring for comorbidities. This procedure is generally performed as an outpatient in an ambulatory care setting. His preoperative studies were essentially unremarkable. Literature notes, "circumferential lysis of the cremasteric muscle through a small subinguinal incision is a safe and effective minimally invasive procedure for physical activity-precipitated painful retractile testicular pain." The procedure may have been appropriately and safely performed on an ambulatory basis in a non-hospital setting and did not require a hospital setting.
Therefore, the requested health service/treatment of Procedures on the Testis in a hospital setting was not medically necessary.