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

Diagnosis: Substance Abuse/Addiction.
Treatment: Inpatient Hospital.
The insurer denied the Inpatient Hospital treatment.  The denial was upheld in whole.

This is the case of a male with past medical history of hypertension, alcohol abuse, pulmonary embolism, thyroid disease, gastroesophageal reflux disease, and homelessness, who presented to the emergency department with chief complaint of nausea, vomiting, and wanting to stop drinking.

On presentation, he was afebrile with heart rate 71, respiratory rate 21, and with oxygen saturation of 96% on room air.  Exam otherwise noted the patient to be intoxicated and then tremulous and otherwise alert and oriented.  Labs were notable for white blood cell (WBC) count of 7.6, hemoglobin (HGB) 11.8, platelets 171, sodium 142, potassium 3.5, blood urea nitrogen (BUN) 10, creatinine 0.7, aspartate aminotransferase (AST) 140, alanine aminotransferase (ALT) 39, alkaline phosphatase 170, total bilirubin 2.9, and alcohol level of 219.5.  Urinalysis did not show evidence of infection.  Chest x-ray noted no clear acute process.  Electrocardiogram (EKG) showed no evidence of acute ischemia or arrhythmia.  The patient was given Ativan in the emergency department, and Clinical Institute Withdrawal Assessment (CIWA) score was noted to be 10.  He was brought into the hospital with concern for alcohol withdrawal and plans for intravenous (IV) fluids, CIWA protocol, thiamine, and folic acid.

Overnight and the next day the patient was maintained on the CIWA protocol with CIWA scores noted between 2 and 9.  The patient subsequently decided to leave against medical advice.

The issue in question is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient. 

This is a patient with a history of alcohol abuse, who presented with alcohol intoxication with an alcohol level of 219 and subsequent concern for alcohol withdrawal.  He was noted to have a normal heart rate on presentation without severe hypertension, to be intoxicated but otherwise alert and oriented, and to have a CIWA score of 10 in the emergency department.  He was subsequently treated overnight with IV fluids, Ativan as needed, folic acid and thiamine.  CIWA scores recorded were noted to be between 2-9 with the patient alert and oriented and subsequently choosing to leave against medical advice.  In the absence of altered mental status, persistent tachycardia with severe hypertension, persistent vomiting, history of severe withdrawal/delirium tremens, and with CIWA scores ranging from 2-9 indicative of mild withdrawal, the inpatient stay was not medically necessary.  The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Cardiac Cardiac problems /Chest Pain
Inpatient Hospital

The patient is a female with known coronary artery disease status post (S/P) stent implant. The patient  has a history of hypertension, hyperlipidemia, obesity, and colon cancer. The patient presented to the emergency department (ED) with complaints of chest pain radiating to the left arm for three days. The patient was admitted for further work up, seen by the cardiology consultant, had an echocardiogram and medications were adjusted. The patient's electrocardiogram (ECG) was unremarkable and the  troponins were normal. The health plan's determination of medical necessity is overturned in whole.
This patient has known coronary artery disease (CAD) with stent implant, as well as a history of hypertension, hyperlipidemia, and obesity. The patient had a thrombolysis in myocardial infarction (TIMI) score of 3 based on risk factors, aspirin use, and known coronary artery disease. This put the patient  at higher risk for death or cardiac complications and made the  admission at the inpatient level of care appropriate.
TIMI risk score - Analysis of data from the TIMI 11B and ESSENCE trials found seven variables to be independently predictive of outcome in patients with unstable angina (UA) or a non-ST elevation myocardial infarction (NSTEMI). These criteria were defined as the TIMI risk score. 
Normally a TIMI score of 3 or greater indicates higher risk and that the patient should be admitted to the inpatient level of care. This patient's admission was appropriate and medically necessary, as the TIMI score was 3.
Appeal type: Medical necessity
Decision: Overturned

Endocrine/Metabolic/Nutritional - Diabetes
Diabetic Equipment, Supplies and Self-Management Education

The patient is an adolescent female diagnosed with T1DM with hyperglycemia as a child. This request is for HCPCS A9274 Omnipods. As reported; she has used insulin pump; BG (blood glucose) monitoring; CGM (continuous glucose monitor) to achieve good control on her BGs. Her Medtronic 530 G was OOW (out of warranty) and in disrepair. She was using a Dexcom CGM and doing well. Unfortunately; an incident occurred while she was home alone. She had a serious hypoglycemic episode. She was quite symptomatic, heart pounding, dizzy, nauseous and alone. She was able to have the wherewithal to treat with oral carbohydrate while being coached by her parents on the phone. The low resolved. She was on the Medtronic closed loop automatic delivery system. She was diagnosed with depression and PTSD from this accident. She is terrified to use the Medtronic pump, which is still under warranty. The health plan has denied HCPCS Code A9274 Omnipods as not medically necessary.

The health plan's determination is overturned. The request is for supplies (HCPCS Code A9274). The request is not for a new insulin pump (HCPCS Code A9278). The patient has been using the Omni pod insulin pump. Given the fact that the request is for supplies, not an insulin pump, the request is consistent with generally accepted standards of medical practice. The request is consistent with the patient's condition and most appropriate supply given the fact that the patient failed on the previous insulin pump. The request is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Orthopedic / Musculoskeletal
Inpatient Hospital

The patient is a male with a history of tobacco use, asthma, and hyperlipidemia. He presented to the emergency room with pain and swelling on the left side of the face, as well as chills and rhinitis. On exam, he was afebrile, and the vital signs were otherwise normal. He did not appear toxic. There was some left facial swelling. Labs were notable only for an elevated white blood cell (WBC) count of 16000. A computed tomography (CT) scan of the facial bones revealed soft tissue swelling over left maxilla consistent with an abscess and cellulitis, that was perhaps involving the maxillary alveolus. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous antibiotics and parenteral analgesics. The following day the ear, nose, and throat (ENT) consultant evaluated the patient and concluded that the patient did not have an ENT abscess and that the oral maxillofacial surgeon should be consulted. One day later the oral maxillofacial surgeon noted the report of improvement from the patient but concluded that there was possible osteomyelitis of the maxillary bone. Continuation of intravenous antibiotics along with surgical debridement was recommended. However, the patient did not want to remain in the hospital and was discharged on oral antibiotics, with a plan to see his dentist as an outpatient.

The health plan's determination is overturned in part.

Based on a review of the information provided, a one day acute care inpatient stay was medically necessary. The rationale for the inpatient stay was that the patient presented with objective evidence of a potentially life-threatening condition including facial erythema and tenderness, leukocytosis, and imaging consistent with maxillary osteomyelitis. The appropriate treatment, which would have been at the acute inpatient level of care, was intravenous antibiotics and urgent surgical debridement. However, there was a significant delay in service obtaining consultations that persisted to the point that the patient felt compelled to leave the hospital. Therefore, one day of acute inpatient care was medically necessary, but the second day was not.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Homozygous sickle cell disease 
Treatment: Inpatient admission 

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

This patient is a female with a history of homozygous sickle cell disease.  The patient presented to the Emergency Room (ER) complaining of cough, back and joint pain consistent with previous sickle cell pain crises.  The patient's vital signs were not abnormal, and the patient was not hypoxic.  The laboratories revealed hemoglobin of 10.2 and a chest x-ray showed no infiltrates.  In the ER, the initial physical examination noted that the patient appeared distressed, and the patient's pain persisted despite multiple doses of intravenous therapy (IV) analgesics.  On the medicine admission note, the patient's pain was noted to be 6/10 and intermittently 10/10 in intensity and hydration was started at 150 cc/hr.  The patient's pain management plan was ibuprofen and Dilaudid 2 mg every 4 hours as needed for severe pain.  

Based on the review of the medical records provided, the inpatient admission is not considered medically necessary.  While the patient's pain was consistent with pain crisis and required intravenous analgesics (i.e. opioid) on an as-needed basis, there was no indication that the patient required continuous intravenous (IV) infusion of opioid pain medications.  As per Brandow, et al. (2018), majority of sickle cell disease pain episodes are managed at home with the use of long and short-acting opioids.  The article indicates that those who are admitted for pain control are at a severity that requires patient controlled analgesia (PCA), continuous infusion of opioids for adequate pain control.  

In this case, the patient did not have any signs or symptoms of unstable disease or complicated crises, such as acute chest syndrome.  The patient was discharged after a short inpatient stay indicating that the patient's pain management could have been managed at an observation level, and did not require continued hospital stay.  

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

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

Diagnosis: Growth Hormone Deficiency  

Treatment: Nutropin AQ  

The insurer denied the pre-service request for Nutropin AQ.  The denial was reversed.  

This is a young female patient with a medical history of growth hormone deficiency.  

A request was made by her Endocrinologist for Nutropin.  She had a GH stimulation test with glucagon and arginine peaked at 1.3 and 3.  Prior to the request a series of tests were performed.  Her bone age was at a chronological age (CA) for her years.  Her height velocity is reported to be 4.5 cm/year.  Her pubic hair was at Tanner 1.  She had a magnetic resonance imaging (MRI) with normal results.  Her insulin-like growth factor -1 (IGF1) was 101 (125-541).  The Z-score was -2.1.  Her mother's height is 172.72 cm and her father's height is 185.42 cm; therefore, the mid-parental height is 172.57 cm (1.43 SDS).  

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 auxological, biochemical and sometimes radiological findings.  The auxological 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 standard deviation (SD) below the mean; 2) height more than 1.5 SD below the mid-parental height; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years.  The biochemical criteria include low IGF1 or insulin-like growth factor-binding protein 3 [IGFBP3] or GH stimulation testing with a peak GH less than 10ng/ml.  

This patient met biochemical criteria.  GH stimulation testing peaked at less than 10 ng/ml.  The patient had a low IGF1.  The patient met auxological criterion 2 as her height is more than 1.5 SD below target height SD.  The patient met both auxological and biochemical criteria for the diagnosis of GH deficiency.  

The health plan did not act reasonably or with sound medical judgment or in the best interest of the patient as the requested treatment is medically necessary.  

The carrier's denial of coverage for the preservice request for Nutropin AQ is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type II diabetes mellitus 
Treatment:Continuous glucose monitoring system
The insurer denied the Continuous glucose monitoring system.
The denial is upheld.
The proposed CGM system is not medically necessary.

This is a female diagnosed with type II diabetes mellitus (T2DM). This request is for continuous glucose monitor (CGM) Libre Freestyle (K0553). As per the denial letter; the patient uses insulin; her A1C was 6.1 %.  As per the provider's note; the patient suffers from highly fluctuating blood glucose (BG) levels with hyperglycemia that needs regular monitoring. 

Note - there are no log sheets provided for review.

The requested device is a flash glucose monitoring system [1-4] that is FDA approved for persons age 18 and older with diabetes. It has been shown to be effective in patients with type II diabetes who are on intensive insulin therapy. It was associated with sustained reduction in hypoglycemia and safely and effectively replaces blood glucose monitoring [5, 6].
	
The patient has no documentation of being on an intensive insulin regimen.  The patient does not have documentation of self-checking of blood glucoses four or more times a day. Therefore, the request is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.
The Inpatient admission was not medically necessary.

The patient is a male with no significant past medical history, social history of being a former smoker and a family history of premature CAD (coronary artery disease). He presented to the hospital for evaluation of chest pain.  

The patient was hemodynamically stable. The ECG (electrocardiogram) revealed normal sinus rhythm, with T-wave inversion in leads III and AVF, and a 1 mm ST elevation in V2. Cardiac troponin was negative. The patient was admitted to rule out unstable angina. Echocardiogram revealed normal LV (left ventricle) function. A nuclear stress test was obtained and was normal, and the patient was discharged with a plan for outpatient follow-up.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test. Ischemia was ruled out by stress testing. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer
Treatment: Proton Beam Therapy
The insurer denied the Proton Beam Therapy.
The denial is upheld.

The Proton Beam Therapy is not medically necessary.

The patient is a female with a diagnosis of stage pT1cN0 (i+) right breast carcinoma s/p (status post) bilateral mastectomy and chemotherapy.  Adjuvant radiation therapy was recommended, and proton beam radiation therapy (PBRT) was requested.

In this case, the patient is a female with a diagnosis of stage pT1cN0 (i+) right breast carcinoma s/p bilateral mastectomy and chemotherapy.  Adjuvant radiation therapy was recommended, and proton beam radiation therapy was requested.  However, based upon and in conclusion of the review above, the proposed treatment is not considered medically necessary for this individual under these unique circumstances.
		
Proton beam radiation therapy is a type of very precise external radiation treatment in which protons are used to treat cancer and other conditions.  Compared to photon, a proton beam that is delivered with sufficient energy has a low "entrance dose."  A proton beam also has a high-dose "Bragg peak" region, which is designed to cover the entire tumor and there is no "exit dose" beyond the tumor involved in proton radiation therapy.  Because of this unique property, proton beam therapy is highly successful in minimizing damage to normal tissue and surrounding organs, resulting in fewer side effects.  It is an FDA-approved procedure and it is not subject to IRB (institutional review board) review.

Although proton beam radiation therapy has been shown to be safe and effective for certain tumors that are adjacent to critical structures such as CNS (central nervous system) lesion, there is insufficient clinical peer-review literature for supporting its use for the treatment of breast carcinoma.  There are other established alternatives available, such as conventional conformal or IMRT (intensity-modulated radiation therapy) photon therapy that have been shown to be safe and effective for the adjuvant treatment of breast cancers.  

There are several phase I and II clinical trials still evaluating the role of proton therapy for breast cancer.  The report of ASTRO's emerging technology committee also does not include proton therapy for breast cancer.  

In this case, a proton/photon comparison plan was done.  The ipsilateral lung and heart received less dose with the proton plan compared to the photon plan.  However, the doses to those structures were within tolerance per Quantec limit for both the proton and photon plans.  The requested proton beam radiation therapy, therefore, is not considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental malocclusion of skeletal class II-retruded mandible, normal vertical growth pattern, permanent dentition, class II canines, mild maxillary crowding, mild mandibular crowding, and moderately excessive overjet
 
Treatment: Dental braces 

The insurer denied coverage for dental braces. The denial is upheld. 

This patient is a male who presents with dental malocclusion of skeletal class II-retruded mandible, normal vertical growth pattern, permanent dentition, class II canines, mild maxillary crowding, mild mandibular crowding, and moderately excessive overjet.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with soft tissue damage.  The insurer has denied coverage for orthodontic treatment as not medically necessary.

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary.

Automatically qualifying condition of deep impinging overbite with soft tissue damage is not supported.  Based on the HLD score of 13, and the information provided, the dental malocclusion has no skeletal ramifications for orthodontic care.  The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for the dental braces (pre-service) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sciatica
 
Treatment: Inpatient admission

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

This patient is a female who presented to the emergency department complaining of severe back pain.  The patient indicated it started approximately 2 months prior.  The patient does have a diagnosis of sciatica.  The physical exam indicated the patient had normal sensation and motor function.  The physician indicated the patient should undergo laboratory diagnostic studies.  The patient was evaluated and underwent a surgical consult.  She stated she was only able to ambulate a short amount of time.  She also endorsed that she was recently seen in the urgent care and was started on prednisone as well as Flexeril and naproxen.  Her pain was refractory to the above medications prompting a visit to the chiropractor.  An MRI was performed the day prior to the presentation to the emergency department revealing herniated disc.  

The recommendation was made to admit the patient for further evaluation and possible surgical intervention.  The documentation indicated she denied bowel or bladder incontinence and she was able to ambulate.  Laboratory studies did not reveal any significant abnormalities.  An MRI did reveal chronic disc degeneration with facet arthritis at L5-S1 with a large central and left-sided disc herniation producing broad compression of the thecal sac and proximal left S1 nerve root.  The re-evaluation indicated the patient was resting and denied the need for pain medication.  She underwent surgical intervention which included an L5-S1 laminotomy with microdiscectomy and lysis of adhesion as well as foraminotomies and an epidural steroid injection.  The documentation detailed she did not have any complication during surgical intervention.  The patient was discharged with instruction to follow-up given the period of stability after surgical intervention.

This patient did not meet criteria for hospital admission. She had low back pain that had been present for 2 months with no documented neurologic deficit. There is no documentation of bowel or bladder malfunction or of difficulty ambulating. There is no documentation that she could not take oral medication. Finally, there is no documentation of imminent paralysis or rapid progression that would have warranted a hospital admission prior to surgery.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.