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

Diagnosis: Diabetes Mellitus
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with insulin-dependent diabetes with a history of poor compliance who was brought to the emergency department (ED) for one day of hyperglycemia, ketonuria, and vomiting. At triage, she appeared well. Her blood pressure (BP) was 121/66, heart rate (HR) 93, temperature (T) 98.5 degrees Fahrenheit, respiratory rate (RR) 20, and oxygen (O2) saturation 97% on room air.
The ED provider documented a normal, non-toxic appearing patient with a normal physical exam. Blood glucose was 565. Blood potential hydrogen (pH) was 7.36, bicarbonate 22, with normal electrolytes and complete blood count (CBC). The urine showed ketones and sugar. She was given intravenous (IV) fluid in the ED. The ED provider documented no vomiting, no shortness of breath, no distress. "Will place in observation for hyperglycemia secondary to non-adherence. On arrival to the pediatric floor, her vital signs were normal. Her physical exam showed an alert, active, and cooperative patient with a normal physical exam. The glucose had come down from 565 to 432. Later in the morning, she was seen by the endocrinologist who updated her sliding scale of insulin. She was tolerating by mouth (PO) the entire time and was discharged home. At issue is the medical necessity of an inpatient stay.
The inpatient admission was not medically necessary.
This diabetic teen patient had a history of non-compliance with her regimen and presented with hyperglycemia as well as sugar and ketones in her urine. Her vital signs were normal at all times and all examiners reported that she appeared well. There were two possible reasons for admission: diabetic ketoacidosis or hyperglycemia leading to hyperosmolar state with dehydration. She had neither.
The American Diabetes Association states "The severity of diabetic ketoacidosis (DKA) is defined by the degree of acidosis: mild, venous pH 7.2-7.3; moderate, pH 7.1-7.2; and severe, pH less than (<) 7.1." (1). The Pediatric Endocrine Society states "DKA is generally categorized by the severity of the acidosis, varying from mild (venous pH: < 7.30; bicarbonate concentration: < 15 millimoles per liter (mmol/L)) to moderate (pH: < 7.2; bicarbonate: < 10) to severe (pH: < 7.1; bicarbonate: < 5)." (2) A third consensus statement defines DKA as "Elevated serum or urine ketones (greater than the upper limit of the normal range) and serum bicarbonate < 15 mmol/L or blood pH < 7.3" She did not have clinical DKA, as her pH and bicarbonate were normal.
She also did not have any laboratory or physical exam evidence of dehydration or cardiovascular problems from a hyperosmolar state caused by hyperglycemia.
To whatever extent she was mildly "dry" or "heading toward" DKA, she was fully fluid repleted and on the road to metabolic correction with the treatment she received in the ED. She did not require any inpatient management. Care could have been provided at a lower level than inpatient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ischemic Cardiomyopathy.
Treatment: Wearable Cardioverter Defibrillator (LifeVest).

The insurer denied Wearable Cardioverter Defibrillator (LifeVest). The determination is upheld.

The patient has dyslipidemia, tobacco use and coronary artery disease (CAD). He suffered a previous myocardial infarction and is status/post (s/p) cardiac catheterization showing severe 3 vessel disease, s/p percutaneous coronary intervention (PCI) to the proximal left anterior descending, and ischemic cardiomyopathy, with an echocardiogram (ECHO) from 3/2020 showing an ejection fraction (EF) of 20-25% and then 30%. He is receiving guideline-directed medical therapy with carvedilol, losartan and Lasix. A LifeVest was ordered.
During an office visit with an electrophysiologist, he complained of dyspnea with minimal exertion, such as walking 1/2 block or up one flight of stairs. 
An implantable cardioverter defibrillator (ICD) implant was recommended, and a subcutaneous ICD was planned. At issue is whether a Wearable Cardioverter Defibrillator (LifeVest) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The proposed health service of a wearable cardioverter defibrillator ( LifeVest) is not likely to be more beneficial than standard, guideline-directed medical therapy and revascularization for this patient's illness. There are some data from clinical trials of the LifeVest post-myocardial infarction. In the Vest Prevention of Early Sudden Death Trial (VEST), reference 4 below, there was no difference in sudden cardiac death in patients immediately post-myocardial infarction who were treated with the LifeVest versus standard med therapy. No definitive data are available on comparative efficacy versus alternative (or no) treatment.
For patients with ischemic cardiomyopathy who are s/p recent revascularization, the LifeVest (wearable defibrillator) is given a IIB indication per the current American Heart Association (AHA) Science Advisory (reference 1 below). A IIB indication means that there is some divergence of opinion, but the weight of evidence is not in favor of treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

According to the submitted medical records, the patient is female has a listed diagnosis of chronic migraine without aura. Headaches are reported to have worsened after head trauma. An office visit reports patient has never been on any prophylactic agents. An appeal letter states she had side-effects to topiramate, but those are not detailed. There is no office visit note or any other legible documentation regarding such side-effects. Asthma is mentioned, as is the fact she is on antidepressants. There are no comments or specifics as to why switching current anti depressants to ones known to improve migraines is not feasible or has not been considered.

The health plan's determination is upheld. Emgality is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There is no evidence from any large, randomized, controlled study to support that Emgality would be superior to all available alternative treatments for this patient, as documented in the medical records.
In fact, there is insufficient evidence, as published in high quality peer reviewed literature to support that Emgality would be safe and effective for this patient.
The CGRP trials, including the ones for Emgality, did not include pediatric patients. Consequently, Emgality is not Food and Drug Administration (FDA) approved for the pediatric population, and its use is not endorsed by the manufacturer for the pediatric population.
A recent review of the treatment of migraines in the pediatric population by Kenneth Mack makes no mention whatsoever of the use of any CGRP blockers including Emgality.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a history of migraine headaches. Onset of headaches had been about 12 months prior. The patient reported onset of daily headaches. Headaches were described as being 2/10 on the Visual Analog Scale (VAS) on most days with a 7/10 headache one day a week. The medical history is notable for anxiety, depression, hypothyroid and asthma. At the time of a neurology consult the treating provider recommended initiation of a prophylactic therapy. The patient specifically was prescribed Emgality. 

The health plan's determination is upheld. Emgality is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. To date, there is not any high grade evidence to support the use of any of the CGRP based drugs in pediatric patients with migraine headaches. All of the clinical studies completed to date of the CGRP based drugs have only evaluated the drugs for use in the adult population.
Rather, at the present time there is an ongoing phase 3 clinical trial of Emgality being performed in the pediatric population with episodic migraine (A Study of Galcanezumab (LY2951742) in Participants 6 to 17 Years of Age With Episodic Migraine (REBUILD)--ClinicalTrials.gov Identifier: NCT03432286).
Recent practice guidelines from the American Academy of Neurology on the prophylaxis of pediatric migraine also made no mention on the use of CGRp based drugs in the pediatric/adolescent population (Oskoui, et al 2019). Rather, Oskoui, and colleagues made other recommendations for prophylactic treatments that have published bodies of literature available to support their use.
Given the absence of any evidence from well-designed clinical studies to support that the requested drug is safe and/or effective for pediatric use, the requested medication would not be likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Such a conclusion cannot otherwise be made at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a body weight and height that is consistent with an adult female. The patient is a migraineur with the very significant co-morbidity of major depression as well as asthma, which in turn complicates the risk profile of her treatment strategy for her migraines. Under review is the medical necessity of Emgality for the treatment of her migraines.

The health plan's determination is overturned. Emgality is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient's co-morbid affective disorder is now being treated with Lexapro, making the use of amitriptyline or nortriptyline potentially quite hazardous because of serotonin syndrome. Other common migraine medicines such as beta blockers are contraindicated because of her asthma and depression, particularly with Inderal. Topiramate therapy for her migraines resulted in adverse psychiatric effects. Botox is a reasonable next step for her, but the same issues about age (i.e. 18 vs. 15), while specious with respect to neurobiological differences, apply. Therefore, this leaves the antibodies that target CGRP. Since Emgality has a substantial record of safety and tolerability, as well as being efficacious in migraine headache therapy, its use is indicated for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache, Arm Weakness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency room with right arm weakness and a headache. On presentation to the emergency room, the weakness had resolved. He only complained of a mild headache. He was admitted to the hospital as an acute inpatient. He underwent a computed tomography (CT) scan of the head that was unremarkable and a magnetic resonance imaging (MRI) scan of the brain that was unremarkable. He was discharged from the hospital on aspirin. At issue is the medical necessity of an acute inpatient admission.
An acute inpatient stay was not medically necessary. The patient presented to the hospital with a history of right arm weakness and headache. When he was evaluated in the hospital, he did not have right arm weakness. He only endorsed a mild headache. As such, the patient had no neurologic deficit, even in the emergency room. He was admitted to the hospital with a mild headache. He then underwent diagnostic testing including a CT scan of the head, which was unremarkable, and an MRI of the brain, which was unremarkable. The patient did not have evidence of an acute stroke or other acute neurologic process. As the patient had no neurologic deficit, he did not require any rehabilitation. He was at his baseline level of functioning at or around the time of admission. The patient did not have any significant laboratory abnormalities. He was treated for the chronic conditions of hypertension and hyperlipidemia. He was given aspirin for stroke prevention. None of this care required an acute inpatient stay. Transient ischemic attack is routinely evaluated and treated at a lower level of care in the United States. In some locations, transient ischemic attack is even referred for rapid outpatient follow up rather than any hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal
Pharmacy/Prescription Drugs

Diagnosis: Osteoporosis
Treatment: Forteo
The insurer denied Forteo. The health plan's determination is upheld. 

The patient is a male with osteoporosis of unclear etiology and a toe fracture. Forteo is being requested and was denied by the health plan. He has not tried any other agents. He does not have a history of hypogonadal osteoporosis or osteoporosis associated with excessive steroid use. His provider has stated he has IBS (irritable bowel syndrome) and many dental carries but there is no mention of reflux or gastritis.

Forteo 600mcg/2.4 mL Pen Injector is not medically necessary for this patient. The patient has not tried and failed/has an intolerance to one of the preferred agents and having a diagnosis of IBS or dental carries is not considered a contraindication. There is not a medical reason he cannot try one of the preferred agents.
For the treatment of osteoporosis, it is generally recommended to start with an oral bisphosphonate unless there is an intolerance or contraindication. According to UpToDate, 'intravenous (IV) bisphosphonates, zoledronic acid (ZA) and ibandronate, offer an alternative for individuals who cannot tolerate oral bisphosphonates or who find the dosing regimen more convenient. ZA is the only IV bisphosphonate that has demonstrated efficacy for fracture prevention in men, and it is therefore our agent of choice'. 'For men who cannot tolerate oral or IV bisphosphonates or who have difficulty with the dosing requirements, options include teriparatide (PTH (parathyroid hormone) 1-34) or denosumab. For men with severe osteoporosis (low BMD (bone mass density) [T-score <-2.5] and at least one fragility fracture), or men who have failed previous therapy (e.g., continue to fracture after one year of bisphosphonate therapy).' 
As stated, there is no medical reason the patient cannot try a preferred agent before trying Forteo (tariparatide). IBS and a history of dental carries are not considered a contraindication to one of the preferred agents on the health plan's formulary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Musculoskeletal/Orthopedic- Fracture
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This case describes a patient who sustained an acute injury to both shoulders and chest wall. This occurred after the patient's car slipped off of a car jack and pinned the patient underneath the vehicle. Evaluation at the hospital revealed a right mid-shaft clavicle fracture and a left shoulder acromioclavicular (AC) joint separation. The patient was provided a sling for immobilization and no further orthopedic intervention was recommended. The patient worked with physical therapy (PT) and occupational therapy (OT). The patient was deemed stable for discharge. 

The requested Inpatient Stay was not medically necessary for this patient. This determination is based upon the provided medical records in this case and the recommendations of the current, peer-reviewed literature as documented by Burnham and colleagues in Orthopedics in 2016 and by Cook and associates in the Journal of the American Academy of Orthopedic Surgeons in 2018.
The provided medical records in this case document that this patient with a history of hyperlipemia sustained acute injuries to both of his shoulders. Evaluation at the hospital revealed a right clavicle fracture and left shoulder AC joint injury. An orthopedic consultation was obtained, and the consultant recommended non-surgical management of these injuries with outpatient follow up. The patient was discharged the next day.
In addition, the treatment recommendations made for this patient were consistent with the conclusions of the current, peer-reviewed orthopedic literature as documented by Burnham and colleagues in Orthopedics in 2016 and by Cook and associates in the Journal of the American Academy of Orthopedic Surgeons in 2018. The non-surgical management of this patient's shoulder injuries did not require inpatient hospital admission. Thus, the determination in this case should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Calculus along tooth roots; bone loss
Treatment: Deep Gum and Root Cleaning Upper Right and Left and Lower Right and Left Quadrants
The insurer denied the Deep Gum and Root Cleaning Upper Right and Left and Lower Right and Left Quadrants.
The denial is overturned. 

The patient is a female requesting dental benefits for four quadrants of scaling and root planning.

Yes, the Deep Gum and Root Cleaning Upper Right and Left and Lower Right and Left Quadrants are medically necessary.

In the second, clearer set of x-rays presented, it is apparent that there is calculus (tartar) along the roots of multiple teeth in all four quadrants. There is also bone loss seen in these x-rays in the four quadrants. These conditions are appropriate for the application of the requested procedures. The scaling and root planning are medically necessary in all 4 quadrants.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe cognitive impairment
Treatment: Increase of Personal Care Services to 24 hours/day, 7 days/week (live-in) for a total of 91 hours/week 
The insurer denied the Increase of Personal Care Services to 24 hours/day, 7 days/week (live-in) for a total of 91 hours/week.
The denial is overturned. 

The patient is an female with a history of severe cognitive impairment secondary dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 91 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

The proposed treatment of Increase of Personal Care Services to 24 hours/day, 7 days/week (live-in) for a total of 91 hours/week is deemed medically necessary. 

This is an female with a history of severe cognitive impairment secondary dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to progressively worsening cognitive decline from dementia, the patient has demonstrated progressively worsening gait ataxia, frequent falls, anxiety/depression and increased dependence on others to complete her ADLs (activities of daily living). Hence, the currently approved plan of 35 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment Increase of Personal Care Services to 24 hours/day, 7 days/week (live-in) for a total of 91 hours/week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive Decline.
Treatment: Consumer Directed Personal Assistance services 24 hours per week.

The insurer denied Consumer Directed Personal Assistance services 24 hours per week. The determination is overturned.

The patient has a history of age related cognitive decline, carpal tunnel syndrome, hand tremor, cervical stenosis with radiculopathy, left sided weakness, osteoarthritis, transient ischemic attack (TIA), diabetes mellitus (DM) Type 2, constipation, urinary incontinence, insomnia, gastroesophageal reflux disease (GERD), and hyperlipidemia who had been assigned 18 hours/week of Consumer Directed Personal Assistance Services (CDPAS) services. The patient had a telephonic assessment tool assessing the patient at maximal assistance with tasks of ordinary housework and shopping while extensive assistance with tasks of meal preparation, managing finances, managing medication, stairs, transportation, bathing, dressing lower body. The patient was assessed at limited assistance with tasks of phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use and independent with tasks of bed mobility and eating. The assessment tool noted the patient had meals on wheels 7 days/week.
There was a request to increase CDPAS services to 24 hours/week. The insurer sent a final adverse determination letter stating the requested increase was not medically necessary. The denial also stated the patient's daughter requested an increase in CDPAS hours due to a decline in health condition with the need for more assistance with daily activities and requested a decrease in delivery of meals from 4 days/week to 3 days/week while increasing CDPAS help so that the aide could assist the patient with cooking Chinese meals. The plan further noted the reported change in medical condition and/or the patient's ability to perform daily tasks did not impact the patient's current personal care needs. The plan also recommended discussing a schedule with CDPAS to better fit the patient's needs. At issue is the medical necessity of Consumer Directed Personal Assistance services 24 hours per week.
The requested health service/treatment of Consumer Directed Personal Assistance services 24 hours per week is medically necessary.
The patient's informal helper and caregiver reported a change in medical condition and/or ability to perform daily tasks with request to increase CDPAS hours. The plan relied on an assessment tool performed over the telephone to make a decision on medical necessity of CDPAS hours. The denial noted the patient had delivery of meals 4 days per week and the prior assessment tool did not take into account assistance needed to prepare meals the other 3 days per week. Personal care services are medically necessary when assistance with the 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: Overturned

Dental Problems. 
Dental/Orthodontic Procedure. 

Diagnosis: Class I malocclusion and anterior crossbite. 
Treatment: Braces/monthly visits. 

The insurer denied braces/monthly visits. The health plan's determination is overturned. 

The patient in question is a male with a Class I malocclusion and anterior crossbite of tooth # (number) 7. Tooth #7 is showing signs of wear on the disto-incisal line angle. Tooth #27 is displaced labially. He is treatment planned for 24-30 months of orthodontics with extraction of tooth #24 to correct his malocclusion. 

The Braces and Monthly Visit [x12] are medically necessary. 
The patient has maxillary and mandibular crowding with tooth #7 in crossbite. This tooth has a high risk for restorative problems in the future due to its traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Tooth #27 already has slight recession, and further movement of tooth #27 is likely due to its position relative to tooth #26 and will lead to the need for future for periodontal grafting on this tooth. Extraction of tooth #24 combine with orthodontics will allow for correction of the crossbite and alignment of the lower teeth without moving tooth #27 labially and risking further recession. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, the Braces and Monthly Visit [x12] are medically necessary.