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

Diagnosis: Abdominal pain, nausea, vomiting
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is upheld.

The patient is a teenaged female. She presented with abdominal pain, nausea and vomiting. The patient underwent evaluation, including imaging revealing a 1.3cm (centimeter) ovarian cyst. 
The concern was for an ovarian torsion. She was taken to the operating room and underwent a diagnostic laparoscopy. No torsion was identified. She was transferred to the recovery room. She required IV (intravenous) pain medication and anti-emetics. She was discharged home the next day with outpatient follow up.
The inpatient hospital stay was denied coverage by the health plan as not medically necessary. This is being appealed.

The Inpatient Admission was not medically necessary.

According to ACOG (American College of Obstetricians and Gynecologists), "The ERAS (enhanced recovery after surgery) principles represent an evidence-based approach to surgical management that challenges traditional surgical management paradigms. The use of ERAS [enhanced recovery after surgery] pathways has resulted in more rapid surgical recovery, shorter length of stay, greater patient satisfaction, and decreased costs when compared with traditional approaches. These benefits have been replicated across the spectrum of gynecologic surgeries, 
including open and minimally invasive approaches and benign and oncologic surgeries. The implementation of the ERAS [enhanced recovery after surgery] program requires collaboration from all members of the surgical team. Successful ERAS [enhanced recovery after surgery] pathway implementation across the spectrum of gynecologic care has the potential to improve patient care and health care delivery systems, and the use of ERAS [enhanced recovery after surgery] pathways should be strongly encouraged within institutions."
An outpatient observation bed is an alternate level of healthcare compromising of 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 possible ovarian torsion. After surgery she was not ready for discharge same day due to pain, nausea, and grogginess from surgery. She required observation and nursing care to assist with her ambulation and medical management of her pain and nausea. This could have been done in an observation status. By post-operative day 1, the patient was ready for discharge requiring less than a 24 hour stay. Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided under an observation status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: opioid withdrawal symptoms

Treatment is medically supervised inpatient detoxification

The insurer denied coverage for medically supervised inpatient detoxification

The denial is overturned

This adult male was admitted to the inpatient substance detoxification treatment for opioid detoxification treatment. He reportedly had opioid withdrawal symptoms including abdominal cramps, gastrointestinal upset, chills, tremors, fatigue, nausea, irritable mood, anxiety, joint pain, loose stools, body aches, restlessness, yawning, gooseflesh, and change in pupil size. It was reported that his COWS score (The Clinical Opiate Withdrawal Scale) was 13, and then 11, 10, and 9 so he still had withdrawal symptoms reported even while taking Methadone. He reportedly had a past inpatient substance detoxification treatment but did not complete it. He reportedly was discharged with an admission date to another facility for further substance rehabilitation treatment.
   
This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment as the medical records provided enough specific evidence to support that he required this level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case this patient used multiple substances daily in large amounts, so he was at risk for severe withdrawal and overdose and required inpatient medical hospital detoxification treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use serious substances despite past recent inpatient substance treatment a few weeks prior to this admission, and he needed detoxification medication, Methadone, to modify withdrawal from opioids. He reportedly was taking Methadone and still had reported withdrawal during some of the detoxification treatment so he was at risk of severe withdrawal if not in this setting. He reportedly lacked sober support which resulted in his relapse so he likely could not stop use and get detoxification treatment if not in this 24-hour inpatient detoxification treatment setting. He also likely would have relapsed again as evidenced by relapsing after a recent past inpatient substance detoxification treatment in which he did not complete.

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 medically supervised inpatient detoxification services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Endocrine/Metabolic/Nutritional
Inpatient Hospital

Diagnosis: jaundice
treatment: inpatient stay
The insurer denied Inpatient Hospital Admission: Upper Level of Nursery Care (Neonatal Intensive Care Unit). The health plan's determination is upheld. 

This female infant was born by vaginal delivery at 37.5 weeks estimated gestational age to a 24 year old primigravida. The infant's birth weight was 2700 grams, and the Apgar scores were 8 at one-minute and 9 at five-minutes of age. She was appropriate for gestational age (AGA). The mother was blood type B+ (positive) and Coomb's negative.

The Inpatient Hospital Admission: Upper Level of Nursery Care (Neonatal Intensive Care Unit) was not medically necessary for this patient.
The patient was hemodynamically stable, breathing unassisted room air, did not require intravenous fluids, did not require an exchange transfusion of intravenous immunoglobulin. There was no clinical documentation to support that there were any risk factors for neurotoxicity. The patient's care did not meet the level of care requested, Neonatal Intensive Care Unit (NICU).
Per the Milliman Care Guidelines (MCG) criteria :Per the Neonatal Facility Levels of Care, Level IV care (NICU care) is indicated for those infants who require surgical repair of complex congenital or acquired condition, need urgent pediatric medical or surgical subspecialist care, or require extreme support services such as high frequency ventilation, extracorporeal membrane oxygenation, nitric oxide administration, hypothermia therapy, dialysis, or perioperative care for surgery for severe defects or conditions.
Because the patient did not meet any of the criteria for NICU care, it was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Acne
Treatment: Formulary exception for Winlevi 1% Cream
The health plan denied Winlevi 1% Cream.
The denial is upheld.

The patient is an adult male with acne, treated with clindamycin and benzoyl peroxide. The provider is requesting Winlevi cream. The health plan requires use of three or more formulary agents such as adapalene, benzoyl peroxide, clindamycin, erythromycin, Tretinoin and tazarotene.

The formulary alternatives are: adapalene cream/gel; adapalene-benzoyl peroxide gel; benzoyl peroxide; clindamycin gel/lotion/solution/foam; clindamycin-benzoyl peroxide gel; erythromycin gel/solution erythromycin-benzoyl peroxide gel; sulfacetamide sodium lotion 10% (copyright); tazarotene cream/gel; tretinoin cream/gel.

The formulary medications would also be effective for this patient, and would have similar possible adverse effects such as dryness and irritation. The formulary agents are also appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis suppurativa. 
Treatment: Simponi aria injection (golimumab J1602). 

The insurer denied coverage for Simponi aria injection (golimumab J1602). 

The denial is overturned. 
 
This patient is an adult male with a diagnosis of severe hidradenitis suppurativa.  The patient has failed therapy with infliximab and adalimumab and numerous antibiotics.  The request is for golimumab. 

Based on the provided documentation as well as the standard of care, Golimumab is medically necessary in the treatment of this patient's hidradenitis suppurativa.  The patient has very severe long standing hidradenitis suppurativa.  He has failed conventional therapies with antibiotics as well as Infliximab and Humira.  The use of Golimumab is supported by case reports and is a reasonable alternative in the care of this patient.  The request for Golimumab is approved for the treatment of the patient's hidradenitis suppurativa. 

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 Simponi aria injection (golimumab J1602) is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: benign prostatic hyperplasia (BPH) 
Treatment: Myrbetriq
The insurer denied Myrbetriq. The health plan's determination is upheld.

This is a male with a diagnosis of benign prostatic hyperplasia (BPH) and overactive bladder. Coverage is being requested for Myrbetriq 25 milligrams (mg) capsules. He has had a dry mouth in the past with an unspecified anticholinergic medication. The plan formulary drugs include tolterodine, darifenacin, solifenacin, oxybutynin and trospium.

A formulary exception is not indicated.
Per the American Urological Association (AUA) "Guideline Statement:
If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a 3-adrenoceptor agonist may be tried. Clinical Principle"
The Plan's formulary agents are acceptable treatment alternatives with a low risk of potentially risky destabilization. They are all anticholinergic medications and can be expected to have anticholinergic side effects. The Policy requires documentation of a trial or contraindication to 3 (three) formulary agents. A formulary exception is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
inpatient hospital

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

The patient is a transgender woman (body mass index (BMI) 29) who presented with a complaint of right upper abdominal pain of 4-hours duration. Her past medical history is notable for having no chronic medical health conditions. She was admitted to the hospital. Vital signs were normal at the time of presentation. She was tender in the right upper quadrant. The surgical history and physical (H&P) documents an elevated white blood cell (WBC) count of 17 with normal liver enzymes and bilirubin. Ultrasound identified findings of cholecystitis. Laparoscopic cholecystectomy was recommended and planned. The patient was started on intravenous (IV) antibiotics.

The inpatient hospital admission was not medically necessary. This patient was a previously medically healthy patient who presented to the hospital with complaint of abdominal pain. Imaging and surgical consultation established the diagnosis of cholecystitis for which cholecystectomy was recommended. At the time of presentation and at the time of surgical assessment, the patient had normal vital signs and was without fever.
Surgery (cholecystectomy) was performed. The perioperative and early post-surgical recovery were uncomplicated, and the patient had normal vital signs and tolerated a diet following surgery. She was discharged from the inpatient setting following the initial recovery period. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Right ear pain and swelling
Treatment: Inpatient admission
The health plan denied Inpatient admission.
The determination is Overturned.

The patient is a male who was transferred for right otalgia, bloody otorrhea, and auricular edema. He was admitted for intravenous antibiotic therapy for concerns for progressive cellulitis and treated with Unasyn. A computed tomography (CT) maxillofacial scan and chest x-ray (CXR) were performed which did not show an abscess.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient admission is medically necessary for this patient. The patient was transferred to the treating facility for a higher level of care. There was a concern for progressive cellulitis in the auricular region. Progressive cellulitis can quickly transform to chondritis and abscess which may be more difficult to treat without prompt recognition. Thus, intravenous antibiotics may be best in this clinical situation to prevent more rapid progression of auricular cellulitis transforming into abscess and chondritis. The patient was discharged after several days of intravenous antibiotics until the patient was deemed medically stable for discharge and thus could be managed on an outpatient regimen. The patient was evaluated daily to determine continued need for hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion, overjet
Treatment: Braces and monthly visits
The health plan denied braces and monthly visits.
The health plan's denial is overturned.

The patient is a female child. The request is for orthodontic benefits with monthly visits. The patient has a Class II skeletal malocclusion with moderate upper and lower crowding. She has a deep bite with a severely excessive overjet.

The health plan denied coverage of the request due to the patient having a handicapping index scale score of 18. The denial is being appealed.

The patient has an overjet in excess of 9 mm (millimeters) with incompetent lip closure. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem, and the monthly visits are needed to do follow ups and make sure treatment is progressing properly.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer
Treatment: intensity modulated radiation therapy (IMRT) (code G6015-35 fractions and code 77386-35 fractions) with image guided radiation therapy (IGRT) (code G6002-35 fractions and code 77387-35 fractions)
The insurer denied coverage for intensity modulated radiation therapy (IMRT) (code G6015-35 fractions and code 77386-35 fractions) with image guided radiation therapy (IGRT) (code G6002-35 fractions and code 77387-35 fractions).

The denial is overturned.
 
Intensity modulated radiation therapy (IMRT) (code G6015-35 fractions and code 77386-35 fractions) with image guided radiation therapy (IGRT) (code G6002-35 fractions and code 77387-35 fractions) is considered medically necessary for this patient.

The treating physician provided dose volume histogram (DVH) comparison of three-dimensional conformal radiotherapy (3D CRT) and IMRT (Intensity modulated radiation therapy). 18% (percent) of the right lung received 1000 centigrays (cgy) compared to 61% (percent) by 3D CRT (three-dimensional conformal radiotherapy). Mean heart dose was 118 cgy (centigrays) by IMRT (Intensity modulated radiation therapy) compared to 978 cgy (centigrays) from 3D CRT (three-dimensional conformal radiotherapy). Based on this comparison, IMRT (Intensity modulated radiation therapy) is medically appropriate and necessary.

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 intensity modulated radiation therapy (IMRT) (code G6015-35 fractions and code 77386-35 fractions) with image guided radiation therapy (IGRT) (code G6002-35 fractions and code 77387-35 fractions) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis. 
Treatment: Home health care. 

The insurer denied Personal Care Services: 12-13 Hours per Day, 7 Days per Week - Up to 91 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of multiple sclerosis, neurogenic bladder with urinary incontinence and need to self catheterize, severe constipation, fecal incontinence, and legal blindness who had been assigned PCA (personal care aide) services. 

Personal Care Services: 12-13 Hours per Day, 7 Days per Week - Up to 91 Hours per Week medically are necessary for this patient. 

There is documentation from the patient's urologist, neurologist, and gastroenterologist of medical necessity of increased PCA services. The plan incorrectly stated the patient had indwelling urinary catheter as it was documented the patient intermittently catheterized. The plan also recommended physical therapy (PT) and occupational therapy (OT) to improve the patient's functioning; however, the patient's neurologist noted the patient had not had any significant benefit from the services. The patient requires total assistance with locomotion and maximum assistance with transfer toilet and toilet use and therefore has 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's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The plan's video assessment underestimated the patient's care needs. 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, PCA services 12-13 hours/day, 7 days/week, to total up to 91 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis. 
Treatment: Rinvoq 30 milligrams (mg) extended release (ER) tablets. 
The insurer denied the request for Rinvoq 30 mg ER tablets. 
The health plan's determination is upheld. 

The patient is a female with moderate to severe atopic dermatitis, and also moderate to severe alopecia areata (over 50 percent (%) scalp hair loss and reported at a clinic visit as asymptomatic), for which the patient has been on Tofacitinib long-term. At this visit, the eyebrows and eyelashes had full growth, although the patient had significant pitting. The patient has tried and failed topical Clobetasol ointment and steroid injections for these two conditions. The patient was reported to be taking both Rinvoq (30 milligrams (mg) per day) and Xeljanz (10 mg twice daily). 

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

The requested health service/treatment of Rinvoq is not medically necessary. 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, or Mycophenolate Mofetil), or to biologic agents more newly approved for this condition (Dupixent or Adbry). Rinvoq is not proven to be superior to all other formulary alternatives as per comparative, controlled studies, and is only Food and Drug Administration (FDA) approved for second-line systemic therapy behind the other, aforementioned systemic therapies. Any concurrent use of Rinvoq and Xeljanz, both potent Janus Kinase inhibitors, is not medically appropriate or indicated for any condition at this time. 
Therefore, as per the patient's health plan policy language [1], and consistent with current medical literature [2-6], the requested Rinvoq is not medically necessary and does not meet the health plan coverage requirements. 

The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Pharmacy/prescription drug

Diagnosis: age-related osteoporosis
Treatment: Forteo
The insurer denied Forteo. The health plan's determination is upheld.

This is a case review for a female being prescribed Forteo for the diagnosis of Age-Related Osteoporosis without Current Pathological Fracture. The patient does not have a history of fragility fractures. She has a history of a prior fracture of a rib after a fall with normal healing. 

Forteo is not medically necessary for this patient.
The patient has received two years of therapy with Forteo, which is a parathyroid hormone/parathyroid hormone-related protein analog therapy for osteoporosis. This class of therapy is not typically indicated for initial management of age related osteoporosis but is considered in some cases of which are severe, as evidenced by T-score -3.5 or greater. The studies which evaluated the efficacy of this medication lasted 18 to 21 months, and therefore the safety and efficacy of prolonged usage has not been demonstrated.
According to Rosen, "due to the lack of proven efficacy beyond two years and cost, a single course of PTH (parathyroid hormone) /PTHrP (Parathyroid hormone-related protein) analog treatment in most patients should be limited to two years duration."
There is also no listed contraindication to other available osteoporosis therapy options available to the patient. Therefore, Forteo is not medically necessary.