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

Diagnosis: Endocrine/metabolic /nutritional/growth hormone deficiency
Treatment:Pharmacy /Prescription drugs   
The insurer denied Norditropin 
The denial is upheld in whole

This patient started growth hormone . Growth velocity prior to growth hormone was reported at 3.6 centimeter (cm) per year. The patient's height on  was 133.1 cm, 9th percentile at age  years . The patient's height on was at the 11th percentile confirming a normal height velocity. The bone age was 11.
No, Norditropin is not medically necessary for this patient.
The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:
Classic Growth Hormone (GH) deficiency
Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, [3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 yr more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml.
The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10.
The patient did not meet height and height velocity criteria as pretreatment height and height velocity are normal.
 Idiopathic Short stature
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]. FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS 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 does not have a pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria. 
The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied the Braces and monthly visits.
The determination is overturned.

The patient has with anterior and posterior crossbites and moderate crowding. She is treatment planned to correct her bite. Her health plan denied the claim on the basis that treatment is not medically necessary. At issue is the medical necessity of braces and monthly visits.
This patient presents with anterior and posterior crossbites, crowding, and constricted arches. She would be a candidate for orthopedic rapid maxillary expansion to assist with orthodontic correction. Such a procedure can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced.(4) The patient is nearing the end of the time that orthodontics alone can correct her crossbite.
Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems Decay cavities  
Treatment:Dental Procedures  
The insurer denied Outpatient Surgery Service(s): Facility Charge for Dental Procedure 
The denial is overturned in whole

The patient  with no reported medical problems. Per the letter of medical necessity written by the  dental specialist, a board-certified  dentist,the dental condition was consistent with a diagnosis of severe early childhood caries. Several of these teeth required extensive restoration with fillings, crowns, pulp treatment, and extractions.  In line with the current recommendations of the American Academy of Pediatric Dentistry, the provider determined that the patient was most safely treated in an outpatient surgical setting under General Anesthesia. 
Yes. The procedure, anesthesia, and any other facility charges are medically necessary, as determined by the current guidelines of the American Academy of Pediatric Dentistry.
The child's young age, combined with his extreme dental needs, required him to have general anesthesia to protect his safety and developing psyche during the required dental care (which was to prevent and eliminate pain, swelling, and/or infection).
The treatment plan proposed for this patient would be too much for the child to handle in the office setting.  The time it would take in the office to complete the work, in addition to the need for local anesthesia in the office setting vs. the operating room (OR), would be too much for the child to handle.  Completing the procedures under general anesthesia in the OR would ensure that the child has his treatment completed compassionately and properly under ideal circumstances.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This male patient has a history of known coronary artery disease (status post intervention with stent), angina pectoris, diabetes mellitus, aortic regurgitation, hypertension, hyperlipidemia, polyneuropathy and positive stress test.  The patient presented to the hospital for left heart catheterization and possible percutaneous coronary intervention.  The patient was found to have 60-70% stenosis of his left main artery, 70-80% stenosis of his proximal left anterior descending (LAD) artery, and 80-90% in-stent restenosis (ISR) of his mid LAD. A successful percutaneous coronary intervention (PCI) was performed to the patient's distal left main and proximal LAD, with successful excimer laser coronary angioplasty and percutaneous transluminal coronary angioplasty of the mid LAD in-stent restenosis.  There were no complications during the procedure.  The patient was admitted to the Telemetry unit post-procedure for monitoring.  The patient's blood pressure was elevated to 199/83 after the procedure and he received 2 doses of intravenous hydralazine.  The patient also reported chest pain post procedure but his electrocardiogram (EKG) showed no change from his prior EKG.   The patient remained stable overnight and was discharged the next day.
 
Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient procedure. The patient's clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and angioplasty. The patient could have been safely monitored at the ambulatory level that allows up to 23-hours of monitored care post procedure. 

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

The medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma exacerbation; Influenza

Treatment: Hospital admission

The insurer denied coverage for the hospital admission.

The denial is upheld.

This female patient has a history of asthma, Grave's disease (not on treatment), gastroesophageal reflux disease, and gastritis.  The patient presented to the Emergency Department (ED) with complaints of cough with wheezing and shortness of breath.  The patient reported upper respiratory tract infection (URTI) symptoms for several days.  She had seen her primary medical doctor (PMD) who prescribed oral antibiotics and Tamiflu.  The patient had not taken Tamiflu.  The patient had some worsening of her symptoms and presented to the ED.  At presentation to the ED, her vital signs were temperature 98.3, heart rate 109, blood pressure 99/63 mm Hg, respiratory rate 17, and oxygen (O2) saturation 98%.  The patient was in in no acute distress.  There is no use of accessory muscles noted.  Lung exam revealed mild wheeze.  Cardiovascular system was normal.  Abdomen was soft, and non-tender.  The patient was alert and oriented x3.  There was a non-focal exam. White blood cell (WBC) count was 4.5 K.  Hemoglobin was 12.4 and electrolytes were within normal limits (WNL).  CO2 was 17.

The patient was admitted to the hospital with asthma exacerbation and Influenza. Her chest x-ray was negative.  Influenza screen came back positive for Influenza B.  Peak expiratory flow (PEF) was 270.  There was no jugular venous distention.  Lungs were clear.  Abdomen was soft and non-tender. The patient was treated with oral Prednisone, oral Tamiflu and bronchodilators. The patient improved with treatment.

The patient remained stable after admission.  Her lungs remained clear.  She was in no acute distress and was tolerating oral intake.  There was no evidence of pneumonia.  She was seen by endocrinology who recommended follow-up in the outpatient setting with repeat labs once influenza was resolved.

This patient did not need acute hospitalization.  The patient could have been placed in observation status and discharged home on oral steroids and other oral medications after a period in observation when diagnostic studies and treatment could have been initiated.  This patient had also been evaluated by endocrinology who did not recommend any specific treatment.  As per progress notes, the patient was afebrile and hemodynamically (HD) stable, oxygen saturations were good on room air.  She was not hypoxic. The patient was stable for follow-up in an outpatient setting after an initial brief stay in observation status.  

The health plan acted reasonably with sound medical judgment.

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

Diagnosis: Abscess
Treatment: Arestin on Tooth #14 and #15 (D4381)
The insurer denied the Arestin on Tooth #14 and #15 (D4381). 
The denial is upheld. 

The patient is a female requesting benefits for antimicrobial periodontal therapy.

No, the proposed Arestin on Tooth #14 and #15 (D4381) was not medically necessary. 

The use of antimicrobial therapy is not recommended until after conventional periodontal therapy is performed. The patient had scaling and root planing performed at the same time as the antimicrobial treatments. Before antimicrobial treatments are used, there needs to be some time after scaling and root planing procedures to see how much healing happens without the drugs. If, after a reasonable amount of time, the patient's pocket depths have not shrunk enough just from the scaling, then the use of the antimicrobial is warranted to supplement the initial treatment (scaling and root planing). In this case, the patient had both therapies performed at the same time and it is not known if only the scaling and root planing would have sufficed alone to reduce the inflammation and pocket depths.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient hospital

Diagnosis: Appendicitis 
treatment: Inpatient hospital stay. The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man who presented to the emergency department (ED) with a history of progressively worsening abdominal pain of several hours duration. His evaluation included physical exam, labs, and a computed tomography (CT) scan. He was without fever at the time of presentation. Vital signs were normal. Lab data identified a white blood cell (WBC) count of 14 K. A CT scan yielded the diagnosis of acute appendicitis without perforation. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained.

The inpatient hospital stay was not medically necessary in this case. The records indicate that this patient presented to the ED with acute appendicitis and underwent an appendectomy. The patient sustained a serosal tear of the small bowel at the time of surgery. This was identified and repaired without incident. The post-surgical course was uncomplicated. Vital signs remained normal. Diet progression was tolerated. The records support that this patient could have reasonably and appropriately been treated at a lower level of care. This lower level of care would have permitted operative treatment, post-surgical monitoring, diet progression, overnight care, and provision of antibiotics.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus 
Treatment: Inpatient admission 

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

This patient is an obese male with a history of asthma and a previous hospital admission for status asthmaticus to the Pediatric Intensive Care Unit (PICU). He had been experiencing chest tightness and coughing for one day after playing basketball.  He was treated with albuterol on two occasions at home with no improvement in his symptoms. Since his symptoms had not improved with treatments in the home, the mother decided to bring him to the Emergency Room (ER) for additional treatment. 

In the ER he was noted to have respiratory distress with retractions and evidence of increased work of breathing.  There was upon auscultation of the lungs decreased air entry and wheezing. There was a family history of asthma in both parents and he has been exposed to cigarette smoking in the home.  He was treated prednisone, oxygen, terbutaline and 3 doses of albuterol and Atrovent inhalation therapy.  Blood testing indicated a degree of acidosis with a CO2 of 18. When his respiratory symptoms did not improve with treatment in the ER the decision was made to admit him with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 2 hours. 
 
The insurer has denied the 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 a cough, wheezing and respiratory distress. When there was ongoing respiratory distress with persistent wheezing and increased work of breathing, it was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with albuterol every 2 hours.  He was not stable enough to be sent home since the need for frequent albuterol administration could not have been safely administered in the home. 

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

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Dx: Orthopedic/Musculoskeletal
Tx: Inpatient Hospital
Denied: Inpatient stay
Denial: OVERTURNED in whole

The patient is a male who presented to the emergency room (ER) with low back pain radiating to the right leg for 3 weeks. He had lifted a heavy box 3 weeks prior to presentation and developed progressive radiculopathy. He was noted to have difficulty controlling his bowel and bladder. On exam he had intact sensation in the lower extremities and 5/5 strength in the lower extremities. Per operative report, the patient had severe right L5 radiculopathy with weakness and difficulty ambulating, and the magnetic resonance imaging (MRI) of the lumbar spine showed a large L4-5 right disk herniation with neural compression.
The patient was admitted to the hospital and cleared for surgery.  He underwent a right L4-5 microdiscectomy and hemilaminotomy.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned, in whole.
This is a patient with a history of 3 weeks of severe pain radiating to the right leg from the low back. Per the surgeon's report, he had severe radiculopathy in the L5 distribution, and had weakness in right leg. He had signs of possible impending compartment syndrome with Difficulty with bowel and bladder control. Symptoms and exam correlated with the MRI findings of a large L4-5 disk herniation.
In light of neurologic deficits and possible impending compartment syndrome correlating with the MRI findings, surgical treatment with L 4-5 laminotomy, microdiscectomy, and decompression was performed. Preoperative clearance on the day of admission was appropriate prior to surgery, and the surgical treatment on the following day was performed as appropriate. In light of the deficits and possible impending cauda equina syndrome, inpatient monitoring until the following morning was medically necessary. As the patient had improved appropriately, the discharge on 12/13/19 was appropriate.
It must be noted that this was not a simple case of a disk herniation with leg pain; rather, this patient had neurologic deficits with possible compartment syndrome. As such, inpatient level of care with appropriate monitoring and frequent neurologic checks was indicated, as adverse change in the neurologic function after the surgery may require prompt revision surgery. Such care is not possible at other than inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite.
Treatment:  Braces.

The insurer denied the braces.  The denial was overturned.

The patient is a male.  The request is for orthodontic benefits.

The patient has teeth #s 10 and 11 in crossbite (i.e., reverse bite).  This is an "automatic qualifier" according to the handicapping index scale, and the patient has two teeth with this problem.  Correction of these anterior crossbites with orthodontic treatment is medically necessary to prevent these teeth from most probably chipping and/or fracturing, due to the increase in stress these teeth have by their being out of their proper position.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Problems - Injury/Trauma to the Mouth.
Treatment:  Dental/Orthodontic Procedure.
The insurer denied the dental implants and related services for preparation of the jaw for the dental implants.  The denial was overturned.

The patient is a female who lost teeth #8, #9 and #10 due to trauma.  The provider repaired the ridge with bone grafts and placed implants in these areas.  This treatment was denied by the insurance, as it states that alternate treatments are available.

The health plan's determination is overturned.  The options in this case to restore function are an implant, partial denture or a bridge.  Implants are the best option.  A partial denture has been shown to lead to the loss of adjacent teeth and have less chewing efficiency than implants.  A bridge is considered radical treatment, as adjacent tooth structure must be drastically reduced in this process. The bridge has been regarded as the standard of care for some time in the replacement of single and multiple missing teeth.  However, to obtain optimal functional and aesthetic results for full-veneer bridges, a significant reduction in the amount of tooth structure is necessary occasionally predisposing to endodontic, periodontal, and structural complications.  The abutment teeth often become carious and have an increased rate of needing a root canal procedure.  If one of the abutment teeth are lost, a longer span bridge would be required.  The implant procedure is more conservative and has a better prognosis.  Implants have a high rate of success, do not require procedures on adjacent teeth and are not susceptible to caries.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3:

Diagnosis: Cystic Fibrosis

Treatment: CPT codes 88299 [Unlisted cytogenetic study] and 81228 [cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., bacterial artificial chromosome [BAC] or oligo-based comparative genomic hybridization [CHG] microarray analysis)]

The insurer denied coverage for CPT codes 88299 [Unlisted cytogenetic study] and 81228 [cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., bacterial artificial chromosome [BAC] or oligo-based comparative genomic hybridization [CHG] microarray analysis)]. The denial is upheld.

The patient is a female with a history of infertility and cystic fibrosis (CF) carrier. The patient underwent genetic testing (CPT codes 88299 - cytogenetic study. Traditionally, morphology-based grading had been the primary technique used for in vitro fertilization (IVF) to evaluate and select the most competent embryos for transfer. Technologies have been developed in the fields of genomics, transcriptomics, proteomics, metabolomics, and time-lapse imaging to try to assist in the selection of the best embryos. However, a focus has been on analysis of 24-chromosome copy number for evaluation and transfer of only diagnosed euploid embryos, also known as preimplantation genetic testing for aneuploidy (PGT-A). Several molecular techniques have been utilized during IVF cycles to determine ploidy including fluorescence in situ hybridization (FISH), comparative genomic hybridization (CGH), array CGH (aCGH),digital polymerase chain reaction (dPCR), single-nucleotide polymorphism (SNP)array, real-time quantitative PCR (qPCR), and next-generation sequencing (NGS). 

In both the United States and Europe, preimplantation genetic diagnosis for monogenic disorders (PGT-M) has been used with increasing frequency for preconception management. Prenatal diagnosis and pregnancy termination are also employed for the management of serious single-gene diseases. In 2018, the Practice Committee of the American Society for Reproductive Medicine (ASRM) recommended PGT-M with IVF as a significant advance over post-conception diagnosis and pregnancy termination in the case of single-gene (monogenic) disorders. 

The ASRM, in its Practice Committee Opinion, does not support co-testing of PGT-M and PGT-A at this time due to the need for further studies. Therefore codes 88299 and 81228 do not have final approval from the appropriate regulatory bodies for this patient's diagnosis. 

Thus, the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for CPT codes 88299 [Unlisted cytogenetic study] and 81228 [cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., bacterial artificial chromosome [BAC] or oligo-based comparative genomic hybridization [CHG] microarray analysis)]; testing performed should be upheld.