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

Diagnosis: Autism. 
Treatment: Private duty nursing. 

The insurer denied Private Duty Nursing: 25 Hours per Week. The health plan's determination is overturned. 

The patient is female child with multiple medical problems including Wolf-Hirschhorn syndrome, high-functioning autism, asthma, feeding difficulties with malnutrition and gastroesophageal reflux status post gastrostomy tube placement, constipation, obstructive sleep apnea status post adenoidectomy, and history of aspiration with bronchitis/pneumonia. She has violent behavioral outbursts (scratching, kicking) attributed to her diagnosis of autism that place her at risk of danger to herself and others. She lacks safety awareness and does not learn from previous accidents/injuries. Skilled nursing needs include gastrostomy tube care, administration of gastrostomy tube feedings, medication administration including breathing treatments, maintenance of aspiration and reflux precautions, monitoring of respiratory status and administration of breathing treatments as needed, close monitoring of patient's behavior to prevent injury, and assistance with all activities of daily living above and beyond what is required for a typical child her age. 

Additional Private Duty Nursing: 25 Hours per Week is medically necessary for this patient. 

According to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents With Chronic Disease, "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens."  Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." 
Based on the documentation provided by the private duty nurse, primary care pediatrician, and pediatric gastroenterologist, this child needs additional hours of private duty nursing. While it is a useful guideline, the template does not take into consideration this child's lack of sleeping, lack of safety awareness, and propensity to repeat dangerous behaviors over and over again. She must be monitored constantly so that she does not cause injury to her gastrostomy tube, attempt to eat things that place her at risk of aspiration, take her medications to completion, or otherwise cause harm to herself. While her mother is a trained caregiver, it is neither safe nor reasonable to expect her to perform the level of care necessary without the requested additional hours of private duty nursing, remembering that the child does not sleep much at night. Based on this child's medical history as well as the current standard of care, the requested 25 hours per week of private duty nursing services are medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-healing ulcer of lower extremity.
Treatment: 78452 - Myocardial Perfusion Imaging (MPI), Pre-service.
The insurer denied the 78452 - Myocardial Perfusion Imaging (MPI), Pre-service.
The denial is overturned. 

The patient is a male smoker with poorly controlled diabetes mellitus, dyslipidemia and peripheral vascular disease. He was evaluated for vascular angiogram due to a non-healing ulcer of his lower extremity, prior to angiography with possible surgical revascularization. The patient is unable to exercise, and his exertional capacity is compromised due to severe peripheral arterial disease and leg pain. His exertional tolerance cannot be assessed. His ECG (electrocardiogram) is abnormal with anterior T-wave inversions.  Pharmacological nuclear stress test was requested to rule out ischemic heart disease, evaluate the patient with ECG (electrocardiogram) abnormalities and assess his surgical risk for possible lower extremity revascularization.

Yes, the proposed 78452 - Myocardial Perfusion Imaging is medically necessary.

The patient has a high pre-test probability of coronary artery disease, based on the history of significant risk factors, including age, gender, history of smoking, uncontrolled diabetes mellitus, dyslipidemia and presence of peripheral vascular disease. His ECG (electrocardiogram) is abnormal, with T-wave inversions suggestive of ischemia. The patient is unable to exercise for a regular treadmill exercise stress test, and his exertional capacity cannot be assessed due to peripheral arterial disease and leg pain. Therefore, given the history, comorbidities and ECG (electrocardiogram) findings, as well as inability to exercise, it would be consistent with the currently accepted standard of care that this patient be assessed for ischemic heart disease with nuclear perfusion imaging, and thus the requested test is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: knee osteoarthritis
Treatment: Hyaluronan Injections 
The insurer denied Hyaluronan Injections. The health plan's determination is upheld. 

This case describes a male patient with a complaint of bilateral knee pain and known bilateral knee osteoarthritis. The provided medical records document that the patient underwent bilateral injections of Gel One to provide pain relief. The patient's health plan denied these injections as not medically necessary. At issue in this case is the medical necessity of the Hyaluronan Injections.

The hyaluronan injections were not medically necessary for this patient. This determination is based upon the recommendations of the current, peer-reviewed orthopedic literature with respect to viscosupplementation injections done for knee osteoarthritis and the clinical practice guideline on knee osteoarthritis from the American Academy of Orthopedic Surgeons. A recent article published by Jevsevar and colleagues in the Journal of Bone and Joint Surgery in 2015 was a meta-analysis which concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid (HA) treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of non-blinded or improperly blinded trials." A second article published by Tammachote and associates in the Journal of Bone and Joint Surgery in 2016 was a prospective, randomized study which concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." Lastly, the evidence-based guideline on knee osteoarthritis published by the American Academy of Orthopedic Surgeons did not endorse viscosupplementation as an effective treatment for this condition. Thus, based upon the peer-reviewed literature, the Hyaluronan Injections are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroparesis; Diarrhea
Treatment: Wireless Motility Capsule
The insurer denied the Wireless Motility Capsule.
The denial is upheld. 

The patient is a female with POTS (postural orthostatic tachycardia syndrome), gastroparesis, iron deficiency, weight loss, abdominal pain and diarrhea.

The patient's colonoscopy was negative. NM (nuclear medicine) gastric emptying study was consistent with gastroparesis. The patient's provider is requesting Smart Pill motility testing.

No, the Wireless Motility Capsule is not medically necessary.

There is no medical literature to support that the requested Smart Pill ingestible pH (potential of hydrogen) and pressure capsule has a positive effect on health options in a patient with gastroparesis diagnosed by gastric emptying study, and chronic diarrhea with a negative colonoscopy. It is therefore unproven in this patient's clinical scenario. As it is not supported by medical literature, the requested Smart Pill ingestible pH (potential of hydrogen) and pressure capsule are not clinically appropriate or accepted standard of medical care, and are is not medically necessary.

The requested Smart Pill ingestible pH (potential of hydrogen) and pressure capsule are unproven and not medically necessary. The health plan therefore acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath; Wheezing.
Treatment: Inpatient admission.

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

The patient is a female with severe persistent asthma. She presented to emergency room with worsening SOB (shortness of breath) and wheezing.

The patient was found to have asthma exacerbation. She was treated with IV (intravenous) steroids and nebulization treatments. The patient was admitted to acute in hospital level of care.

The patient was admitted to acute in hospital level of care. The patient had continued wheezing and was tachycardic. Despite treatment with IV (intravenous) steroids, the patient continued to have diffuse wheezing and tachycardia. The patient remained on IV (intravenous) steroids.

Pulmonary consultation was obtained. The patient was continued on IV (intravenous) steroids. Despite IV (intravenous) steroids and nebulization, the patient continued to have difficult-to-treat asthma exacerbation.

Antibiotics were started empirically.

The patient's symptoms improved, and the transition for IV (intravenous) steroids to oral steroids was made.

The patient's asthma exacerbation continued to improve. She was able to breathe better without wheezing, and she was able to tolerate oral prednisone and oral antibiotics.

The patient was discharged home.

Yes, the Inpatient admission was medically necessary.

The patient had asthma exacerbation that did not improve significantly with emergency room care. The patient had failed outpatient therapy as well as emergency room therapy. She had moderate-to-severe asthma exacerbation with treatment-resistant exacerbation. She required prolonged IV (intravenous) steroids as well as antibiotics. The patient also had past history of intubations and cardiac arrest from asthma exacerbation.  The acute patient stay was therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral arterial disease, left great toe callus.
Treatment: Outpatient Surgery Services, Pre-service.

The insurer denied the Outpatient Surgery Services, Pre-service.  The denial is upheld. 

The patient is a male with peripheral arterial disease and a left great toe callus that splits open.  The request is for left lower extremity arterial re-intervention.

No, the proposed Outpatient Surgery Services are not medically necessary.

The patient has hypertension, diabetes, and peripheral arterial disease (PAD) with a left great toe callous that re-splits and is not infected. He has no calf claudication or rest pain. He has a history of right first and second toe gangrene with resections. He is status post left lower extremity arterial revascularization. Ankle-brachial index (ABI) was 1.44 on the right and 1.20 on the left pre-exercise and 0.95 on the right and 0.95 on the left post exercise, all of which are within normal limits. The arteries were borderline non-compressible due to calcification and the plethmysography demonstrated good pulsatility. A lower extremity arterial ultrasound demonstrated a left distal superficial femoral artery (SFA)/popliteal artery stenosis with a mid posterior tibial artery stenosis and a chronic mid anterior tibial artery occlusion. 

The patient has normal left lower extremity non-invasive ankle-brachial index (ABI) studies without indication that the left lower extremity arterial stenoses/occlusions are significant. There is no indication that the arteries were significantly calcified/non-compressible to give false ankle-brachial index (ABI) readings. Toe blood oxygen pressure measurements were not obtained. The patient does not have left lower extremity calf claudication or rest pain to suggest significant peripheral arterial disease (PAD). The patient has a left great toe callus that re-splits though is not infected. Even though the arterial ultrasound demonstrated left lower extremity stenoses/occlusion, the other tests did not demonstrate these to be significant. The requested left lower extremity arterial revascularization was not medically necessary, as standards of care were not met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a past medical history of hypertension, hyperlipidemia and coronary arterial disease who was referred by his cardiologist for a planned coronary angiogram given his symptoms of exertional shortness of breath and a positive nuclear stress test. On the day of admission, the patient was hemodynamically stable. He underwent coronary angiography and had a stent placed to the proximal left anterior descending artery. He was monitored overnight and discharged home in a stable condition. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of the inpatient stay is not medically necessary. This patient had stable angina symptoms and an abnormal stress test. He was referred for outpatient coronary angiography. The procedure report was reviewed in detail and there were no intraprocedural adverse events. Post procedure, he was hemodynamically stable and he had a mild hematoma at the access site that was managed appropriately. He was monitored overnight and continued to be stable. His other medical conditions remained stable as well. Based on the current standard of care and latest literature review, this patient could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pericardial Effusion
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient who was admitted to the hospital after an echocardiogram that had been performed in his physician's office showed a moderate sized pericardial effusion with excessive respiratory variation in mitral inflow velocity consistent with early tamponade physiology. The echocardiogram was performed as part of a scheduled stress test; the effusion was an unexpected finding. The patient's medical history was remarkable for coronary artery disease, hypertension, hyperlipidemia and diabetes. Upon admission, his blood pressure was 112/67 millimeters of mercury (mmHg) with a heart rate of 78 beats/minute. His temperature was 99.1 degrees Fahrenheit (F). He was treated with colchicine and steroids and his ticagrelor (an antiplatelet agent) was held. An echocardiogram showed a small circumferential partially organized pericardial effusion with mild respiratory variation in mitral inflow without definite signs of cardiac tamponade. A repeat study again showed a small partially organized pericardial effusion with mild respiratory mitral inflow variation. There was no chamber compression. The patient was discharged. The medical necessity for an inpatient admission is under review.
An inpatient level of admission was medically necessary.
This patient, who was on dual antiplatelet therapy with aspirin and ticagrelor, presented with a moderate sized pericardial effusion. While he was hemodynamically stable, an echocardiogram showed signs of early cardiac tamponade, which is especially worrisome in patients on antiplatelet or anticoagulant therapy given the risk for an acute increase in effusion size due to bleeding. If this were to occur, rapid hemodynamic deterioration would be expected. Thus, treatment with anti-inflammatory agents and discontinuation of antiplatelet drugs, along with careful and continuous monitoring with the ability to intervene emergently, if needed, was medically necessary. This warranted an inpatient level of care until the patient's effusion was shown to be decreasing in size and the mitral inflow pattern variation improved and stabilized.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits times (x) 12 for medical necessity. 
The denial was overturned.
 
The patient is a female with a Class II severely crowded malocclusion. Teeth 6 and 11 are ectopic and completely blocked out of the arch. Teeth 18 and 31 are ectopic as well. She has treatment planned for orthodontic treatment with extraction of teeth 5, 12, 21 and 28 to address the crowding and bite.

At issue is the medical necessity of braces and monthly visits times (x) 12 for this patient.

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

The requested health service/treatment of braces and monthly visits x 12 is medically necessary for this patient.

Treatment need indices, such as the Handicapping Labio-Lingual Deviation (HLD) Index used by the health plan, are used commonly in Europe and many states in the United States (US) as an objective indicator for treatment need. The criteria of the health plan require for approval a HLD score of 26 or above. Using the health plan criteria, the patient is scored at a 27 with a 4 for overjet, 3 for overbite, 12 for ectopic 6, 11, 18 and 31, 5 for mandibular crowding, and 3 for labiolingual spread.  

Furthermore, untreated impacted lower molars bring about the risks of periodontal problems, tooth decay, and external root resorption in the adjacent molar roots. Orthodontic treatment to correct the position of teeth 18 and 31 is medically necessary to protect the mandibular first molars.

Therefore, the requested health treatment of braces and monthly visits x 12 is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Endocrine
Growth Hormone

Diagnosis: Growth hormone deficiency
Treatment: Norditropin
The insurer denied Norditropin. The health plan's determination is upheld. 

The patient is a female who has been diagnosed with growth hormone deficiency (GHD) and is seeking growth hormone (GH) treatment under that indication. Her mother's height is 61.5 inches and father's height is about 65 inches. Her growth chart shows that her height was 89.5 centimeters (cm) (-1.2 standard deviation (SD)) and weight was 14.5 kg (kilograms) (+0.3 SD) 5 years and 2 months ago. She was seen by her primary care provider over 6 months ago for development of pubic and axillary hair. She also had body odor for a couple of months. Her evaluation showed luteinizing hormone (LH) 0.02, follicle-stimulating hormone (FSH) 1.59 , estradiol 19, testosterone 13, 17 hydroxyprogesterone 34, Dehydroepiandrosterone (DHEAS) 101 and IGF-1 (insulin like growth factor 1) 148. Thyroid function test showed normal free T4 (free thyroxine test) and normal thyroid stimulating hormone (TSH) while anti-thyroid antibodies were positive. Clinical impression was precocious puberty, and she was referred to pediatric endocrinology.

Norditropin is not medically necessary for this patient.

Diagnosis of growth hormone (GH) involves clinical history (with primary consideration given to the genetic background, degree of short stature and growth velocity), physical examination, auxologic data, bone age determination, measurement of insulin-like growth factor 1 (IGF-1) and IGF binding protein 3 (IGFBP-3), provocative growth hormone testing and an MRI (magnetic resonance imaging) of the pituitary.

Overall, this patient has grown 32 cm in 4.84 years which gives her a growth velocity of 6.6 cm per year (+1.0 SD). She clearly does not meet the criteria for the diagnosis of GHD. Although this patient underwent GH stimulation testing and her peak GH response was less than 10, in the absence of clinical criteria she cannot be diagnosed GHD based solely on GH stimulation test. The new Pediatric Endocrine Society guidelines recommend against reliance on GH provocative test results as the sole diagnostic criterion for the diagnosis of GHD because of limited sensitivity and specificity. 

This patient is short for her age, but she is not from tall parents and her midparental height is only 60.75+/-2 inches. She developed body odor, pubic hair and axillary hair all of which are consistent with premature adrenarche. Her estradiol was early pubertal which may suggest borderline precocious puberty. Early/precocious puberty is known to compromise adult height which is not due to GHD.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis.

Treatment: Inpatient stay.

The insurer denied coverage for the inpatient stay.

The denial is upheld. 

This is a female patient who had acute appendicitis.  The patient presented to the Emergency Department (ED), was admitted, underwent an uneventful laparoscopic appendectomy, and was discharged the day after the procedure.  There are no reported complications after the procedure, and no clinical evidence indicating that the patient was unstable for discharge on the day of the procedure.  Outpatient appendectomy is as safe and effective, with complication rates, readmission rates, and satisfaction equivocal to those patients kept in observation. [1-3] 

The inpatient hospital admission was not medically necessary.  This surgery can be performed as an outpatient/observation stay.  The patient presented to the ED with left lower quadrant abdominal and periumbilical pain for approximately 4 hours.  There was associated nausea and vomiting.  The patient had a computed tomography (CT) scan that was positive for acute uncomplicated appendicitis.  The patient was afebrile.  White blood cell (WBC) count was 20.9.  The patient underwent an uneventful laparoscopic appendectomy.  There were no documented complications.  The patient was noted to be tolerating sips of clears and there is no indication of nausea or vomiting.  Admission may be necessary for patients with severe systemic illness (e.g., sepsis), poorly controlled comorbidities (e.g., COPD [chronic obstructive pulmonary disease], chronic heart failure), or complications from the procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care. [1-3]  According to clinical documentation, there is no documentation to support inpatient admission for this patient.  

There is no documentation indicating that the patient was unstable for discharge on the day of the procedure.  Peer-reviewed literature also indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis. [1-3]  Suitable criteria for same-day discharge include hemodynamic stability, tolerating liquids, and pain controlled on oral medications. [4, 5]  Per clinical documentation, all same-day discharge criteria were met.  

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

The carrier's denial of coverage for the inpatient stay is upheld.  The medical necessity is not substantiated.