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

Diagnosis: Short Stature. 
Treatment: Nutropin AQ Nuspin 10 pen-injector 10mg (milligrams) /2mL (milliliters). 
The insurer denied: Nutropin AQ Nuspin 10 pen-injector 10mg (milligrams) /2mL (milliliters). 
The denial is upheld. 

This case review regards an adolescent female patient followed for short stature. She has a weight below the first percentile and familial short stature based on parental heights. She has been followed by a pediatric endocrinologist. Her evaluation to date includes a growth hormone stimulation test 2 years ago that she passed with a peak growth hormone of 12. She has had multiple bone age x-rays with previous ones 3 years ago and last year being younger than her chronological age and giving her a normal predicted adult height for her genetic potential. Her most recent bone age 9 months ago showed a bone age closer to her chronological age and giving her an expected adult height prediction of 57 inches. Her most recent labs from 9 months ago show pubertal gonadotropins and estradiol with normal insulin-like growth factor binding protein 3 (IGF-BP3) for her age and insulin-like growth factor 1 (IGF-1) less than -2 for z-score based on Tanner 2 reference. Last year, the patient had normal thyroid function. Previously her growth velocity was low for her age. More recently, she had an increase in her height velocity from 6 months ago, through last month and over that time she grew 1.1 inches, giving her a height velocity between the 25th to 50th percentiles during the time period. 

The requested health service is not medically necessary. 

The patient has shown good growth velocity from 6 months ago through last month and previously had a growth hormone stimulation test she passed 2 years ago. There is discrepancy between bone age readings from 17 months ago and 9 months ago and with low weight percentile over time this can explain somewhat low insulin-like growth factor-1 level. There is also a family history of the patient's mother being a late bloomer. Records do not indicate that growth hormone is needed at this time for the patient or that there is indication for growth hormone per the patient's health plan. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented for premature ventricular contraction (PVC) ablation. The patient has left ventricular (LV) dysfunction suggestive of PVC medicated cardiomyopathy. His ejection fraction (EF) was 40 percent (%). His PVC burden was 28.5%. His cardiomyopathy initially was diagnosed during hospitalization with coronavirus (COVID-19). 
His echocardiogram revealed mild left ventricular dilatation, moderately decreased left ventricular systolic function (diffuse), ejection fraction 40%, mildly increased LV wall thickness, Ejection fraction was 40%. 

The Inpatient Hospital Admission was not medically necessary for this patient. The patient was scheduled for PVC ablation electively and presented for the procedure from home. The procedure was elective. The patient was stable, without any evidence of acute cardiac deterioration. Prior to procedure, his evaluation revealed stable vital signs, and normal physical examination. His left ventricular (LV) ejection fraction was moderately depressed, but he was not in heart failure. 
The procedure went as planned, without any complications. After the procedure, the patient was stable, and was observed overnight by routine protocol. The patient was treated with oral medications. He was on continuous positive airway pressure (CPAP) overnight because that is what he was using at home prior to admission. The patient was discharged home in stable condition. 
Based on the above, an inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee Pain
Treatment: Gel-One
The insurer denied Gel-One.
The determination is upheld.

This is a male patient with a complaint of right knee pain. The records show that he underwent a magnetic resonance imaging (MRI) scan of the right knee which confirmed chondromalacia patella in the right knee. The menisci and collateral ligaments were normal, as were the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). Prior plain radiographs of both knees revealed no arthritic changes in this patient's right knee. The provider recommended performing a Gel-One injection for the patient's right knee. The patient's health plan denied coverage for the injection with a determination that it was not medically necessary. At issue in this case is the medical necessity of the proposed Gel-One injection for the patient's right knee.

The requested health service/treatment of Gel-One injection for this patient's right knee is not medically necessary for this patient. The provided medical records document that this patient was suffering from persistent right knee pain. Plain radiographs revealed no arthritic changes in the involved knee.
A subsequent right knee MRI scan was obtained which revealed chondromalacia of the patella in the right knee. The proposed Gel-One injection is not FDA (Food and Drug Administration) approved for this indication. The Food and Drug Administration (FDA) approval for Gel-One states that "Gel-One is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to non-pharmacologic therapy, non-steroidal anti-inflammatory drugs (NSAIDs) or simple analgesics, for example, acetaminophen." The plain radiographs obtained of this patient's right knee did not reveal any osteoarthritic changes. Therefore, the patient does not meet the FDA-approved indication for this injection. The peer-reviewed article entitled "A Comprehensive Review of Viscosupplementation in Osteoarthritis of the Knee" does not include chondromalacia of the patella as an indication to pursue this type of injection. Therefore, the medical necessity of the proposed Gel-One injection is not established.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is a male who presented with right upper quadrant (RUQ) pain and nausea. A RUQ ultrasound (US) revealed gallstones and some GB (gallbladder) wall thickening. The patient had stable vital signs and was treated with nothing by mouth (NPO) and intravenous (IV) antibiotics. In the morning, the patient reported resolution of pain and was able to tolerate a regular diet and was discharged home on oral antibiotics. Under review is the inpatient stay.

The inpatient hospital admission was not medically necessary.
The patient had right upper quadrant (RUQ) pain with findings of cholelithiasis and possible acute cholecystitis. The patient had resolution of pain, did not proceed with surgery and was discharged home tolerating a regular diet with oral antibiotics within a 23 hour period. A lower level of care was appropriate for this patient's presentation.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a young male with asthma, allergies, and attention deficit hyperactivity disorder (ADHD) who presented with an asthma exacerbation.
He was well until the day prior to presentation when he developed a cough as well as post-tussive emesis. He developed wheezing throughout the day and had shortness of breath and nausea. He was receiving albuterol and Singulair at home but his symptoms continued to worsen. His past history was significant for a history of multiple urgent care and emergency visits for asthma.

Inpatient Hospital Admission was medically necessary for this patient.
This is a young child with a history of significant asthma who presented with a severe asthma exacerbation. He received appropriate and aggressive treatment in the emergency department but continued to have significant symptoms with respiratory distress and even required supplemental oxygen for a period of time. At the initial hospitalization he was requiring albuterol/atrovent nebulized treatments every 2 hours as well as intravenous fluids.
The decision making at the time of admission for this patient was consistent with his presentation with severe asthma and his continued respiratory distress despite appropriate and intensive treatment, and the need for ongoing intensive treatments along with close monitoring potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain.
Treatment:  Inpatient hospital.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This is a case of a female admitted for the diagnosis of chest pain. The patient presented with chief complaint of diffuse abdominal pain and midsternal chest pain for one day prior to admission. She had a past medical history of ectopic pregnancy. Vital signs demonstrated blood pressure 100/57, pulse 83, respiratory rate 20, temperature 36.2C (degrees Celsius) and O2 (oxygen) saturation 100% (percent). Physical exam showed normal appearance with no altered mental status. Creatinine was 0.68 with glucose 101. Aspartate aminotransferase (AST) was 185 with alanine aminotransferase (ALT) 219. Troponin was negative.

The inpatient hospital services were not medically necessary. The patient in this case was admitted for abrupt onset chest pain but did not have an established diagnosis known to be life-threatening. She did not have acute coronary syndromes such as ST-Elevation Myocardial Infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) or unstable angina. She did not have aortic dissection, pulmonary embolism, pneumothorax, tamponade, or mediastinitis. She had elevated liver function testing which improved without specific intervention. Her chest pain symptoms also improved without specific intervention, and she was then recommended to follow up on outpatient basis. She did not have any hemodynamic instability or hypoxia.

Although the patient required services in the hospital setting the monitoring, diagnostics testing, and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain.
Treatment: Pain Management injections.
The insurer denied Pain Management injections.
The determination is upheld.

This is a patient who was diagnosed with back pain. There is a single progress note submitted for review noting the patient to have complaints of low back pain, acute or chronic, and debilitating in nature, rated at 8/10 without radiation. The pain is minimally alleviated with Tylenol and ibuprofen.  It was stated that pain has been present for more than 3-4 months and trials of conservative management including physical therapy, chiropractic, acupuncture, and over-the-counter (OTC) medications have not improved the symptoms. The pain is interfering with activities of daily living and self-care. The provider states the patient had an x-ray in the past showing multilevel degenerative changes (x-ray not provided). At issue is the medical necessity of pain management injections.
The requested health service/treatment of pain management injections is not medically necessary for this patient. The patient is noted to have complaints of chronic low back pain with subjective sensation of weakness/heaviness in the extremities. The physical exam is suggestive of facet-mediated pain with positive facet loading. It was noted the patient's pain has been present for more than three months. However, although the provider states that the patient has had conservative treatment with physical therapy, chiropractic, acupuncture, and over-the-counter (OTC) medications that have not improved symptoms, there continue to be no specific dates or duration for these treatments identified. Guidelines require evidence of at least 6 weeks of chiropractic, physical therapy, or home exercise program and at least three weeks of nonsteroidal anti-inflammatory drugs as well as at least six weeks of activity modification. These criteria were not met. Additionally, there were no imaging studies submitted for review to rule out other obvious causes for the pain (e.g., disc herniation, radiculitis, discogenic or sacroiliac pain). Medical necessity is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot infection
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with developmental delay, seizures on Keppra, chromosomal anomaly, hypothyroidism on Synthroid, and eczema, who was brought to the emergency room with left foot redness and pain. About two months earlier, he had been hospitalized for intravenous (IV) antibiotics to treat right ankle cellulitis, where the wound culture grew methicillin-sensitive staphylococcus (staph) aureus and streptococcus (strep) pyogenes. He did not have a fever or any systemic symptoms; he was eating and drinking well and was able to walk. His vital signs were normal. His exam was normal except for left foot redness and warmth (4 x 2 inches) with a central excoriated area with a picked off scab (1 x 2 centimeters (cm)). His white blood cell count (WBC) was normal. His C-reactive protein (CRP) was 0.5. The impression was cellulitis. The patient was admitted for intravenous antibiotics. The admission history and physical (H&P) reiterated the emergency department (ED) information. He was put on cefazolin intravenous (IV). The next day, the infectious disease consultant documented "great improvement as compared to photos uploaded to media tab. Erythema is almost completely resolved. Small patch of denuded skin noted, but no active drainage. Labs are reassuring with a normal WBC and CRP." He was discharged home the next day on oral Augmentin. At issue is the medical necessity of an inpatient emergency admission.
An inpatient emergency admission was not medically necessary. 
The patient presented with a local skin infection. Documentation suggested that it was acquired from his scratching his eczema. He was not on outpatient antibiotics. There was no indication that the infection was rapidly progressive. He was not febrile and had no systemic symptoms, could bear weight and walk on the extremity. He was eating and drinking as usual. There are oral skin infection antibiotics with excellent bioavailability, such as the Augmentin he was discharged home on. There is no support in the medical record for a decision to initiate treatment with intravenous antibiotics in the hospital as opposed to oral antibiotics in the outpatient setting with outpatient follow up to ensure efficacy (or, if worsening or not improving, to then admit for intravenous antibiotics).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Itching of Right Upper and Lower Extremity

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented with complaints of tingling, itching to the right upper extremity and right lower extremity x 1 week. There was no weakness of the limbs, slurring of speech, facial asymmetry, or dizziness. The patient reported having a deep vein thrombosis (DVT) to the right lower extremity previously.  The patient was escorted from triage to a room. The nurse noted patient with complaints of right sided numbness x 1 week. The patient was ambulatory without difficulty. Examination found decreased strength in the right upper extremity. Chest X-ray showed no acute or significant abnormalities.  Electrocardiogram (ECG) noted normal sinus rhythm. A computed tomography (CT) of the head showed no acute findings. CT angiogram of the neck showed no acute findings. Magnetic resonance imaging (MRI) showed no acute intracranial abnormality. 

The assessment for stroke includes the FAST (Face, Arm, Speech, Time) acronym. Facial drooping, arm shift, slurred speech, and time. The Milliman Care Guidelines (MCG) MG-N GRG Neurology guidelines note the need for observation when a patient has symptoms of stroke so that a timely assessment can be made. Admission criteria is based on the results of testing and whether further treatment is required. 

The patient's assessment in the emergency department did not detect any signs of a possible cerebrovascular accident (CVA). There was no indication that the patient needed to be admitted. Once testing has been completed in the emergency department, the patient could have been discharged home and followed up with her primary care physician. The MCG guidelines criteria for admission were not met.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post tumor surgery; COPD (chronic obstructive pulmonary disease); Chronic pain
Treatment: Increase Consumer Directed Personal Assistance Services To 37 Hours Per Week
The insurer denied: Increase Consumer Directed Personal Assistance Services To 37 Hours Per Week
The denial is upheld.

This patient is an adult female. Her medical conditions include a history of brain tumor surgery 7 years ago. Denial of consumer directed personal assistance services to 37 hours per week is being appealed. The health plan approved a total of 32 hours per week. The patient's Uniform Assessment System evaluation completed 6 months ago shows minimally impaired cognition and functional status with the need for extensive to maximal assistance with all activities of daily living (ADLs), except limited assistance with bed mobility and eating. She does not have incontinence. A letter from the patient's provider notes that the patient has chronic obstructive pulmonary disease (COPD) and chronic pain. She has gait and mobility problems.

The Increase Consumer Directed Personal Assistance Services To 37 Hours Per Week is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of consumer directed personal assistance services to 37 hours per week is being appealed. The health plan approved a total of 32 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 6 months ago shows the need for extensive to maximal assistance with all activities of daily living, except limited assistance with bed mobility and eating. She does not have incontinence. An appeal statement notes the patient has gait and mobility problems. The information provided does not support that the patient has functional limitations requiring an increase in personal assistance services from 32 to 37 hours per week. The approved personal assistance services 32 hours per week is appropriate to meet this patient's needs for assistance with activities of daily living. The requested increase in personal assistance services to 37 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity

Treatment: Ozempic injection (semaglutide)

The insurer denied coverage for Ozempic injection (semaglutide)

The denial is upheld 

The patient has obesity with a body mass index (BMI) of 33.97. He has been counseled about eating a healthy diet and exercising. The medical record lists multiple other diagnoses including obstructive sleep apnea (OSA), gastroesophageal reflux disease (GERD), hypertension, and anxiety. He does not have a diagnosis of diabetes. His physician is requesting Ozempic for weight loss. 

UpToDate has an article titled "Obesity in adults: Drug therapy." The article states that a number of medications are approved by the Food and Drug Administration (FDA) for the treatment of obesity. These medications should be used in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those individuals with a body mass index (BMI) of 30 or a body mass index (BMI) of 27 in patients with weight-related comorbidities. Semaglutide is a glucagon-like peptide 1 (GLP-1) receptor agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction as well as improvement in glycemia and lipids. 

This patient has obesity with comorbid conditions. Semaglutide is beneficial for a patient with a body mass index (BMI) of 30 or above. However, there is a semaglutide (Wegovy) that has Food and Drug Administration (FDA) approval for weight loss when the patient does not have diabetes. Ozempic only has Food and Drug Administration (FDA) approval for the treatment of diabetes. Semaglutide is approved for weight loss when given as Wegovy. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Ozempic injection (semaglutide) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Face and lip swelling. 
Treatment: inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

This is an adult male who presented to the emergency department (ED) with angioedema. He had a history of prior angioedema. He had been seen in urgent care for face and lip swelling and hives the day prior and was given Benadryl and Decadron. His symptoms recurred and he returned to the emergency department (ED). Vital signs were Heart Rate 104 beats per minute, Blood Pressure 173/94 and Temperature 36.9 degrees Celsius. Mouth swelling and tachypnea/mild stridor were noted. No uvula swelling, no rash was noted. Because of the history of recurrence, it was decided to admit the patient. Laryngoscopy showed no vocal cord, epiglottis or tongue swelling. 

The recommendation was for discharge planning, according to the Ear, Nose, Throat (ENT) specialist note. After transfer to the floor the physical examination was normal except for hoarseness. Laboratory tests showed mild azotemia. C1 esterase inhibitor levels were normal. Troponin levels were normal. Electrocardiogram (EKG) showed early repolarization with no change in subsequent tracings during the admission. 

Milliman Care Guidelines (MCG) Head Neck Disease (GRG) states that stridor requiring inpatient care should have one or more of the following: respiratory distress unresponsive to emergency treatment, hypercarbia, and infection causing symptomatic upper airway obstruction The patient did not have these or airway blockage or inability to swallow. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the hospital admission is not substantiated.