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

Diagnosis: Idiopathic Short Stature (ISS).
Treatment: Nutropin AQ (somatropin) Nuspin 5.

The insurer denied coverage for Nutropin AQ Nuspin 5.  The denial is overturned.

This is a child diagnosed with idiopathic short stature (ISS). This request is for Nutropin. His growth hormone (GH) stimulation test with arginine and clonidine peaked at 11.9. His magnetic resonance imaging (MRI) was normal. His insulin like growth factor (IGF1) was 72 (28-181); Z-score (measure the distance from a fixed point to the mean) was -0.4 SD [standard deviation]; insulin like growth factor binding protein (IGFBP3) was 4.5 (1-4.7). His testes were 2 milliliters (ml) bilaterally and pubic hair was at tanner 1. He declined below the curve beginning at an early age. This represents a slow height velocity.

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines  [4, 5, 6, 7, 8, 9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS [standard deviation score] less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary. The references provided are the most current/relevant to the case. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Nutropin AQ Nuspin 5 is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems - Missing teeth
Treatment: Dental/Orthodontic Procedures - Dental Implants
The Health Plan denied the dental implants as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

The patient presents to the office of her Dental Provider for evaluation and treatment of teeth # (number) 17, 19, 20, 29, 30 and 31. Provided for review are previous letters of appeal and denial, a narrative from the Dental Provider, a full mouth panoramic radiograph from an unknown date, one page of American Dental Association (ADA) claims forms, a health history, and clinical notes from one visit. The planned treatment of implant placement (6010) for teeth #17, 19, 20, 29, 30 and 31 is at issue.

The medical necessity of dental implants in these sites, teeth #17, 19, 20, 29, 30, and 31 has not been established. There is nothing in the documentation that indicates that the patient has had a partial denture provided and that the partial denture did not function correctly. There is nothing in the provided documentation that shows that the patient uses a partial denture currently. Further, based on the provided documentation, the teeth do not appear to have been prepped for a partial denture in the past. There is a comment that the patient has a history of the partial denture failing, but this history is not supported by the radiographic documentation which shows that none of the teeth have rest seats prepared for them, guide planes, nor any of the other adjustments made to teeth prior to fabrication of a partial denture. In short, the teeth show that if there is a partial denture, it could not have been constructed properly, and only after it were to be constructed properly could it be determined that it failed. There has been no evaluation of any current prosthesis by the doctor. The need for implants has not been established. Prior to an implant, there is the need for a treatment plan and a comprehensive examination which was not done according to the notes submitted for review. From the notes available, there is no evaluation of the existing teeth, the status of said teeth, an evaluation of the residual ridge nor anything specific to the patient. The notes provided show that the patient is not to have implant therapy at this time as the need is not supported. There is not a standard of care for any specific number of implants. Hence the treatment of implant placement (6010) for sites #17, 19, 20, 29, 30 and 31 is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain (anemia).
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The patient is a female. She underwent a full acute hospitalization for the complaints of abdominal pain and the finding of anemia.

The patient had presented to an urgicare center with the complaints of emesis, diarrhea and sharp right lower abdominal pain for three days preceding the presentation. On presentation the vital signs were within normal limits. The patient evidenced right lower abdominal pain on examination. The white count was elevated at 14.4. The hemoglobin was 9.7.

The patient was admitted and she received IV (intravenous) fluids, supportive care, and underwent an endoscopy which was unrevealing. The patient was discharged once deemed stable.

The patient had a history of prior morbid obesity, peripheral neuropathy, and hypothyroidism. The patient had a surgical history of gastric bypass, cholecystectomy and a c-section (Caesarean section). The platelet count, alkaline phosphatase and liver enzymes were elevated. An ultrasound showed an ovarian cyst. A CT (computed tomography) scan showed a left diaphragmatic hernia and a suspected gastro-gastric fistula in the setting of a prior gastric bypass.

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had anemia and an elevated white count with moderate elevation of liver enzymes; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. A gastro-gastric fistula is a chronic condition and an endoscopy could have been performed as an outpatient. As such, the care could have been rendered at a lesser level.

No, the Inpatient admission was not medically necessary. The treatment as provided was medically appropriate, but not medically necessary at the level at which it was rendered.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had anemia and an elevated white count with moderate elevation of liver enzymes, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. A gastro-gastric fistula is a chronic condition and an endoscopy could have been performed as an outpatient. As such, the care could have been rendered at a lesser level.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Consumer Directed Personal Assistance Services (CDPAS)
The insurer denied Consumer Directed Personal Assistance Services (CDPAS) 84 hours/week. The health plan's determination is overturned. 

The patient is a female with past medical history of osteoarthritis, spinal stenosis, dementia, asthma, osteoporosis, macular degeneration, anemia, diabetes mellitus type 2, hypertension, stool incontinence, indwelling urinary catheter, hearing loss, AVM (arteriovenous malformation) colon, and uneven leg since left hip replacement who had been assigned Consumer Directed Personal Assistance Services (CDPAS) based on assessment tool performed via telephone assessing patient at total assistance with managing finances and maximum assistance with tasks of meal preparation, ordinary housework, managing medication, phone use, shopping, transportation and equipment management. With tasks of stairs, bathing, personal hygiene, dressing upper/lower body, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of walking, locomotion, and transfer toilet. 

Consumer Directed Personal Assistance Services: 84 Hours per Week is medically necessary for this patient.

There is documentation in the medical record that the patient has had a decline in functional capacity with need for increased assistance at home. The patient requires assistance with emptying Foley catheter twice daily, checking blood sugar twice daily, and requires assistance with walking and locomotion when she has taken her pain medication for severe pain. The telephonic assessment underestimated the patient's care needs and there was noted to be an improvement in assistance needs with tasks of managing finances, phone use, equipment management, personal hygiene, and eating despite documentation that the patient had had worsening functional capacity. The patient has intermittent bowel incontinence. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met with adaptive equipment and medical supplies alone. The requested increase in CDPAS is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS 84 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: Chest Pain. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male. He was hospitalized for chest pain. He presented to the hospital ED (emergency department) for evaluation of midsternal chest discomfort radiating to the back and shoulders and associated with left arm/hand numbness/tingling. His past medical history was pertinent for recent OP (outpatient) work up for the same with abnormal stress test and echocardiogram and recommendation to follow up with cardiology, GERD (gastroesophageal reflux disease), obesity, HLP (hyperlipidemia) and HTN (hypertension). 

The patient's vital signs were stable. BP (blood pressure) was 136-167/97-100, HR (heart rate) was 68. EKG (electrocardiogram) showed SR (sinus rhythm) and no acute ST-T changes. There were no arrhythmias. Troponin levels were 0.48-0.041. Cardiac catheterization showed mild, 30% LAD (left anterior descending) stenosis and normal LVEF (left ventricle ejection fraction). Chest CTA (Computed Tomographic Angiography) was negative for PE (pulmonary embolism). There were no procedural complications, and he was discharged to home. 

No, the Inpatient admission was not medically necessary. 

Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient stay are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome (ACS), chest pain that is indicative of a serious cardiac condition like pulmonary embolism (PE) or aortic dissection, evidence of acute myocardial infarction (AMI), pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which a lower level of care has failed or is not considered appropriate. The care he received, including cardiac catheterization like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the requested acute inpatient hospitalization is not medically necessary. 

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperemesis

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay.

The denial is upheld.

The patient presented to the emergency department for hyperemesis.  The patient reported this was her third hospital visit for the same complaint.  The patient was in no acute distress.  The patient had 4-5 days of abdominal pain, nausea, vomiting, and inability to tolerate oral intake.  The patient stated she was told her symptoms may be related to her daily marijuana use but noted that she had not used marijuana in a few days.  The patient had an endoscopy scheduled but was too nauseous to follow-up.  There were ketones in the urine.  The patient was hypokalemic and had metabolic alkalosis in line with nausea and vomiting.  The patient was admitted to telemetry due to hypokalemia.  She was evaluated by a Gastroenterologist, was stabilized, and was discharged.

Patients that need hospitalization are those with the following signs and symptoms:  volume depletion/dehydration, altered mental status, significant rectal bleeding, prolonged symptoms (more than a week), severe abdominal pain, comorbidities such as HIV (human immunodeficiency virus) and diabetes (immunocompromised status), age greater than or equal to 65 years, recent hospitalization or antibiotics, pregnancy, or weight loss.  There was no fever or severe abdominal pain requiring hospital admission rather than ambulatory setting such as observation.  Lab data showed mild acid/base derangement, mild hypokalemia, and mild dehydration based on urine specific gravity but nothing that warranted acute hospital inpatient admission status.  Hydration, intravenous pain medications, and monitoring in ambulatory setting would be appropriate for this patient and would not have jeopardized her well-being.  Telemetry can be accomplished as "Observation" rather than "Inpatient" or "Admission" and the same treatment administered. 

The denial for acute admission for hospital is upheld based on literature.

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

Diagnosis: Right Groin Abscess
Treatment: Hospital admission
The insurer denied coverage for hospital admission.
The denial is upheld.

The patient has a past medical history significant for hyperlipidemia and presented to the emergency department with complaints of right groin abscess that started as an ingrown hair. Vital signs on presentation included: Temperature 98.0, Blood Pressure 136/90, Pulse 95, Respiratory Rate 18, Oxygen saturations 98% (percent) on room air. Laboratory results included the following: white blood count (WBC) 9.2, hemoglobin (HGB) 15.6, hematocrit (HCT) 45.9, creatinine 0.92, and glucose 97.

The patient was admitted to the hospital and started on intravenous antibiotics (clindamycin) for a right groin abscess. Imaging studies demonstrated a collection measuring 10 x 11 x 27 mm (millimeters). The patient underwent a bedside incision and drainage procedure with ultrasound guidance. He tolerated the procedure without complications. Wound culture grew methicillin-sensitive Staphylococcus aureus. The patient remained afebrile, hemodynamically stable, and was discharged on oral antibiotics to continue management as an outpatient.

According to the documentation, the patient presented with groin abscess that started from an ingrown hair. Otherwise, he was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. The patient had a localized infection that required a bedside incision and drainage (I&D) procedure. Based on the above findings, the patient met criteria for observation level of management.  

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

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral Arm Numbness.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

The patient was transferred for a neuro evaluation.  The patient was brought in by ambulance.  The patient had subjective complaints of bilateral arm numbness and weakness for 4-6 weeks.  The patient also complained of a rash to the bilateral palms that had been present for approximately the same amount of time.  She was unsure if it was related.  The patient noted decreased grip strength and had significant numbness to her right forefinger and middle finger.  The patient's blood pressure was 114/95.  The physical examination revealed the range of motion was not limited.  There was decreased sensation of the bilateral hands right greater than left in the radial aspect.  There was decreased grip strength. The patient underwent laboratory studies, and electrocardiogram (EKG), and a magnetic resonance imaging (MRI) revealing spinal stenosis and multilevel disc bulging.   The patient underwent a medical admission for an extensive work-up as metastasis was on the differential.  It was noted the admission was medically necessary, as the treatment was beyond the capabilities of the emergency department for possible cervicalgia and hand numbness.  The patient was subsequently discharged and was to follow-up with neurosurgery, orthopedics, and her primary care physician.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered medically necessary for this patient.

While the patient had symptoms suggesting spinal cord compression, this was ruled out by advanced imaging studies that could have been done during her emergency visit while she under observation.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.  The denial is upheld.

The patient presented after an episode of syncope. She reported having rectal bleeding. There was a history that she had colon cancer but declined treatment. She was abusing drugs on a daily basis as well as being on a Methadone program. She was afebrile and the vital signs were stable. The white blood count (WBC) count was 2.7 and the hemoglobin was 11.2. A head computed axial tomography (CAT) scan was negative for acute disease. The pancytopenia was attributed to the patient's immune compromise status. The gastroenterology consult advised that the bleeding can be evaluated as an outpatient. The cardiologist diagnosed a non-ischemic cardiomyopathy or amphetamine induced cardiomyopathy and recommended losartan and an outpatient workup. The syncope was felt to be related to substance abuse. The hemoglobin remained stable.

Milliman Care Guidelines (MCG) clinical indications for admission for Syncope (M-340) include hemodynamic instability, severe altered mental status, a cardiac finding that requires immediate intervention, a severe cardiac arrhythmia, and severe dehydration. The patient did not have these conditions.

Clinical indications for admission for Lower Gastrointestinal Bleeding (MCG M-182) include hemodynamic instability, ongoing active bleeding, failure to control bleeding after a colonoscopy, severe coagulopathy, severe anemia, peritoneal signs, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had syncope that was felt to be related to substance abuse. She did not have an acute cardiac or neurological event. She had bleeding and required a colonoscopy but this could have been done as an outpatient. She had multiple chronic medical problems. However, she did not meet MCG criteria for inpatient care for either Syncope of Lower Gastrointestinal Bleeding. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Inflammatory bowel disease (IBD) arthropathy.
Treatment:  Rasuvo.

The insurer denied Rasuvo.  The determination is overturned.

The patient has ulcerative colitis (UC) associated arthritis. The patient has inflammatory bowel disease (IBD) arthropathy, and the diagnosis listed is 'enteropathic arthropathies, unspecified site'.  Per a letter from the patient's provider, he has IBD arthropathy.  He has active joint inflammation on Remicade 10 milligrams (mg)/ kilogram (kg) every 4 weeks (the maximum dose) and oral methotrexate (MTX) 15 mg weekly.  His provider is requesting subcutaneous (SQ) MTX, given a concern for reduced oral absorption due to the history of ulcerative colitis.  He has tried and failed Humira and cyclosporine.  He has been on and off of steroids for years.  At issue is the medical necessity of the Rasuvo.

Rasuvo (injectable MTX) is medically necessary for this patient. The patient is already on oral MTX and continues to have breakthrough joint inflammation.  Switching to a SQ form of the drug (Rasuvo) is a reasonable next step, as it has had better bioavailability. The patient is already on maximum doses of Remicade and still has breakthrough joint pain.  According to UpToDate, a trial of methotrexate (MTX) is an option in patients with inflammatory bowel disease (IBD) associated arthritis and 'subcutaneous injection of MTX is a treatment option which provides higher bioavailability of the drug, especially at doses greater than 15 milligrams (mg)'.  Thus, Rasuvo is medically necessary at this time as an add on to Remicade for the treatment of IBD arthritis in this patient.